Neurodevelopmental assessment of normocephalic children born to Zika virus exposed and unexposed pregnant people

BACKGROUND

Studies examining the association between in utero Zika virus (ZIKV) exposure and child neurodevelopmental outcomes have produced varied results.

METHODS

We aimed to assess neurodevelopmental outcomes among normocephalic children born from pregnant people enrolled in the Zika in Pregnancy in Honduras (ZIPH) cohort study, July-December 2016. Enrollment occurred during the first prenatal visit. Exposure was defined as prenatal ZIKV IgM and/or ZIKV RNA result at enrollment. Normocephalic children, >6 months old, were selected for longitudinal follow-up using the Bayley Scales of Infant and Toddler Development (BSID-III) and the Ages & Stages Questionnaires: Social-Emotional (ASQ:SE-2).

RESULTS

One hundred fifty-two children were assessed; after exclusion, 60 were exposed and 72 were unexposed to ZIKV during pregnancy. Twenty children in the exposed group and 21 children in the unexposed group had a composite score <85 in any of the BSID-III domains. Although exposed children had lower cognitive and language scores, differences were not statistically significant. For ASQ:SE-2 assessment, there were not statistically significant differences between groups.

CONCLUSIONS

This study found no statistically significant differences in the neurodevelopment of normocephalic children between in utero ZIKV exposed and unexposed. Nevertheless, long-term monitoring of children with in utero ZIKV exposure is warranted.

IMPACT

This study found no statistically significant differences in the neurodevelopment in normocephalic children with in utero Zika virus exposure compared to unexposed children, although the exposed group showed lower cognitive and language scores that persisted after adjustment by maternal age and education and after excluding children born preterm and low birth weight from the analysis. Children with prenatal Zika virus exposure, including those normocephalic and have no evidence of abnormalities at birth, should be monitored for neurodevelopmental delays. Follow-up is important to be able to detect developmental abnormalities that might not be detected earlier in life.

Neonatal outcomes according to different degrees of maternal morbidity: cross-sectional evidence from the Perinatal Information System (SIP) of the CLAP network

BACKGROUND

The burden of maternal morbidity in neonatal outcomes can vary with the adequacy of healthcare provision and tool implementation to improve monitoring. Such information is lacking in Latin American countries, where the decrease in severe maternal morbidity and maternal death remains challenging.

OBJECTIVES

To determine neonatal outcomes according to maternal characteristics, including different degrees of maternal morbidity in Latin American health facilities.

METHODS

This is a secondary cross-sectional analysis of the Perinatal Information System (SIP) database from eight health facilities in five Latin American and Caribbean countries. Participants were all women delivering from August 2018 to June 2021, excluding cases of abortion, multiple pregnancies and missing information on perinatal outcomes. As primary and secondary outcome measures, neonatal near miss and neonatal death were measured according to maternal/pregnancy characteristics and degrees of maternal morbidity. Estimated adjusted prevalence ratios (PRadj) with their respective 95% CIs were reported.

RESULTS

In total 85,863 live births were included, with 1,250 neonatal near miss (NNM) cases and 695 identified neonatal deaths. NNM and neonatal mortality ratios were 14.6 and 8.1 per 1,000 live births, respectively. Conditions independently associated with a NNM or neonatal death were the need for neonatal resuscitation (PRadj 16.73, 95% CI [13.29-21.05]), being single (PRadj 1.45, 95% CI [1.32-1.59]), maternal near miss or death (PRadj 1.64, 95% CI [1.14-2.37]), preeclampsia (PRadj 3.02, 95% CI [1.70-5.35]), eclampsia/HELPP (PRadj 1.50, 95% CI [1.16-1.94]), maternal age (years) (PRadj 1.01, 95% CI [<1.01-1.02]), major congenital anomalies (PRadj 3.21, 95% CI [1.43-7.23]), diabetes (PRadj 1.49, 95% CI [1.11-1.98]) and cardiac disease (PRadj 1.65, 95% CI [1.14-2.37]).

CONCLUSION

Maternal morbidity leads to worse neonatal outcomes, especially in women suffering maternal near miss or death. Based on SIP/PAHO database all these indicators may be helpful for routine situation monitoring in Latin America with the purpose of policy changes and improvement of maternal and neonatal health.

The burden of stillbirths in low resource settings in Latin America: Evidence from a network using an electronic surveillance system

OBJECTIVE

To determine stillbirth ratio and its association with maternal, perinatal, and delivery characteristics, as well as geographic differences in Latin American countries (LAC).

METHODS

We analysed data from the Perinatal Information System of the Latin American Center for Perinatology and Human Development (CLAP) between January 2018 and June 2021 in 8 health facilities from five LAC countries (Bolivia, Guatemala, Honduras, Nicaragua, and the Dominican Republic). Maternal, pregnancy, and delivery characteristics, in addition to pregnancy outcomes were reported. Estimates of association were tested using chi-square tests, and P < 0.05 was regarded as significant. Bivariate analysis was conducted to estimate stillbirth risk. Prevalence ratios (PR) with their 95% confidence intervals (CI) for each predictor were reported.

RESULTS

In total, 101,852 childbirths comprised the SIP database. For this analysis, we included 99,712 childbirths. There were 762 stillbirths during the study period; the Stillbirth ratio of 7.7/1,000 live births (ranged from 3.8 to 18.2/1,000 live births across the different maternities); 586 (76.9%) were antepartum stillbirths, 150 (19.7%) were intrapartum stillbirths and 26 (3.4%) with an ignored time of death. Stillbirth was significantly associated with women with diabetes (PRadj 2.36; 95%CI [1.25-4.46]), preeclampsia (PRadj 2.01; 95%CI [1.26-3.19]), maternal age (PRadj 1.04; 95%CI [1.02-1.05]), any medical condition (PRadj 1.48; 95%CI [1.24-1.76, and severe maternal outcome (PRadj 3.27; 95%CI [3.27-11.66]).

CONCLUSIONS

Pregnancy complications and maternal morbidity were significantly associated with stillbirths. The stillbirth ratios varied across the maternity hospitals, which highlights the importance for individual surveillance. Specialized antenatal and intrapartum care remains a priority, particularly for women who are at a higher risk of stillbirth.

The impact of maternal morbidity on cesarean section rates: exploring a Latin American network of sentinel facilities using the Robson's Ten Group Classification System

BACKGROUND

Latin America has the highest Cesarean Section Rates (CSR) in the world. Robson's Ten Group Classification System (RTGCS) was developed to enable understanding the CSR in different groups of women, classified according to obstetric characteristics into one of ten groups. The size of each CS group may provide helpful data on quality of care in a determined region or setting. Data can potentially be used to compare the impact of conditions such as maternal morbidity on CSR. The objective of this study is to understand the impact of Severe Maternal Morbidity (SMM) on CSR in ten different groups of RTGCS.

METHODS

Secondary analysis of childbirth information from 2018 to 2021, including 8 health facilities from 5 Latin American and Caribbean countries (Bolivia, Guatemala, Honduras, Nicaragua, and the Dominican Republic), using a surveillance database (SIP-Perinatal Information System, in Spanish) implemented in different settings across Latin America. Women were classified into one of RTGCS. The frequency of each group and its respective CSR were described. Furthermore, the sample was divided into two groups, according to maternal outcomes: women without SMM and those who experienced SMM, considering Potentially Life-threatening Conditions, Maternal Near Miss and Maternal Death as the continuum of morbidity.

RESULTS

Available data were obtained from 92,688 deliveries using the Robson Classification. Overall CSR was around 38%. Group 5 was responsible for almost one-third of cesarean sections. SMM occurred in 6.7% of cases. Among these cases, the overall CSR was almost 70% in this group. Group 10 had a major role (preterm deliveries). Group 5 (previous Cesarean section) had a very high CSR within the group, regardless of the occurrence of maternal morbidity (over 80%).

CONCLUSION

Cesarean section rate was higher in women experiencing SMM than in those without SMM in Latin America. SMM was associated with higher Cesarean section rates, especially in groups 1 and 3. Nevertheless, group 5 was the major contributor to the overall CSR.

Willingness to participate in in-the-moment surveys triggered by online behaviors

Surveys are a fundamental tool of empirical research, but they suffer from errors: in particular, respondents can have difficulties recalling information of interest to researchers. Recent technological developments offer new opportunities to collect data passively (i.e., without participant's intervention), avoiding recall errors. One of these opportunities is registering online behaviors (e.g., visited URLs) through tracking software ("meter") voluntarily installed by a sample of individuals on their browsing devices. Nevertheless, metered data are also affected by errors and only cover part of the objective information, while subjective information is not directly observable. Asking participants about such missing information by means of web surveys conducted in the moment an event of interest is detected by the meter has the potential to fill the gap. However, this method requires participants to be willing to participate. This paper explores the willingness to participate in in-the-moment web surveys triggered by online activities recorded by a participant-installed meter. A conjoint experiment implemented in an opt-in metered panel in Spain reveals overall high levels of willingness to participate among panelists already sharing metered data, ranging from 69% to 95%. The main aspects affecting this willingness are related to the incentive levels offered. Limited differences across participants are observed, except for household size and education. Answers to open questions also confirm that the incentive is the key driver of the decision to participate, whereas other potential problematic aspects such as the limited time to participate, privacy concerns, and discomfort caused by being interrupted play a limited role.

Vulnerability to snakebite envenoming and access to healthcare in the Terai region of Nepal: a geospatial analysis

Background

Snakebite envenoming is a neglected tropical disease that mainly affects poor populations in rural areas. In hyperendemic regions, prevention could partially reduce the constant risk, but the population still needs timely access to adequate treatment. In line with WHO's snakebite roadmap, we aim to understand snakebite vulnerability through modelling of risk and access to treatment, and propose plausible solutions to optimise resource allocation.

Methods

We combined snakebite-risk distribution rasters with travel-time accessibility analyses for the Terai region of Nepal, considering three vehicle types, two seasons, two snakebite syndromes, and uncertainty intervals. We proposed localised and generalised optimisation scenarios to improve snakebite treatment coverage for the population, focusing on the neurotoxic syndrome.

Findings

In the Terai, the neurotoxic syndrome is the main factor leading to high snakebite vulnerability. For the most common scenario of season, syndrome, and transport, an estimated 2.07 (15.3%) million rural people fall into the high vulnerability class. This ranges between 0.3 (2.29%) and 6.8 (50.43%) million people when considering the most optimistic and most pessimistic scenarios, respectively. If all health facilities treating snakebite envenoming could optimally treat both syndromes, treatment coverage of the rural population could increase from 65.93% to 93.74%, representing a difference of >3.8 million people.

Interpretation

This study is the first high-resolution analysis of snakebite vulnerability, accounting for uncertainties in both risk and travel speed. The results can help identify populations highly vulnerable to snakebite envenoming, optimise resource allocation, and support WHO's snakebite roadmap efforts.

Funding

Swiss National Science Foundation.

Effectiveness of Telemedicine Compared with Standard Care for Patients with Rheumatic Diseases: A Systematic Review

Objective: The aim of this study was to systematically review the evidence on the effectiveness of telemedicine compared to standard care for patients with rheumatic diseases. Methods: A search was performed in MEDLINE, EMBASE, and the Cochrane Database of Systematic Reviews; for the gray literature, GREYNET databases and a snowball search were used. MeSH or Emtree terms. Three authors independently selected systematic reviews, randomized controlled trail (RCTs), or non-RCTs with patients with autoimmune or inflammatory rheumatic diseases, where telemedicine was compared with standard care. Effectiveness was measured in terms of disease activity, quality of life, and functional activity. The patients' satisfaction was also measured. The risk of bias was assessed by the Cochrane collaboration tool for RCTs and AMSTAR II for systematic reviews. Results: Four RCTs, one cross-out study, and five systematic reviews were included. The studies were conducted with rheumatoid arthritis patients, and one study involved patients with systematic lupus erythematosus. The interventions mainly involved teleconsultation and telemonitoring, with patient-reported outcomes (PROs) being compared with standard care. Four studies measured the effectiveness of telemedicine using PROs, in which three of the RCTs did not find differences in the clinical outcomes, and one found that telemedicine improved the remission of diseases, functional impairment, and radiographic joint damage progression. Two studies measured patient satisfaction with telemedicine and standard care without a significant difference between the groups. Conclusions: Despite heterogeneity between studies, the findings were remarkably consistent in demonstrating that there was no significant difference between the telemedicine group and the control group in terms of PROs and patient satisfaction. Patients should be offered the option of telemedicine to manage their diseases as part of health-care support. Further research is needed on the effectiveness of telemedicine in the long term for patients with rheumatic diseases.

Efficacy and safety of empagliflozin in glycogen storage disease type Ib: Data from an international questionnaire

PURPOSE

This paper aims to report collective information on safety and efficacy of empagliflozin drug repurposing in individuals with glycogen storage disease type Ib (GSD Ib).

METHODS

This is an international retrospective questionnaire study on the safety and efficacy of empagliflozin use for management of neutropenia/neutrophil dysfunction in patients with GSD Ib, conducted among the respective health care providers from 24 countries across the globe.

RESULTS

Clinical data from 112 individuals with GSD Ib were evaluated, representing a total of 94 treatment years. The median age at start of empagliflozin treatment was 10.5 years (range = 0-38 years). Empagliflozin showed positive effects on all neutrophil dysfunction-related symptoms, including oral and urogenital mucosal lesions, recurrent infections, skin abscesses, inflammatory bowel disease, and anemia. Before initiating empagliflozin, most patients with GSD Ib were on G-CSF (94/112; 84%). At the time of the survey, 49 of 89 (55%) patients previously treated with G-CSF had completely stopped G-CSF, and another 15 (17%) were able to reduce the dose. The most common adverse event during empagliflozin treatment was hypoglycemia, occurring in 18% of individuals.

CONCLUSION

Empagliflozin has a favorable effect on neutropenia/neutrophil dysfunction-related symptoms and safety profile in individuals with GSD Ib.

Estimating and predicting snakebite risk in the Terai region of Nepal through a high-resolution geospatial and One Health approach

Most efforts to understand snakebite burden in Nepal have been localized to relatively small areas and focused on humans through epidemiological studies. We present the outcomes of a geospatial analysis of the factors influencing snakebite risk in humans and animals, based on both a national-scale multi-cluster random survey and, environmental, climatic, and socio-economic gridded data for the Terai region of Nepal. The resulting Integrated Nested Laplace Approximation models highlight the importance of poverty as a fundamental risk-increasing factor, augmenting the snakebite odds in humans by 63.9 times. For animals, the minimum temperature of the coldest month was the most influential covariate, increasing the snakebite odds 23.4 times. Several risk hotspots were identified along the Terai, helping to visualize at multiple administrative levels the estimated population numbers exposed to different probability risk thresholds in 1 year. These analyses and findings could be replicable in other countries and for other diseases.

What is the impact of snakebite envenoming on domestic animals? A nation-wide community-based study in Nepal and Cameroon

Snakebite envenoming is a life-threatening disease in humans and animals and a major public health issue in rural communities of South-East Asia and sub-Saharan Africa. Yet the impact of snakebite on domestic animals has been poorly studied. This study aimed to describe the context, clinical features, treatment, and outcomes of snakebite envenoming in domestic animals in Nepal and Cameroon. Primary data on snakebite in animals were recorded from a community-based nation-wide survey on human and animal snakebite in Nepal and Cameroon (Snake-byte project). Mobile teams collected data on snakebite in humans and animals in 13,879 and 10,798 households in Nepal and Cameroon respectively from December 2018 to June 2019. This study included 405 snakebite cases (73 in Nepal and 332 in Cameroon) in multiple types of animals. An interview with a structured questionnaire collected specific information about the animal victims. Snake bites in animals took place predominantly inside and around the house or farm in Nepal (92%) and Cameroon (71%). Other frequent locations in Cameroon were field or pasture (12%). A large diversity of clinical features was reported in all types of envenomed animals. They showed either a few clinical signs (e.g., local swelling, bleeding) or a combination of multiple clinical signs. Only 9% of animal victims, mainly cattle and buffaloes and less frequently goats, sheep, and dogs, received treatment, predominantly with traditional medicine. The overall mortality of snakebite was 85% in Nepal and 87% in Cameroon. Results from this nationwide study show an important impact of snakebite on animal health in Nepal and Cameroon. There is a need for cost-effective prevention control strategies and affordable snakebite therapies in the veterinary field to save animal lives and farmer livelihood in the poorest countries of the world. The WHO global strategy to prevent and control snakebite envenoming supports a One Health approach, which may help develop integrated solutions to the snakebite problem taking into account human and animal health.

Seroprevalence of Anti-SARS-CoV-2 Antibodies Three Months Post Infection in Healthcare Professionals at an Oncology Hospital in Northern Portugal

N/a.

Microcephaly Outcomes among Zika Virus-Infected Pregnant Women in Honduras

The impact of Zika virus (ZIKV) infection on pregnancies shows regional variation emphasizing the importance of studies in different geographical areas. We conducted a prospective study in Tegucigalpa, Honduras, recruiting 668 pregnant women between July 20, 2016, and December 31, 2016. We performed Trioplex real-time reverse transcriptase-PCR (rRT-PCR) in 357 serum samples taken at the first prenatal visit. The presence of ZIKV was confirmed in seven pregnancies (7/357, 2.0%). Nine babies (1.6%) had microcephaly (head circumference more than two SDs below the mean), including two (0.3%) with severe microcephaly (head circumference [HC] more than three SDs below the mean). The mothers of both babies with severe microcephaly had evidence of ZIKV infection. A positive ZIKV Trioplex rRT-PCR was associated with a 33.3% (95% CI: 4.3-77.7%) risk of HC more than three SDs below the mean.

Novel transdisciplinary methodology for cross-sectional analysis of snakebite epidemiology at national scale

Background

Worldwide, it is estimated that snakes bite 4.5–5.4 million people annually, 2.7 million of which are envenomed, and 81,000–138,000 die. The World Health Organization reported these estimates and recognized the scarcity of large-scale, community-based, epidemiological data. In this context, we developed the “Snake-Byte” project that aims at (i) quantifying and mapping the impact of snakebite on human and animal health, and on livelihoods, (ii) developing predictive models for medical, ecological and economic indicators, and (iii) analyzing geographic accessibility to healthcare. This paper exclusively describes the methodology we developed to collect large-scale primary data on snakebite in humans and animals in two hyper-endemic countries, Cameroon and Nepal.

Methodology/Principal findings

We compared available methods on snakebite epidemiology and on multi-cluster survey development. Then, in line with those findings, we developed an original study methodology based on a multi-cluster random survey, enhanced by geospatial, One Health, and health economics components. Using a minimum hypothesized snakebite national incidence of 100/100,000/year and optimizing design effect, confidence level, and non-response margin, we calculated a sample of 61,000 people per country. This represented 11,700 households in Cameroon and 13,800 in Nepal. The random selection with probability proportional to size generated 250 clusters from all Cameroonian regions and all Nepalese Terai districts. Our household selection methodology combined spatial randomization and selection via high-resolution satellite images. After ethical approval in Switerland (CCER), Nepal (BPKIHS), and Cameroon (CNERSH), and informed written consent, our e-questionnaires included geolocated baseline demographic and socio-economic characteristics, snakebite clinical features and outcomes, healthcare expenditure, animal ownership, animal outcomes, snake identification, and service accessibility.

Conclusions/Significance

This novel transdisciplinary survey methodology was subsequently used to collect countrywide snakebite envenoming data in Nepal and Cameroon. District-level incidence data should help health authorities to channel antivenom and healthcare allocation. This methodology, or parts thereof, could be easily adapted to other countries and to other Neglected Tropical Diseases.

Snakebite envenoming was recently classified as a priority neglected tropical disease by the World Health Organization. Up to five million people are bitten, more than a million envenomed, and around 100,000 victims die, mainly in rural and remote areas of low- and middle-income countries. Snakebite envenoming not only affects victims acutely, but it can also cause long-term disability, disfiguring scars, and heavy economic burden due to treatment costs and inability to work. Previous studies have analyzed snakebite clinical, epidemiological, or socio-economic impacts independently, and little has been done to assess the impact of snakebite in animals and on the livelihoods of the communities that depend upon them.

We present an innovative, holistic, national-scale methodology that includes epidemiology, One Health, economic, and geographic information science approaches into one multi-cluster household survey. We randomly selected 250 sub-district areas from all Cameroonian regions and all Nepali Terai districts, which represented more than 61,000 participants in each country. This methodology could be adapted and implemented in other countries affected by snakebite.

Use of a research app in an online opt-in panel: The Netquest case

The increasing use of mobile devices in the frame of online surveys has been accompanied by the development of research apps. These research apps have the potential to facilitate the process for respondents (e.g. being able to complete surveys when Internet is not available provides more freedom on when and where participants can participate) and fieldwork companies (e.g. the possibility to use push notifications could lead to higher participation rates). However, previous research suggests that panelists may also be reluctant to install an app. In this study, we answer research questions related to the knowledge and use of the Netquest app. We found that a majority of panelist did not know about the app and although sending invitations significantly increased its installation, the overall total of respondents installing the app remained low. Furthermore, the profile of those who installed the app differs from those who did not. The participation of panelists after they installed the app seems stable. The main reason for installing the app is comfort while the main reason for not installing relates to space/battery usage. Most of those who did not install could accept to install the app.

A comprehensive assessment for community-based, person-centered care for older adults

Background

Many health and social needs can be assessed and met in community settings, where lower-cost, person-centered, preventative and proactive services predominate. This study reports on the development and implementation of a person-centered care model integrating dental, social, and health services for low-income older adults at a community dental clinic co-located within a senior wellness center.

Methods

A digital comprehensive geriatric assessment (CGA) and referral system linking medical, dental, and psychosocial needs by real-time CGA-derived metrics for 996 older adults (age ≥ 60) was implemented in 2016–2018 as part of a continuous quality improvement project. This study aims to describe: 1) the development and content of a new CGA; 2) CGA implementation, workflows, triage, referrals; 3) correlations between CGA domains, and adjusted regression models, assessing associations with self-reported recent hospitalizations, emergency department (ED) visits, and clinically-assessed dental urgency.

Results

The multidisciplinary team from the senior wellness and dental centers planned and implemented a CGA that included standard medical history along with validated instruments for functional status, mental health and social determinants, and added oral health. Care navigators employed the CGA with 996 older adults, and made 1139 referrals (dental = 797, care coordination = 163, social work = 90, mental health = 32). CGA dimensions correlated between oral health, medical status, depressive symptoms, isolation, and reduced quality of life (QoL). Pain, medical symptoms, isolation and depressive symptoms were associated with poorer self-reported health, while general health was most strongly correlated with lower depressive symptoms, and higher functional status and QoL. Isolation was the strongest correlate of lower QoL.

Adjusted odds ratios identified social and medical factors associated with recent hospitalization and ED visits. General and oral health were associated with dental urgency. Dental urgency was most strongly associated with general health (AOR = 1.78,95%CI [1.31, 2.43]), dental symptoms (AOR = 2.39,95%CI [1.78, 3.20]), dental pain (AOR = 2.06,95%CI [1.55–2.74]), and difficulty chewing (AOR = 2.80, 95%CI [2.09–3.76]). Dental symptoms were associated with recent ED visits (AOR = 1.61, 95%CI [1.12–2.30]) or hospitalizations (AOR = 1.47, 95%CI [1.04–2.10]).

Conclusion

Community-based inter-professional care is feasible with CGAs that include medical, dental, and social factors. A person-centered care model requires coordination supported by new workflows. Real-time metrics-based triage process provided efficient means for client review and a robust process to surface needs in complex cases.

Effect of Hypothermia and Severity of Hypoxic-Ischemic Encephalopathy in the Levels of C-Reactive Protein during the First 120 Hours of Life

OBJECTIVE

This study aimed to describe normal C-reactive protein (CRP) levels of newborns diagnosed with hypoxic-ischemic encephalopathy (HIE) and assess the influence of therapeutic hypothermia (TH) and the severity of HIE.

STUDY DESIGN

We prospectively recruited infants ≥35 weeks of gestational age diagnosed with HIE from 2000 to 2013 and compared CRP levels in the first 120 hours of life according to the severity of HIE and the use of TH, which was introduced in 2009.

RESULTS

Moderate HIE was diagnosed in 115 newborns, severe HIE in 90 (hypothermia was performed in 151 cases), and mild HIE in 20. Cooled newborns showed lower levels of CRP in the first 34 hours, but reached higher median maximum CRP levels (15.4 vs. 8.5 mg/L), and at a significantly older age (53 vs. 17 hours). Levels of CRP in mild HIE were lower than those of moderate-severe forms. Moderate and severe HIE had similar CRP levels, but time to maximum CRP was significantly less in moderate cases.

CONCLUSION

CRP levels of mild HIE are similar to healthy newborns, while CRP elevations can be expected in newborns with moderate-severe HIE. TH produced a slower rise, with a higher and late maximum CRP peak level.

Acute cholecystitis and residual choledocholithiasis in a situs inversus patient, successful laparoscopic approach and ERCP a case report from Ecuador

Background

Situs inversus totalis is a rare genetic condition characterized by the transposition of organs to the opposite side of the body, consequently, clinical syndromes show an atypical clinical picture creating a challenge for the surgery team and predisposing to delays in treatment and diagnosis. Laparoscopic cholecystectomy is the gold standard for acute cholecystitis, and in patients with situs inversus, the laparoscopic technique must be modified to accommodate the patient's anatomy.

Case presentation

We present the case of a 55-year-old male patient without any past medical history, he presented to the emergency room with abdominal pain in his upper left quadrant. After a thorough examination, acute cholecystitis and situs inversus was diagnosed. He underwent a modified laparoscopic cholecystectomy without complications. In his postoperative period, residual choledocholithiasis was identified and ERCP was done. On follow-ups, the patient is doing well.

Conclusions

Although rare and technically demanding, laparoscopic cholecystectomy and ERCP in a patient with situs inversus is feasible. The altered anatomy could lead to complex procedures, therefore proper planning and careful execution of intraoperative techniques are required to treat these patients safely and effectively.

•

Situs inversus totalis is a rare condition characterized by the transposition of organs to the opposite side of the body.

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Laparoscopic cholecystectomy is the gold standard for acute cholecystitis, even in patients situs inversus.

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Proper planning and careful execution of intraoperative techniques are required to treat these patients safely.

Perceived changes in psychological and physical symptoms after hospital clown performances in a cancer setting

Background: The therapeutic role of humor and hospital clowns has become a focus of interest in recent decades. Most of the research in the area has focused on children; here, we explore the influence of clown performances on adult cancer patients, their companions, and health-care staff.Methods: Ninety-nine cancer patients and 113 companions were assessed pre- and post-interventions performed by professional clowns; 31 health professionals were asked about the possible influence of the presence of clowns in hospital on their work.Results: Patients felt that clowning performances helped to reduce their level of psychological symptoms, but not their physical symptoms. Companions reported improvements in all the psychological symptoms explored. Health professionals reported that the presence of clowns in the workplace improved their well-being.Conclusions: Clowning performances helped to improve psychological functioning in all the populations studied, especially in companions. Adult hospitals should consider promoting clowning interventions to improve general well-being.

A comparative in vitro study of standard facemask jet nebulization and high-flow nebulization in bronchiolitis

Aim of Study: The use of a nebulizer paired with high-flow nasal cannulas (HFNC) has been proposed for drug delivery in bronchiolitis. Particle size nebulized is a relevant factor determining the efficacy of the nebulization. We replicated in vitro the theoretical parameters most widely used in bronchiolitis and we compared the size of the droplet nebulized with a standard nebulizer and a nebulizer integrated into HFNC. Materials and Methods: We used laser diffraction to analyze the particle size nebulized (volume median diameter Dv50). The standard system was a jet nebulizer connected to a facemask with a flow rate of 8 L/min (JN). Three designs were used as nebulizers integrated into HFNC: a vibrating mesh nebulizer set 1) before (HFNC-BH) and 2) after (HFNC-AH) the humidifier, and 3) a jet nebulizer connected before the nasal cannula (HFNC-BNC). HFNC was used with neonatal (3-8 L/min) and infant cannulas (8-15 L/min). Results: Droplet size was similar among the three drugs studied. A lower particle size was obtained when using the nebulization system integrated into HFNC compared to the standard nebulizer, regardless of the flow rate and the nasal cannula used when the position of the nebulizer was before the nasal cannula (p < 0.05): 6.89 µm (JN), 2.49 µm (HFNC-BNC 3 L/min), 2.59 µm (HFNC-BNC 5 L/min), 2.44 µm (HFNC-BNC 8 L/min), 3.22 µm (HFNC-BNC 10 L/min), 3.23 µm (HFNC-BNC 13 L/min), 3.16 µm (HFNC-BNC 15 L/min). The particle size was lower in HFNC-BF compared to the HFNC-AH using neonatal nasal cannula (3-8 L/min) (p < 0.05). Conclusion: The use of a nebulizer integrated with HFNC has shown promising results in an experimental scenario of bronchiolitis. The particle size achieved with the nebulizer placed before the humidifier is equivalent to the one obtained via conventional nebulization, and it is even smaller when the integrated nebulizer is placed before the nasal cannulas.

To what extent are members of an online panel willing to share different data types? A conjoint experiment

Recently, the idea of ‘data fusion’, that is, of combining different types of data, became quite popular because of the advances of new technologies. In particular, several studies started investigating the possibility of combining survey data with other data types in order to get a more complete or accurate picture of the reality and/or to reduce survey burden. One key element, then, is the willingness of people to share different types of data, beyond survey answers. In this article, we investigate to what extent members from an opt-in online panel in Spain are willing to share different types of information that have in general not been studied before in the literature: records of their surrounding sound (audiotracking), information from their email inbox (in different ways, sharing the email credentials, using an email plug-in or redirecting emails, partially or totally), sensorial reactions measured by a wearable device (neuroscience) and public information about them available online. We use a choice-based conjoint analysis in order to study the level of willingness depending on the incentives offered in exchange, and we present the level of willingness by gender and age groups. Overall, we find huge differences in the level of willingness across data types. Increasing the incentives, on the contrary, does not improve the willingness so much, even if there is a positive trend. Some differences are observed across gender and age groups but most of them are not statistically significant.

Incorporating a Nebulizer System Into High-Flow Nasal Cannula Improves Comfort in Infants With Bronchiolitis

BACKGROUND

High-flow nasal cannula (HFNC) is increasingly used to provide respiratory support in infants with bronchiolitis. The delivery of aerosol therapy through a jet nebulizer is widely indicated despite its controversial efficacy and poor tolerability.

METHODS

This randomized cross-over study aimed to evaluate the comfort and satisfaction of the delivery of aerosol therapy using a nebulization system integrated into HFNC compared with the standard practice of using a jet nebulizer with a face mask. The COMFORT-Behavior (COMFORT-B) scale, a visual analog scale, and a numeric rating scale were used by health professionals and caregivers to assess subjects' levels of comfort and satisfaction.

RESULTS

A total of 113 nebulizations (64 via nebulizer with HFNC; 49 via jet nebulizer) were delivered to the 6 subjects included in the study. Use of the nebulizer with HFNC showed increased comfort and satisfaction during nebulization compared to use of the jet nebulizer, as measured by the COMFORT-B scale, the visual analog scale, and the numeric rating scale, with the following median (interquartile range) scores: 10.7 (7-16) versus 14.5 (10-20) (P = .006), 8.5 (6-10) versus 7 (4-9) (P = .02), and 3.84 (3.61-4.07) versus 1.83 (1.58-2.08) (P < .001), respectively. Correlation between the COMFORT-B scale and the visual analog scale using Spearman's rho was -0.757 (P < .001). The intraclass correlation coefficient for the COMFORT-B scale, visual analog scale, and numeric rating scale, as measured by 2 different nurses, was between 0.75 and 0.87.

CONCLUSIONS

The use of a nebulizer incorporated into HFNC therapy results in an increased level of comfort and satisfaction compared to the use of a conventional jet nebulizer in subjects with bronchiolitis who required HFNC therapy. Further studies are needed to determine whether aerosol therapy delivered through HFNC improves the clinical course of this pathology.

The role of posttraumatic stress and posttraumatic growth on online information use in breast cancer survivors

OBJECTIVE

Changes perceived as both positive (eg, posttraumatic growth [PTG]) and negative (eg, posttraumatic stress symptoms [PTSS]) have been associated with intensive Internet use among breast cancer survivors. In this multicenter study, we analyzed the role of PTG and PTSS on the amount of time spent looking for online cancer information, its content, and its psychological impact.

METHODS

Posttraumatic stress symptoms and PTG were assessed in 182 breast cancer survivors by using the Post-traumatic Stress Disorder Checklist and Post-traumatic Growth Inventory questionnaires. Subjects also completed a questionnaire about their behavior when looking for online illness-related information (ie, time spent, type of contents, and psychological impact).

RESULTS

Posttraumatic stress symptoms positively correlated with the amount of time spent looking for cancer-related information, including both medical and psychosocial content. By contrast, PTG showed no relationships with the amount of time, but with a predominant search for cancer-related psychosocial information. The psychological impact of online information was associated with participants' levels of PTG and/or PTSS. Whereas PTG was related to a decrease of women's hope, PTSS was linked to the perception of being less conscious or inadequately informed about the illness, thereby increasing feelings of distress.

CONCLUSIONS

Posttraumatic stress symptoms and PTG show relationships with the amount of time spent online, the type of information accessed online, and the psychological impact of Internet use. Health professionals should prescribe online information according to the psychological response to cancer. There is a need for professional-led online resources to provide patients with timely information as well as support sites to facilitate psychological adjustment.

Amplitude Integrated Electroencephalogram as a Prognostic Tool in Neonates with Hypoxic-Ischemic Encephalopathy: A Systematic Review

Introduction

Perinatal management and prognostic value of clinical evaluation and diagnostic tools have changed with the generalization of therapeutic hypothermia (TH) in infants with hypoxic-ischemic encephalopathy (HIE)

Aim

to ascertain the prognostic value of amplitude integrated electroencephalogram (aEEG) in neonates with HIE considering hours of life and treatment with TH.

Methods

A systematic review was performed. Inclusion criteria were studies including data of neonates with HIE, treated or not with TH, monitored with aEEG and with neurodevelopmental follow-up of at least 12 months. The period of bibliographic search was until February 2016. No language restrictions were initially applied. Consulted databases were MEDLINE, Scopus, CINHAL and the Spanish language databases GuiaSalud and Bravo. Article selection was performed by two independent reviewers. Quality for each individual paper selected was evaluated using QUADAS-2. Review Manager (RevMan) version 5.3 software was used. Forest plots were constructed to graphically show sensitivity and specificity for all included studies, separating patients treated or not with hypothermia. Summary statistics were estimated using bivariate models and random effects approaches with the R package MADA from summary ROC curves. Meta-regression was used to estimate heterogeneity and trends.

Results

from the 403 articles initially identified, 17 were finally included and critically reviewed. In infants not treated with hypothermia the maximum reliability of an abnormal aEEG background to predict death or moderate/severe disability was at 36 hours of life, when a positive post-test probability of 97.90% was achieved (95%CI 88.40 to 99.40%). Positive likelihood ratio (+LR) at these hours of life was 26.60 (95%CI 4.40 to 94.90) and negative likelihood ratio (-LR) was 0.23 (95%CI 0.10 to 0.44). A high predictive value was already present at 6 hours of life in this group of patients, with a positive post-test probability of 88.20% (95%CI 79.80 to 93%) and a +LR of 4.34 (95%CI 2.31 to 7.73). In patients treated with TH the maximum predictive reliability was achieved at 72 hours of life (post-test probability of 95.70%, 95%CI 84.40 to 98.50%). +LR at this age was 24.30 (95%CI 5.89 to 71.30) and–LR was 0.40 (95%CI 0.25 to 0.57). Predictive value of aEEG at 6 hours of life was low in these patients (59.10%, 95%CI 55.70 to 63%).

Conclusion

This study confirms that aEEG´s background activity, as recorded during the first 72 hours after birth, has a strong predictive value in infants with HIE treated or not with TH. Predictive values of traces throughout the following 72 hours are a helpful guide when considering and counselling parents about the foreseeable long-term neurological outcome

Abstract P1-09-07: Effects of breast cancer treatment on markers of metabolic syndrome in a predominantly hispanic patient population

Background: Adjuvant chemotherapy improves survival in early breast cancer, however has been reported to contribute to weight gain and insulin resistance. Hispanics are reported to have higher levels of insulin resistance and features of metabolic syndrome as compared to caucasians and as such may be at higher risk of metabolic decompensation during treatment of their cancer. We sought to evaluate the effects of adjuvant/ neo-adjuvant breast cancer treatment on markers of metabolic syndrome in a predominantly hispanic population. Study was funded by the institutions department of medicine seed grant funds.

Methods: We enrolled 35 consecutive patients who were about to commence adjuvant or neo-adjuvant chemotherapy for breast cancer. Patients with diabetes mellitus or hyperlipidemia were excluded. Fasting glucose, HBA1C, insulin levels, HDL cholesterol, triglyceride levels, waist circumference and blood pressure were measured before starting chemotherapy and then every 3 months for 1 year. Results were analyzed using repeated measures ANOVA for normally distributed data. For data that was not normally distributed, Friedmans non parametric test was utilized.

A survey of dietary habits, exercise frequency and life style factors was administered before initiating treatment and at completion of the study.

Results:

Baseline characteristics: Of the 35 patients enrolled 31 were hispanics (89%). Median age was 47 years (33-68). 31 (82.8%) were over weight or obese. 13 (37%) had insulin resistance as assessed by HOMA (homeostatic model assessment)-IR, and 12 (34%) met the international diabetic federation (IDF) criteria for metabolic syndrome. 17% had stage 1, 52% had stage 2 and 31% had stage 3 disease. Most common chemotherapy regimen used was dose dense doxorubicin, cyclophosphamide and weekly paclitaxel.

No significant change was noted in the fasting glucose, HBA1C levels, insulin levels, HOMA-IR, weight or waist circumference at any point during the 1 year follow up. Triglyceride levels increased from a mean of 162.2mg/dl prior to therapy to 202.8mg/dl by 3 months, p=0.014. HDL-cholesterol fell from a mean of 50.6 mg/dl to 44mg/dl by 3 months, p=0.04.

Both triglyceride levels and HDL levels returned to baseline by 9 months and there was no change noted by 12 months. Overall 12 patients (34%) met the IDF criteria for metabolic syndrome before initiating adjuvant therapy as compared to 14 (40%) at 1 year.

Subgroup analysis of patients with preexisting metabolic syndrome, obesity or insulin resistance (HOMA-IR &gt;3.8) showed similar results.

Analysis of the survey data showed 22 of the 35 patients (62%) had improved their dietary and exercise habits over the course of the study.

Conclusions: Contrary to other studies, we did not find a significant difference in most of the parameters of metabolic syndrome in a predominantly hispanic patient population. A transient increase in triglyceride levels and a decline in HDL cholesterol level was noted at 3 months, however resolved by the 9th month of treatment. Our data suggests that life style modification may mitigate most of the metabolic adverse effects of therapy and women, at the time of diagnosis, may be particularly motivated to make such changes.

Citation Format: Gaur S, Ochoa C, Sanchez L, Nahleh Z. Effects of breast cancer treatment on markers of metabolic syndrome in a predominantly hispanic patient population. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P1-09-07.

Relative contribution of biological variation and technical variables to zone diameter variations of disc diffusion susceptibility testing

OBJECTIVES

Disc diffusion is still largely based on manual procedures. Technical variations originate from inoculum preparation, variations in materials, individual operator plate streaking and reading accuracy. Resulting measurement imprecision contributes to categorization errors. Biological variation resembles the natural fluctuation of a measured parameter such as antibiotic susceptibility around a mean value. It is deemed to originate from factors such as genetic background or metabolic state. This study analysed the relative contribution of different technical and biological factors to total disc diffusion variation.

METHODS

For calculation of relative error factor contribution to disc diffusion variability, five experiments were designed keeping different combinations of error factors constant. A mathematical model was developed to analyse the individual error factor contribution to disc diffusion variation for each of the tested drug-species combinations.

RESULTS

The contribution of biological variation to total diameter variance ranged from 10.4% to 98.8% for different drug-species combinations. Highest biological variation was found for Enterococcus faecalis WT and vancomycin (98.8%) and for penicillinase-producing Staphylococcus aureus and penicillin G (96.0%). Average imprecision of automated zone reading revealed that 1.4%-5.3% of total imprecision was due to technical variation, while materials, i.e. antibiotic discs and agar plates, contributed between 2.6% and 3.9%. Inoculum preparation and manual plate streaking contributed 6.8%-24.8% and 6.6%-24.3%, respectively, to total imprecision.

CONCLUSIONS

This study illustrates the relative contributions of technical factors that account for a significant part of total variance in disc diffusion. The highest relative contribution originated from the operator, i.e. manual inoculum preparation and plate streaking. Further standardization of inoculum preparation and plate streaking by automation could potentially increase the precision of disc diffusion and improve the correlation of susceptibility reports with clinical outcome.

Evo-devo mechanisms underlying the continuum between homology and homoplasy

The different manifestations of equivalence and similarity in structure throughout evolution suggest a continuous and hierarchical process that starts out with the origin of a morphological novelty, unit, or homologue. Once a morphological unit has originated, its properties change subsequently into variants that differ, in magnitude, from the original properties found in the common ancestor. We will look into the nature of morphological units and their degrees of modification, which will provide the starting point for restructuring the concept of "homology," keeping the use of homology as the identity of an anatomical part, and homogeny, as the specific variation of that anatomical part during evolution. We will also show that parallelism has a distinct placement within an evolutionary continuum between homology and homoplasy, whereas the phenomenon of evolutionary convergence is left outside this continuum. We will then provide some epistemological and developmental criteria to justify these distinctions, showing that there is a direct relation between the nature of these concepts and the constraints that developmental mechanisms impose on evolution. Finally, we will propose a hierarchical model that places homology, homogeny, homoplasy, and parallelism, as distinct phenomena within an evolutionary continuum.

Utility of noninvasive ventilation in high-risk patients during endoscopic retrograde cholangiopancreatography

Background:

There is little evidence on noninvasive ventilation (NIV) preventing respiratory complications in high-risk patients undergoing endoscopy procedures.

Objectives:

The objective of this study is to demonstrate that the application of NIV through a nasal interface can prevent the appearance of ventilatory alterations during endoscopic retrograde cholangiopancreatography (ERCP) in patients with risk factors associated with the development of hypoventilation.

Patients and Methods:

A non-randomized interventional study was performed on 37 consecutive high-risk patients undergoing ERCP. During the procedure, 21 patients received oxygen by nasal cannula (3 L/minute) and sixteen received NIV through a nasal mask. Arterial blood gas analyses were conducted before and immediately after the ERCP. An Acute Physiology and Chronic Health Evaluation (APACHE) score pre-ERCP was recorded. The complications during the procedure were recorded.

Results:

The groups with and without NIV were comparable. A post-ERCP pH of <7.35 was found in eight patients, who did not receive ventilatory support (38.1%) compared to zero patients in the NIV group (P = 0.006). A post-ERCP pCO₂ >45 mmHg was found in one case (6.3%) in the NIV-group and in nine cases in the nasal cannula group (42.9%; P = 0.01). The median pCO₂ post-ERCP was lower (36.5 ± 6.2 vs. 44.5 ± 6.8 mmHg) (P = 0.001) and median pH post-ERCP was higher (7.41 ± 0.4 vs. 7.34 ± 0.5) (P = 0.001) in patients treated with NIV. In the multivariate analysis, after adjusting for gender, the APACHE score, pH and pCO₂ pre-ERCP, age, propofol doses, and procedure duration, the following differences were maintained (pCO₂ difference = 5.54, 95% Confidence Interval (CI) =2.3 – 8.7, pH difference = 0.047, and 95% CI = 0.013 – 0.081). Among the 37 procedures, four complications occurred: One in the NIV group and three in the nasal cannula group. None of them was related to NIV.

Conclusions:

Our preliminary results demonstrate that in high-risk patients undergoing ERCP, hypercapnia and respiratory acidosis are frequent. NIV prevents the appearance of these complications.

[General anaesthesia and obstetric bleeding in caesarean section. One year's experience in a university hospital]

INTRODUCTION

Obstetric haemorrhage is an important worldwide cause of morbidity and mortality. General anaesthesia for caesarean section is rarely used. Our goal is to analyse the incidence, causes and risk factors associated with general anaesthesia for caesarean section, and the prevalence of obstetric haemorrhage (HO), its risk factors and predictors of post-caesarean HO together with the use of blood in our hospital population.

METHODS

A retrospective study was conducted on all caesarean section discharge reports from PACU in 2008.

RESULTS

General anaesthesia was required in 12.4% of the patients. Epidural catheter failure as a cause of general anaesthesia was infrequent (2.8%) and within the recommended standards.

CONCLUSIONS

The most frequent indications for caesarean section under general anaesthesia included mainly life-threatening emergencies, and the most important risk factors for general anaesthesia, including coagulation disorders, bleeding in the third trimester, foetal distress and severe pre-eclampsia. General anaesthesia is a risk factor for transfusion, as is abruptio placentae, placenta previa and pre-eclampsia.

[Endovascular treatment of stenosis of the renal artery in transplanted kidney]

INTRODUCTION

The incidence of renal artery stenosis in the transplanted kidney (TRAS) varies between 2 and 23%, being the most frequent vascular complication following renal trasplantation. The delay in diagnosis and treatment can lead to functional graft loss. Percutaneous trasluminal angioplasty with stent (PTAS) is the treatment of choice to restore kidney perfusion.

MATERIALS AND METHODS

Retrospective review of renal transplant casuistic in our institution between September 2005 and August 2009. Were included patients with greater than 70% TRAS and impaired graft function, treated with PTAS. Follow-up at 3, 12 and 36 months was done with creatinine, glomerular filtration rate (GFR) and Doppler ultrasonography (DUS). Technical success was defined as correct stent placement associated with decreased flow, and clinical success as improve renal function during follow-up.

RESULTS

Incidence of TRAS was 7.3% (22/298), 60% PTAS subsidiary. 100% technical success and 84.6% clinical success, 15.4% without changes in renal function. 84% decreases flow rate greater than 70% by DUS, and 26% up to 60%. Wave changes from type III to type II were recorded in 69% and to type I in 33%.

CONCLUSIONS

The PTAS is a safe and effective procedure for the treatment of selected TRAS patients, as it preserves vascular permeability in short and medium term, ensuring the functionality of the graft. DUS is the method of choice for diagnosis and monitoring TRAS.

The role of a peri-urban forest on air quality improvement in the Mexico City megalopolis

Air quality improvement by a forested, peri-urban national park was quantified by combining the Urban Forest Effects (UFORE) and the Weather Research and Forecasting coupled with Chemistry (WRF-Chem) models. We estimated the ecosystem-level annual pollution removal function of the park's trees, shrub and grasses using pollution concentration data for carbon monoxide (CO), ozone (O(3)), and particulate matter less than 10 microns in diameter (PM(10)), modeled meteorological and pollution variables, and measured forest structure data. Ecosystem-level O(3) and CO removal and formation were also analyzed for a representative month. Total annual air quality improvement of the park's vegetation was approximately 0.02% for CO, 1% for O(3,) and 2% for PM(10), of the annual concentrations for these three pollutants. Results can be used to understand the air quality regulation ecosystem services of peri-urban forests and regional dynamics of air pollution emissions from major urban areas.

EUS-guided single-incision needle-knife biopsy: description and results of a new method for tissue sampling of subepithelial GI tumors (with video)

BACKGROUND

The diagnostic efficacy of current tissue sampling techniques for upper GI subepithelial tumors (SETs) appears to be limited. Better tissue acquisition techniques are needed to improve the diagnostic yield in this setting.

OBJECTIVE

Our purpose was to determine the safety and diagnostic yield of EUS-guided needle-knife incision and forceps biopsy (SINK biopsy) of upper GI SETs.

DESIGN

Retrospective database review.

SETTING

Academic tertiary-care referral center.

PATIENTS

This study involved 14 consecutive patients referred for EUS evaluation of upper GI SETs with previous unsuccessful attempts at tissue diagnosis by conventional forceps biopsy.

INTERVENTION

EUS-guided needle-knife incision and forceps biopsy.

MAIN OUTCOME MEASUREMENTS

The safety and diagnostic yield of this method, compared with EUS-guided fine-needle aspiration (EUS-FNA), when possible.

RESULTS

SINK biopsy provided tissue samples that were sufficient for definite histologic diagnosis in 13 of 14 cases (diagnostic yield 92.8%). There were 8 gastric GI stromal tumors. In 7 of 8, the size of SINK specimens allowed immunohistochemical analysis, and the evaluation of malignant potential was carried out by means of mitotic index determination in 5 cases (71.42%). SINK biopsies determined the pathological diagnosis of all (4 of 4) nonmesenchymal lesions. Eight patients underwent both EUS-FNA and SINK, with final histologic diagnosis determined in 6 of 8 cases (75%) by SINK versus 1 of 8 cases (12.5%) by EUS-FNA (Fisher exact test, P = .023). There were no procedure-related complications.

LIMITATIONS

A single-center, retrospective analysis with small sample size.

CONCLUSION

SINK biopsy appears to be an easy, safe, and effective technique for determining the definitive pathological diagnosis, evaluation of the malignant potential, and planning management of SETs. It could be a reliable alternative to conventional FNA, providing larger samples that improve the histologic yield.