Impact of Medicaid Expansion on Stage at Diagnosis for US Adults with Pancreatic Cancer: a Population-Based Study

INTRODUCTION

We evaluated whether Medicaid expansion is associated with earlier stage at diagnosis for pancreatic cancer taking into account key demographic, clinical, and geographic factors.

METHODS

We obtained Surveillance, Epidemiology, and End-Results (SEER-18) data on individuals diagnosed with pancreatic cancer from 2007 to 2016 (< 65 years of age). We defined non-metastatic as either local or regional disease (vs. metastatic disease). To estimate the association of Medicaid expansion with pancreatic cancer stage at diagnosis, we used a difference-in-differences model, at the individual level, comparing those from early-adopting states in 2014 to non-early-adopting states. We utilized cluster-robust standard errors and explored the role of demographic factors (race, sex, insurance at diagnosis), clinical indicator (disease in the head of the pancreas), and county characteristics (Urban Influence Code, Social Deprivation Index).

RESULTS

In the univariable setting, the probability of non-metastatic disease at diagnosis increased by 3.9 percentage points (ppt) for those from Medicaid expansion states post-expansion (n = 36,609). After adjustment for covariates, the ppt was attenuated to 2.7. Of particular note, we observed evidence of interactions with sex and race. The beneficial effect was less pronounced for men (increase in the probability of non-metastatic stage at diagnosis by 2.1ppt) than women (3.6ppt) and non-existent for blacks (- 3.1ppt) compared to whites (4.9ppt) and other races (4.8ppt).

CONCLUSION

Medicaid expansion is associated with increased probability of non-metastatic stage at diagnosis for pancreatic cancer; however, this beneficial effect is not uniform across sex and race. This underscores the need to investigate the impact of policy and implementation strategies on pancreatic cancer survival disparities.

Non-Neoplastic Thoracic Cysts: A Clinicopathologic Study of 136 Cases

Benign cysts of the thoracic cavity represent a group of rare lesions, the spectrum of which is expanding. Most of these are congenital in nature, secondary to abnormal development during embryogenesis while a smaller subset represents acquired lesions. We retrospectively reviewed the clinicopathologic features of 136 patients with thoracic cysts that were treated in our institution over a span of 20 years. The patients were 85 female and 51 male patients with an average age of 51 years. Eighty-four of the patients were asymptomatic (62%), the remainder mainly presented with chest pain, shortness of breath, or cough. Surgical resection was performed in 123 patients while 12 patients were treated with aspiration only and 1 underwent core biopsy. The cyst size ranged from 0.5 to 14.8 cm (mean, 4.4 cm); histologically, the lesions included 50 thymic cysts (28 multilocular; 22 unilocular), 37 bronchogenic cysts, 23 pleuropericardial cysts, 12 unclassified cysts, 6 Müllerian cysts, 5 enteric cysts, and 3 parathyroid cysts. Clinical follow-up revealed that 97 patients were alive and well 4 months to 37 years after initial diagnosis; 25 patients were lost to follow-up and 14 patients died of unrelated causes. The current study is one of the largest studies on the subject with emphasis on clinicopathologic characteristics. This series has a higher incidence of thymic cysts compared with prior publications and covers a wider spectrum of different histologic types than previously reported.

Current status of low-density lipoprotein apheresis treatment for patients with peripheral artery disease and chronic kidney disease in Japanese clinical database

INTRODUCTION

Patients with peripheral arterial disease (PAD) have a poorer prognosis than those without PAD. PAD complications worsen the prognosis of patients with chronic kidney disease (CKD), especially those on maintenance dialysis. Although low-density lipoprotein apheresis (LDL-A) is expected to be effective in treating severe PAD, there are no large-scale reports on the prognosis of patients undergoing LDL-A.

METHODS

We obtained a clinical database from April 2008 to August 2021 and selected 924 238 patients with CKD. We selected patients with disease codes of lower limb arteriosclerosis obliterans, arteriosclerosis obliterans, and critical limb ischemia or foot ulcer. Patients who were prescribed antithrombotic medications were included. Patients who used steroids were excluded. Among these patients, those undergoing blood purification considered LDL-A were selected, and their current status was investigated.

RESULTS

We included 147 patients (113 males and 34 females). The mean patient age was 70 ± 10 years. Diabetes mellitus was present in 86%, ischemic heart disease in 34%, and stroke in 48%. Maintenance dialysis patients accounted for 86% of the patients. Statins were administered to 40% of the patients, and bypass surgery was performed in 2.7%. The median observation period was 812 days, and the mortality rate was 41%.

CONCLUSION

LDL-A was performed in a small population of patients with CKD with the most severe form of PAD. The prognosis for these patients is extremely poor. Therefore, strategies to improve prognosis are important.

Efficacy of quaternary ammonium salt-based disinfectant or chelated copper-zinc footbath solution in the treatment of digital dermatitis on one research dairy farm in Taiwan

BACKGROUND

Footbaths can be used to manage digital dermatitis (DD), a common cause of lameness in dairy cattle. Copper sulfate and chelated copper-zinc (CZS) solutions in footbaths are potentially harmful to the environment.

HYPOTHESIS/OBJECTIVES

To determine if a quaternary ammonium salt-based disinfectant (QASD) footbath is as effective as a chelated CZS solution in controlling DD in dairy cows.

ANIMALS

Fifty-one lactating Holstein cows were randomly assigned to one of two treatment groups, with DD status based on the M-stage scoring system and locomotion score balanced between treatment groups.

MATERIALS AND METHODS

The groups were treated with a 1% QASD or a 2.5% chelated CZS. Footbaths were performed once per week for 15 weeks. Logistic regression was used to analyse clinical improvement. All cows received appropriate medical treatment for DD and other hoof diseases.

RESULTS

Clinical improvement rates were 67% in the QASD group and 38% in the CZS group (p = 0.03). Logistic regression analysis showed that the odds (95% confidence interval) for clinical improvement rate in the CZS group were 0.30 (0.095-0.948) times that of the QASD group (p = 0.04). The M0 score in the QASD and CZS groups increased significantly (p < 0.05) at the end of the 15 week study period. In the QASD group, the proportion of M2, M3 and M4 scores were significantly decreased (p < 0.05).

CONCLUSION AND CLINICAL RELEVANCE

Over a 15 week period, QASD for footbathing was associated with a lower prevalence of active DD lesions than when using CZS.

Evidence for Wnt signaling's central involvement in perinatal nicotine exposure-induced offspring lung pathology and its modulation by electroacupuncture

OBJECTIVE

Many factors during pregnancy can induce intrauterine growth restriction (IUGR), resulting in various adverse perinatal outcomes such as low birth weight and multiple organ disorders. Among these factors, prenatal smoke/nicotine exposure is a common cause of IUGR, often associated with altered fetal lung development. The classical Wnt signaling pathway plays a vital role in lung development, and its alterations are commonly associated with developmental lung pathologies. The purpose of this study was to determine whether electroacupuncture (EA) at "Zusanli" (ST 36) points protects perinatal nicotine exposure (PNE)-induced offspring lung dysplasia through Wnt/β-catenin signaling pathway and to identify specific Wnt signaling pathway targets of EA.

METHODS

Following a well-established protocol, nicotine (1 mg/kg/ body weight) was administered subcutaneously to pregnant Sprague Dawley rat dams from gestational day 6 to postnatal day 21. In the EA group, dams were treated with EA at both ST 36 acupoints, while in another experimental group, Wnt/β-catenin signaling pathway agonist was injected subcutaneously (2 mg/kg/ body weight). Offspring body weight (PND 1, 7, 14, and 21), lung weight, Wnt signaling markers, pulmonary function, and lung morphology were determined at sacrifice on PND 21. Specifically, Western blotting and Real-time PCR were used to detect the protein and mRNA levels of critical Wnt signaling markers Wnt2, Wnt7b, FZD4, FZD7, LRP5, and LRP6 in the offspring lung. The protein levels of β-catenin in lung tissue of offspring rats were detected by ELISA that of LEF-1 by Western blotting.

RESULTS

Compared to the control group, the body and lung weights of the offspring rats were significantly decreased in the nicotine-only exposed group. The pulmonary function determined as FVC, PEF, TV, and Cdyn was also significantly decreased, while PIF was significantly increased. The protein levels and mRNA expression of Wnt2, Wnt7b, FZD4, FZD7, LRP5, and LRP6 in the lung tissue of the PNE offspring rats were significantly increased. With EA administration at ST 36 acupoints concomitant with nicotine administration, the body and lung weights, pulmonary function (FVC, PEF, PIF, TV, and Cdyn), protein and mRNA levels Wnt signaling pathway markers (Wnt2, Wnt7b, FZD4, FZD7, LRP5, LRP6, β-catenin, and LEF-1) normalized and were not different from the control group. Notably, Wnt agonists agonist administration blocked the protective effects of EA against PNE-induced lung morphological, molecular, and function changes, highlighting the central significance of Wnt pathway signaling in PNE-induced offspring pulmonary pathology and its modulation by EA at ST 36 acupoints.

CONCLUSION

Concomitant maternal EA at ST 36 acupoints from gestational day 6 to PND 21 protects against offspring PNE-induced lung phenotype. The protective effect is achieved by regulating the expression of Wnt ligand proteins (Wnt2 and Wnt7b) and receptor proteins (FZD4, FZD7, LRP5, and LRP6) upstream of the Wnt/β-catenin signaling pathway intermediates β-catenin, and LEF-1.

Past Cannabis Use, Health-Related Worry, and Beliefs About Perceived Benefits of Cannabis Among American Indians/Alaska Natives

BACKGROUND

Most adults report beliefs that cannabis has at least one benefit (e.g., stress relief, chronic pain management); however, the benefits are not well established. Beliefs about cannabis benefits are associated with the initiation of use, whereas beliefs about the risks of cannabis are protective factors against its use. Little is known about how health-related beliefs impact cannabis use among American Indians/Alaska Natives (AIAN).

PURPOSE

This exploratory study examined beliefs about perceived benefits (i.e., stress relief, pain management) of cannabis, how beliefs vary as a function of use, and associations between health worry and benefits of cannabis among AIAN adults.

METHODS

Participants (n = 182) were on average 41.4 (SD = 16.3) years old, 63.9% female, and identified as AIAN. Participants were asked questions about general demographics, health-related worry and perceptions, and cannabis use. Linear regressions were conducted to examine associations.

RESULTS

Those who used cannabis in the past year were more likely to agree that cannabis relieves stress and less likely to believe that those who use cannabis should be very worried about their health. Participants who agreed that those who use cannabis should be worried about their health were less likely to report beliefs that cannabis relieves stress or helps with chronic pain.

CONCLUSIONS

Our study confirms the role of health-related perceptions and worry about cannabis products with cannabis use among this population that may be at risk for higher cannabis use. Findings may have implications for cannabis policy at the tribal, state, and federal levels and the need for the development of targeted communications about the true health risks of cannabis.

Microscopic morphology and distribution of the antennal sensilla in the double-spined bark beetle, Ips duplicatus (Coleoptera: Curculionidae)

The double-spined spruce bark beetle, Ips duplicatus, has become an infamous secondary pest of Norway spruce, causing extensive ecological and economic destruction in many Central European countries. Antennae are the primary olfactory organs that play a fundamental role in insect-host chemical communication; therefore, understanding morphology is crucial before conducting electrophysiological investigations. Here, we present our analysis of sensilla types on the antennal surface of I. duplicatus for the first time, using high-resolution-scanning electron microscopy. We studied the external morphological characteristics of antennae and the types, numbers, and distribution of the antennal sensilla in males and females. Our results revealed the presence of five different types of morphologically distinct sensilla: sensilla chaetica, sensilla basiconica, sensilla trichodea, sensilla coeloconica, and Böhm's sensilla. We observed two subtypes of sensilla chaetica (SChI and SChII), four subtypes of sensilla basiconica (SBI, SBII, SBIII, and SBIV), three subtypes of sensilla trichodea (STrII, STrIII, and STrIV) and two subtypes of sensilla coeloconica (SCoI and SCoII), respectively in I. duplicatus males and females. Minor differences in length and numbers between the sexes for some sensilla types were found. Distribution maps for different sensillar types were constructed, and specific areas for the respective sensilla were found. Possible functions of observed sensilla types are discussed. The present study provides a basis for future electrophysiological studies to understand how I. duplicatus detects ecologically important olfactory cues. RESEARCH HIGHLIGHTS: • The first report of morphology and distribution pattern of the antennal sensilla in Ips duplicatus is discussed. • A total of 6 main types and 11 antennal sensilla subtypes were observed in male and female Ips duplicatus. • Minor sex-specific differences were seen in the length and numbers in several sensilla types.

Antenatal prediction models for outcomes of extremely and very preterm infants based on machine learning

PURPOSE

Predicting individual risks for adverse outcomes in preterm infants is necessary for perinatal management and antenatal counseling for their parents. To evaluate whether a machine learning approach can improve the prediction of severe infant outcomes beyond the performance of conventional logistic models, and to identify maternal and fetal factors that largely contribute to these outcomes.

METHODS

A population-based retrospective study was performed using clinical data of 31,157 infants born at < 32 weeks of gestation and weighing ≤ 1500 g, registered in the Neonatal Research Network of Japan between 2006 and 2015. We developed a conventional logistic model and 6 types of machine learning models based on 12 maternal and fetal factors. Discriminative ability was evaluated using the area under the receiver operating characteristic curves (AUROCs), and the importance of each factor in terms of its contribution to outcomes was evaluated using the SHAP (SHapley Additive exPlanations) value.

RESULTS

The AUROCs of the most discriminative machine learning models were better than those of the conventional models for all outcomes. The AUROCs for in-hospital death and short-term adverse outcomes in the gradient boosting decision tree were significantly higher than those in the conventional model (p = 0.015 and p = 0.002, respectively). The SHAP value analyses showed that gestational age, birth weight, and antenatal corticosteroid treatment were the three most important factors associated with severe infant outcomes.

CONCLUSION

Machine learning models improve the prediction of severe infant outcomes. Moreover, the machine learning approach provides insight into the potential risk factors for severe infant outcomes.

Romosozumab is associated with greater trabecular bone score improvement compared to denosumab in postmenopausal osteoporosis

In this study, romosozumab demonstrated significantly greater improvement in trabecular bone score compared to denosumab therapy in postmenopausal women previously treated with antiresorptive agents. Notably, in patients previously treated with anti-resorptive agents, treatment with romosozumab resulted in similar increases in trabecular bone score compared to that of drug-naïve patients.

PURPOSE

Romosozumab significantly increases bone mineral density (BMD) and rapidly reduces fracture risk. Whether romosozumab can improve the spinal trabecular bone score (TBS) as a bone quality indicator merits further investigation.

METHODS

Data for postmenopausal women starting romosozumab or denosumab treatment at Severance Hospital, Korea, were analyzed. Romosozumab and denosumab groups were 1:1 matched using propensity scores, considering relevant covariates. Good responders were defined as those with TBS improvement of 5.8% or greater.

RESULTS

Overall, 174 patients (romosozumab, n = 87; denosumab, n = 87) were analyzed. Matched groups did not differ in age (64 years), weight, height, previous fracture (38%), lumbar spine or femoral neck BMD (T-score, -3.4 and -2.6, respectively), or prior bisphosphonate or selective estrogen receptor modulator (SERM) exposure (50%). The romosozumab group exhibited a greater increase in lumbar spine BMD (15.2% vs. 6.9%, p < 0.001) and TBS (3.7% vs. 1.7%, p = 0.013) than the denosumab group. In patients transitioning from bisphosphonate or SERM, romosozumab users showed greater improvement in TBS compared to denosumab users (3.9% versus 0.8%, P = 0.006); the drug-naive group showed no significant difference (3.6% versus 2.7%, P = 0.472). The romosozumab group had a higher proportion of good responders than the denosumab group (33.3% vs. 18.4%, p = 0.024). Romosozumab therapy for 12 months resulted in 3.8-fold higher odds of a good response in TBS than denosumab after covariate adjustment (adjusted odds ratio 3.85, p = 0.002).

CONCLUSION

Romosozumab could improve bone mass and bone quality, measured by TBS, in postmenopausal osteoporosis, particularly as a subsequent regimen in patients previously taking anti-resorptive agents.

Estrogen inhibits the differentiation of fibroblasts induced by high stiffness matrix by enhancing DNMT1 expression

INTRODUCTION AND HYPOTHESIS

Pelvic organ prolapse(POP) is a multifactorial connective tissue disorder caused by damage to the supporting structures of the pelvic floor. Evidence from several studies suggests that anterior vaginal wall stiffness is higher in patients with POP, but the mechanisms involved remain unknown.

METHODS

Tissue from the anterior vaginal wall of patients with POP or other benign diseases was obtained. The modulus of elasticity of the anterior vaginal wall was measured using a microindenter. Cells were cultured in vitro on acrylamide gels of different stiffness and treated with DNMT1 inhibitor, microtubule polymerisation inhibitor and estrogen. Western blot or immunohistochemical staining was performed to detect DNA Methyltransferase 1, α-smooth muscle actin(α-SMA) expression, and connective tissue growth factor(CTGF) expression.

CONCLUSION

Estrogen can inhibit high stiffness matrix-induced fibroblast differentiation, by enhancing DNMT1 expression. This study may help to elucidate the complex crosstalk between fibroblasts and their surrounding matrix under healthy and pathological conditions and provide new insights into the options for material-related therapeutic applications.

The importance of preconception Hcy testing: identification of a folate trap syndrome in a woman attending an assisted reproduction program

Methylation is a ubiquitous and permanent key biochemical process playing a major role in gametogenesis and embryogenesis in relation to epigenetics and imprinting. Methylation relies on a unique cofactor S-Adenosyl Methionine: SAM. Release of the methyl group onto target molecules is followed by liberation of S-Adenosyl Homocysteine (SAH), and then homocysteine (Hcy), both potent inhibitors of the methylation process. Defective recycling of homocysteine, leading to Hyperhomocysteinemia, is mainly due to reduced activity of MTHFR (Methylene TetraHydroFolate Reductase). However, we described here, in a woman attending an ART program, a rather rare syndrome: The Folate trap syndrome. Due to vitamin B12 deficiency (malabsorption), Hcy cannot be recycled to methionine by the methionine synthase. Transmethylation activity is weak and leads to Hhcy (Hyperhomocysteinhemia). Her Hhcy, over 16µM, was resistant to 5MTHF (5 Methyltetrahydrofolate) associated with a support of the one carbon cycle, a classical efficient treatment for elevated homocysteine. Treatment with Methylcobalamine (associated with adenosyl Cobalamine) allowed a Hcy drop down to 10 µM. Knowing the pleiotropic negative impact of Hcy on gametes, embryos and pregnancy in general, we strongly recommend a Hcy dosage in both members of couples seeking treatment for pregnancy.

Knowledge, Attitude, and Practice of Breast Cancer Patients Toward Lymphedema Complications: Cross-Sectional Study

Breast cancer is commonly treated through surgical resection, but a common complication of the procedure is lymphedema of the upper limbs, which can significantly impact patients' daily life. This study aims to investigate the knowledge, attitude, and practice (KAP) of breast cancer patients with regard to lymphedema complications. This cross-sectional study was conducted by a self-administered questionnaire between August and October 2022 toward breast cancer patients in our Hospital of Traditional Chinese Medicine. A total of 529 breast cancer patients were enrolled, including 186 (35.16%) aged < 50 years old. Participants had moderate knowledge, attitudes, and practices with scores of 18.24 ± 3.145 (possible range: 0-30), 62.24 ± 10.260 (possible range: 17-85), and 63.27 ± 20.967 (possible range: 21-105), respectively. Multivariate logistic regression showed that high school/technical secondary school (OR = 1.880, 95% CI = 1.107-3.194, P = 0.019) and being retired (OR = 0.482, 95% CI = 0.245-0.947, P = 0.034) were independently associated with good knowledge. Knowledge (OR = 1.321, 95% CI = 1.222-1.428, P < 0.001) was independently associated with a good attitude. Furthermore, knowledge (OR = 1.262, 95% CI = 1.151-1.384, P < 0.001) and attitude (OR = 1.122, 95% CI = 1.085-1.160, P < 0.001) were independently associated with good practice. Breast cancer patients have moderate knowledge, attitudes, and practices regarding lymphedema complications. Effective education and self-management programs are needed to improve patients' KAP toward lymphedema.

Multimorbidity in patients with acute heart failure across world regions and country income levels (REPORT-HF): a prospective, multicentre, global cohort study

BACKGROUND

Multimorbidity (two or more comorbidities) is common among patients with acute heart failure, but comprehensive global information on its prevalence and clinical consequences across different world regions and income levels is scarce. This study aimed to investigate the prevalence of multimorbidity and its effect on pharmacotherapy and prognosis in participants of the REPORT-HF study.

METHODS

REPORT-HF was a prospective, multicentre, global cohort study that enrolled adults (aged ≥18 years) admitted to hospital with a primary diagnosis of acute heart failure from 358 hospitals in 44 countries on six continents. Patients who currently or recently participated in a clinical treatment trial were excluded. Follow-up data were collected at 1-year post-discharge. The primary outcome was 1-year post-discharge mortality. All patients in the REPORT-HF cohort with full data on comorbidities were eligible for the present study. We stratified patients according to the number of comorbidities, and countries by world region and country income level. We used one-way ANOVA, χ2 test, or Mann-Whitney U test for comparisons between groups, as applicable, and Cox regression to analyse the association between multimorbidity and 1-year mortality.

FINDINGS

Between July 23, 2014, and March 24, 2017, 18 553 patients were included in the REPORT-HF study. Of these, 18 528 patients had full data on comorbidities, of whom 11 360 (61%) were men and 7168 (39%) were women. Prevalence rates of multimorbidity were lowest in southeast Asia (72%) and highest in North America (92%). Fewer patients from lower-middle-income countries had multimorbidity than patients from high-income countries (73% vs 85%, p<0·0001). With increasing comorbidity burden, patients received fewer guideline-directed heart failure medications, yet more drugs potentially causing or worsening heart failure. Having more comorbidities was associated with worse outcomes: 1-year mortality increased from 13% (no comorbidities) to 26% (five or more comorbidities). This finding was independent of common baseline risk factors, including age and sex. The population-attributable fraction of multimorbidity for mortality was higher in high-income countries than in upper-middle-income or lower-middle-income countries (for patients with five or more comorbidities: 61% vs 27% and 31%, respectively).

INTERPRETATION

Multimorbidity is highly prevalent among patients with acute heart failure across world regions, especially in high-income countries, and is associated with higher mortality, less prescription of guideline-directed heart failure pharmacotherapy, and increased use of potentially harmful medications.

FUNDING

Novartis Pharma.

TRANSLATIONS

For the Arabic, French, German, Hindi, Mandarin, Russian and Spanish translations of the abstract see Supplementary Materials section.

Preservation of fertility in female and male prepubertal patients diagnosed with cancer

Over the past two decades, the importance of fertility preservation has grown not only in the realm of medical and clinical patient care, but also in the field of basic and applied research in human reproduction. With advancements in cancer treatments resulting in higher rates of patient survival, it is crucial to consider the quality of life post-cure. Therefore, fertility preservation must be taken into account prior to antitumor treatments, as it can significantly impact a patient's future fertility. For postpubertal patients, gamete cryopreservation is the most commonly employed preservation strategy. However, for prepubertal patients, the situation is more intricate. Presently, ovarian tissue cryopreservation is the standard practice for prepubertal girls, but further scientific evidence is required in several aspects. Testicular tissue cryopreservation, on the other hand, is still experimental for prepubertal boys. The primary aim of this review is to address the strategies available for possible fertility preservation in prepubertal girls and boys, such as ovarian cryopreservation/transplantation, in vitro follicle culture and meiotic maturation, artificial ovary, transplantation of cryopreserved spermatogonia, and cryopreservation/grafting of immature testicular tissue and testicular organoids.

PGT-A mosaicism based on NGS intermediate copy numbers: is it time to stop reporting them?

Mosaicism represents a genuine real phenomenon, but its high prevalence and undisclosed clinical significance, stress the burden on genetic counseling and the management of PGT-A results. Even though the assumption of mosaicism from NGS intermediate chromosome copy number profiles may represent a reasonable interpretation, other potential technical reasons, including amplification bias, contamination, biopsy technique, or the analysis algorithms, may constitute alternative explanations. Thresholds confining mosaicism ranges are established according to models employing mixtures of normal and abnormal cells with steady conditions of quantity and quality which are unable to reflect the full extent of variability present in a trophectoderm (TE) biopsy specimen. When the concordance of TE with the ICM is considered, mosaic TE biopsies poorly correlate with the chromosomal status of the remaining embryo, displaying mostly ICM aneuploidy in cases of TE high-range mosaics diagnosis and euploidy when mosaicism grade in TE is less than 50% (low-mid range mosaicism), which implies an evident overestimation of mosaicism results. Indeed, a binary classification of NGS profiles that excludes mosaic ranges, including only euploid and aneuploid diagnosis, provides higher specificity and accuracy in identifying abnormal embryos and discarding them. As intermediate copy number profiles do not represent strong evidence of mosaicism but only an inaccurate and misleading assumption, and considering that no increased risk has been reported in the offspring, until diagnosis specificity is improved and its clinical implications are determined, laboratories should consider limiting predictions to euploid and aneuploid and stop reporting mosaicism.

Cryocompression to Reduce Peripheral Neuropathy in Gynecologic Cancer: A Randomized Controlled Trial

OBJECTIVE

To investigate the efficacy of cryocompression therapy to prevent chemotherapy-induced peripheral neuropathy.

METHODS

This single-institution, randomized, self-controlled trial of cryocompression enrolled gynecologic cancer patients planned for five to six cycles neurotoxic chemotherapy. Exclusion criteria were prior neurotoxic chemotherapy or baseline peripheral neuropathy. Participants were randomized to cryocompression on dominant versus non-dominant hand and foot (treatment), with no intervention on the opposite side (control). Compression socks and gloves and ice bags were applied 15 minutes before, during, and 15 minutes after infusion. Primary outcome measures included the PNQ (Patient Neurotoxicity Questionnaire) and the Semmes-Weinstein monofilament test; secondary outcomes included the FACT/GOG-NTX (Functional Assessment of Cancer Therapy/Gynecologic Oncology Group - Neurotoxicity) and patient acceptability and tolerability. Sixty patients completing the study were necessary to detect a 70% reduction in the odds of PNQ grade C or higher peripheral sensory neuropathy with 80% power.

RESULTS

Ninety-one patients were enrolled from January 2021 to October 2022; 69 were eligible for final analysis. Of the 91 patients, 64.8% were White, 30.8% were Black, and 1.1% were Hispanic or Latina. With successive cycles, more patients had sensory PNQ grade C or higher neuropathy on the control side compared with the cryocompression side. Cryocompression decreased the odds of sensory neuropathy (PNQ grade C or higher) by 46% at final visit (odds ratio 0.54, 95% CI 0.31-0.94; P =.03). There was no difference in tactile sensitivity based on the monofilament test between sides at the final visit. At the final visit, average FACT/GOG-NTX-11 (Functional Assessment of Cancer Therapy/Gynecologic Oncology Group - Neurotoxicity 11 Item Version) scores were significantly lower on the cryocompression than the control side (estimate -0.97, 95% CI -1.89 to -0.06; P =.04), as were FACT/GOG-NTX-4 (Functional Assessment of Cancer Therapy/Gynecologic Oncology Group - Neurotoxicity 4 Item Version) scores (estimate -0.35, 95% CI -0.64 to -0.05; P =.02). More than 85% of patients assessed the intervention as acceptable and tolerable.

CONCLUSIONS

Cryocompression therapy reduces subjective chemotherapy-induced peripheral sensory neuropathy in patients who are receiving paclitaxel or cisplatin for gynecologic cancer.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov , NCT04563130.

Precise diagnosis of breast phyllodes tumors using Raman spectroscopy: Biochemical fingerprint, tumor metabolism and possible mechanism

BACKGROUND

Breast fibroadenomas and phyllodes tumors are both fibroepithelial tumors with comparable histological characteristics. However, rapid and precise differential diagnosis is a tough point in clinical pathology. Given the tendency of phyllodes tumors to recur, the difficulty in differential diagnosis with fibroadenomas leads to the difficulty in optimal management for these patients.

METHOD

In this study, we used Raman spectroscopy to differentiate phyllodes tumors from breast fibroadenomas based on the biochemical and metabolic composition and develop a classification model. The model was validated by 5-fold cross-validation in the training set and tested in an independent test set. The potential metabolic differences between the two types of tumors observed in Raman spectroscopy were confirmed by targeted metabolomic analysis using liquid chromatography-tandem mass spectrometry (LC-MS/MS).

RESULTS

A total of 204 patients with formalin-fixed paraffin-embedded (FFPE) tissue samples, including 100 fibroadenomas and 104 phyllodes tumors were recruited from April 2014 to August 2021. All patients were randomly divided into the training cohort (n = 153) and the test cohort (n = 51). The Raman classification model could differentiate phyllodes tumor versus fibroadenoma with cross-validation accuracy, sensitivity, precision, and area under curve (AUC) of 85.58 % ± 1.77 %, 83.82 % ± 1.01 %, 87.65 % ± 4.22 %, and 93.18 % ± 1.98 %, respectively. When tested in the independent test set, it performed well with the test accuracy, sensitivity, specificity, and AUC of 83.50 %, 86.54 %, 80.39 %, and 90.71 %. Furthermore, the AUC was significantly higher for the Raman model than that for ultrasound (P = 0.0017) and frozen section diagnosis (P < 0.0001). When it came to much more difficult diagnosis between fibroadenoma and benign or small-size phyllodes tumor for pathological examination, the Raman model was capable of differentiating with AUC up to 97.45 % and 95.61 %, respectively. On the other hand, targeted metabolomic analysis, based on fresh-frozen tissue samples, confirmed the differential metabolites (including thymine, dihydrothymine, trans-4-hydroxy-l-proline, etc.) identified from Raman spectra between phyllodes tumor and fibroadenoma.

SIGNIFICANCE AND NOVELTY

In this study, we obtained the molecular information map of breast phyllodes tumors provided by Raman spectroscopy for the first time. We identified a novel Raman fingerprint signature with the potential to precisely characterize and distinguish phyllodes tumors from fibroadenoma as a quick and accurate diagnostic tool. Raman spectroscopy is expected to further guide the precise diagnosis and optimal treatment of breast fibroepithelial tumors in the future.

Radiographic assessment of unerupted permanent maxillary canines and their relationship to the phases of dentition in mixed dentition Spanish children: a retrospective cross-sectional study

PURPOSE

Evaluate if there is a significant association between the position and inclination of the unerupted maxillary canine measured on a panoramic radiograph, and their relationship to gender, age of the patient and stage of dentition.

METHODS

138 panoramic radiographs were examined for this retrospective cross-sectional investigation. Only patients living in Madrid, Spain with mixed dentition were included. These measurements were performed on radiographs, considering the inclination and position of the maxillary canines with regards to the midline, and height with respect to the occlusal plane. Spearman's correlation coefficient was used to analyze the relation among the canine angle and height. p < 0.05 was considered to be significant.

RESULTS

The prevalence of patients with an altered canine angle was 10%, while 43.5% had an apparently abnormal position (overlapping at least half of the adjacent lateral incisor root). No statistically significant association was found between these two variables. In 5% of the patients, the maxillary canine was with an anomalous angle and position. Significant differences were obtained when comparing canine height between children with ectopic canines and normal canines (p = 0.032).

CONCLUSION

No significant association was found between the position and inclination of the unerupted maxillary canine in our sample. Ectopic maxillary canines had a higher incidence in girls, although we did not find statistically significant differences between genders. We observed a higher prevalence of abnormal position and inclination of the permanent maxillary canine in early mixed dentition. Maxillary canines were significantly elevated, further from the occlusal plane, in children with ectopic canines.

Age-related changes in thromboelastography profiles in injured children

BACKGROUND

The role of age in mediating coagulation characteristics in injured children is not well defined. We hypothesize thromboelastography (TEG) profiles are unique across pediatric age groups.

METHODS

Consecutive trauma patients younger than 18 years from a Level I pediatric trauma center database from 2016 to 2020 with TEG obtained on arrival to the trauma bay were identified. Children were categorized by age according to the National Institute of Child Health and Human Development categories (infant, ≤1 year; toddler, 1-2 years; early childhood, 3-5 years; older childhood, 6-11 years; adolescent, 12-17 years). Thromboelastography values were compared across age groups using Kruskal-Wallis and Dunn's tests. Analysis of covariance was performed controlling for sex, Injury Severity Score (ISS), arrival Glasgow Coma Scale (GCS) score, shock, and mechanism of injury.

RESULTS

In total, 726 subjects were identified; 69% male, median (interquartile range [IQR]) ISS = 12 (5-25), and 83% had a blunt mechanism. On univariate analysis, there were significant differences in TEG α-angle ( p < 0.001), MA ( p = 0.004), and fibrinolysis 30 minutes after MA (LY30) ( p = 0.01) between groups. In post hoc tests, the infant group had significantly greater α-angle (median, 77; IQR, 71-79) and MA (median, 64; IQR, 59-70) compared with other groups, while the adolescent group had significantly lower α-angle (median, 71; IQR, 67-74), MA (median, 60; IQR, 56-64), and LY30 (median, 0.8; IQR, 0.2-1.9) compared with other groups. There were no significant differences between toddler, early childhood, and middle childhood groups. On multivariate analysis, the relationship between age group and TEG values (α-angle, MA, and LY30) persisted after controlling for sex, ISS, GCS, shock, and mechanism of injury.

CONCLUSION

Age-associated differences in TEG profiles across pediatric age groups exist. Further pediatric-specific research is required to assess whether the unique profiles at extremes of childhood translate to differential clinical outcomes or responses to therapies in injured children.

LEVEL OF EVIDENCE

Prognostic and Epidemiological; Level IV.

Identifying unfamiliar voices: Examining the system variables of sample duration and parade size

Voice identification parades can be unreliable due to the error-prone nature of earwitness responses. UK government guidelines recommend that voice parades should have nine voices, each played for 60 s. This makes parades resource-consuming to construct. In this article, we conducted two experiments to see if voice parade procedures could be simplified. In Experiment 1 (N = 271, 135 female), we investigated if reducing the duration of the voice samples on a nine-voice parade would negatively affect identification performance using both conventional logistic and signal detection approaches. In Experiment 2 (N = 270, 136 female), we first explored if the same sample duration conditions used in Experiment 1 would lead to different outcomes if we reduced the parade size to include only six voices. Following this, we pooled the data from both experiments to investigate the influence of target-position effects. The results show that 15-s sample durations result in statistically equivalent voice identification performance to the longer 60-s sample durations, but that the 30-s sample duration suffers in terms of overall signal sensitivity. This pattern of results was replicated using both a nine- and a six-voice parade. Performance on target-absent parades were at chance levels in both parade sizes, and response criteria were mostly liberal. In addition, unwanted position effects were present. The results provide initial evidence that the sample duration used in a voice parade may be reduced, but we argue that the guidelines recommending a parade with nine voices should be maintained to provide additional protection for a potentially innocent suspect given the low target-absent accuracy.

Nutritional intake in high-performance para athletes

OBJECTIVE

This study aimed to describe the eating habits of para-athletes who attended a specialized training center in Brazil.

METHODS

Participants were recruited from the Sports Training Center at the Universidade Federal de Minas Gerais, Brazil. Energy, macronutrient (expressed in absolute terms and relative to body weight), fiber, cholesterol, and micronutrient intakes were assessed via a food frequency questionnaire, based on intakes over the preceding 12 mo. Sociodemographic factors were assessed using a purpose-designed survey, which included self-reported weight and height. Differences in nutrient intake based on sex, age, body mass index, and sporting factors were evaluated.

RESULTS

A total of 30 para-athletes (in para athletics, para-powerlifting, para-swimming, and para-taekwondo) were included in the study. The median total energy intake was 4089 (2855-5829) kcal. The median consumption of carbohydrates, proteins, and fats was 512.3 (358.7-853.5), 184.5 (118.5-246.4), and 137.1 (96.8-189.5) g/d, respectively. Adolescent athletes had higher protein intakes than adult athletes (P = 0.02). Para-athletes with a longer sports career had lower consumption of fiber (P = 0.01) and thiamine (P = 0.02). Participants with a higher body mass index had higher intake of alcohol (P = 0.04) and monounsaturated fats (P = 0.01). Higher consumption of alcohol was also reported by older para-athletes (P = 0.02).

CONCLUSIONS

We identified a higher saturated fat intake in male than in female para-athletes as well as higher protein intake (g/kg) in younger compared with older athletes. In addition, sociodemographic characteristics influenced the dietary intake of some para-athletes, such as length of sports career, age, and income.

Comorbidity and risk factors of subsequent lower extremity amputation in patients diagnosed with diabetes in Saskatchewan, Canada

OBJECTIVE

Subsequent limb amputation (SLA) may be necessary due to disease progression, infection, or to aid prosthesis fit. SLA in Saskatchewan has increased 3.2% from 2006 to 2019 with minor SLA increasing 9.6% during that period. Diabetes affects a large proportion of patients who require SLA; however, the impact of additional comorbidities is not clear.

METHODS

First-episode subsequent lower extremity limb amputation (SLEA) cases with the presence/absence of diabetes, other comorbidities, and demographic characteristics from 2006-2019 were retrieved from Saskatchewan's Discharge Abstract Database. Logistic regression was performed to examine the magnitude of the odds of SLEA.

RESULTS

Among the 956 first-episode SLEA patients investigated, 78.8% were diagnosed with diabetes. Of these, 76.1% were male and 83.0% were aged 50 + years. Three comorbidities: renal failure (AOR = 1.9, 95% Cl 1.1 - 3.0), hypertension (AOR = 3.0, 95% Cl 2.0 - 4.5), and congestive heart failure (AOR = 2.0, 95% CI 1.2 - 3.2), conferred the highest odds of SLEA. The odds of SLEA is greatest for those aged 50-69 years, males, Registered Indians, and associated with a prolonged hospital stay.

DISCUSSION

These data are important as they may help medical providers identify patients at the highest risk of SLEA and target interventions to optimize outcomes.

Dental caries in the Myanmar population: Findings from the first national oral health survey in 2016-2017

OBJECTIVES

This study aimed to investigate the dental caries status of indicator age groups as mentioned in the WHO pathfinder methodology, compare caries experiences among those age groups according to gender and geographical location, and assess the association between dental caries and related risk factors in primary and permanent dentition.

METHODS

A sample of 5928 participants aged 6, 12, 15-18, 35-44 and 60-74 years were recruited from 21 selected townships in the first Myanmar national oral health survey. Clinical oral examinations and questionnaire-based surveys were conducted from December 2016 to January 2017.

RESULTS

The prevalence of dental caries in primary teeth was 85.3% with a mean dmft of 5.7 at age 6 years. The prevalence of dental caries in permanent teeth and mean DMFT were 36.5% and 0.8 at 12 years, 43.8% and 1.1 at 15-18 years, 64.7% and 3.0 at 35-44 years, and 93.6% and 11.5 at 60-74 years. Missing teeth were higher in 60-74-year-olds, with 27 participants being fully edentulous. There were significant differences in caries experiences between males and females aged 15-18, 35-44 and 60-74 years. In the adjusted logistic regression, consumption of sweets or candies three times or more a day showed significantly higher risks of dental caries in primary teeth. Age, gender, consumption of sweets or candies and consumption of sweet drinks were associated factors for dental caries in permanent teeth.

CONCLUSION

The findings from the first national oral health survey indicate that caries in primary teeth is an important oral health problem for Myanmar children. Tooth loss was also found to be a concern in the aging population. National oral health policies and strategies need to be developed to promote awareness and understanding of oral health, in particular the role of risk factors such as sugary foods and drinks in tooth decay in children and adults.

Nurses' experiences of perceiving violence and abuse of women in Saudi Arabia: A phenomenological study

AIM

To explore the practices, understanding, and experiences of nurses and nursing students about domestic violence and abuse in Saudi Arabia.

BACKGROUND

Domestic violence and abuse is a well-known public health issue and a clear violation of human rights resulting in detrimental effects on women's health.

INTRODUCTION

Societal and cultural barriers in Saudi Arabia limit women's rights and disclosure of violence within marriage and families, preventing access to health care and support. There are few reports of this phenomenon in Saudi Arabia.

METHODS

We used a hermeneutic phenomenological approach to acquire in-depth insights into nurses' perceptions and experiences regarding domestic violence and abuse. Eighteen nurses and student nurses were recruited from Riyadh, Saudi Arabia, using convenience sampling. Data were gathered between October 2017 and February 2018 through in-depth semistructured interviews, organized using NVivo 12 and analyzed manually to identify consistent themes. This study adhered to the consolidated criteria for reporting qualitative research.

FINDINGS

An overarching concept of "being disempowered" was identified, which was present at three levels: a lack of nurses' professional preparation, insufficient organizational structures and processes, and wider social and cultural components.

CONCLUSION

This study provides an in-depth account of nurses' practices, understanding, and experiences of domestic violence and abuse, highlighting the sensitivity and difficulties of addressing the problem in hospitals across Saudi Arabia and potentially other similar countries.

IMPLICATIONS

The study's findings will inform the development of nursing education and practice in Saudi Arabia, as well as pave the way toward formulating effective strategies with needed modifications in curriculum, organizations, policy, procedures, and laws.

[Holistic treatment of endometriosis]

BACKGROUND

The pain phenomena caused by endometriosis are manifold. In addition to nociceptive pain there is also a nociplastic reaction with central sensitization. Atypical symptoms, such as acyclic lower abdominal pain, radiating pain, nonspecific bladder and intestinal complaints or even depression increasingly occur in addition to the classical cyclic complaints, such as severe dysmenorrhea, cyclic lower abdominal pain, dyspareunia, dysuria and dyschezia. Due to the diffuse range of symptoms, affected patients often consult not just gynecologists but also specialists from other disciplines (internal medicine, gastroenterology, orthopedics, pain therapy, psychology etc.).

OBJECTIVE

The complexity of endometriosis is presented. The resulting approaches to multimodal interdisciplinary holistic treatment are described.

RESULTS

Interdisciplinary concepts should be involved in the optimal treatment of endometriosis patients along with hormonal and surgical treatment, mostly under the supervision of a gynecologist and pain management, dietary changes, psychological support and physiotherapeutic management should also be included. This article provides an overview of possible treatment strategies for chronic symptomatic endometriosis.

CONCLUSION

Based on multimodal treatment strategies and regarding the complex pathophysiological alterations of this disease, the complex complaints that significantly impair the quality of life of endometriosis patients can be greatly improved.

Metaplastic Breast Carcinoma: Clinicopathologic Features and Recurrence Score Results From a Population-based Database

OBJECTIVES

Metaplastic breast carcinoma (MBC) is a rare, aggressive form of cancer comprising epithelial and mesenchymal elements. The purpose of this study was to use population-based data to review the clinicopathologic, molecular features, and outcomes of MBC.

METHODS

Surveillance, Epidemiology, and End Results Program (SEER) data were used to identify MBC and invasive ductal carcinoma (IDC), no special type (NOS) between 2004 and 2015. Results from Oncotype DX's 21-gene assay linked to SEER registries were included for hormone receptor (HR)-positive tumors. χ 2 analysis was performed to determine the differences between MBC and IDC. Kaplan-Meier curves and multivariate Cox proportional hazards models were used for breast cancer specific death (BCSD).

RESULTS

Compared with IDC, NOS (n=509,864), MBC (n=3876) were more likely to present at an older age, be black, have negative lymph nodes, be >2 cm, grade 3, and triple negative (TN). All subtypes [HR-positive/human epidermal growth receptor 2 (HER2)-negative, HR-positive/HER2-positive, HR-negative/HER2-positive, and TN] had higher BCSD than IDC, NOS. 22.3% of MBC cases were HR-positive. HR-positive MBCs tested for a recurrence score (RS) 65% were high-risk compared with 16.8% of IDC, NOS. Within the MBC cohort, no significant differences in BCSD were identified with respect to different molecular subtypes. In a fully adjusted model, TN or HER2-positive status did not adversely affect BCSD compared with HR-positive MBC.

CONCLUSIONS

All molecular subtypes of MBC had a poorer prognosis compared with IDC, NOS. The different molecular subtypes of MBC did not affect the BCSD. HR-positive MBC patients had a significantly higher high-risk RS than IDC, NOS patients.

Small for gestational age at preterm birth identifies adverse neonatal outcomes more reliably than antenatal suspicion of fetal growth restriction

BACKGROUND

Fetal growth restriction (FGR) is an important reason for premature delivery and a leading cause of perinatal morbidity and mortality. We aimed to evaluate whether classification as small for gestational age (SGA; <10th centile) at birth or antenatal suspicion of FGR was more strongly associated with neonatal morbidity and mortality in preterm infants.

METHODS

A retrospective audit of infants born between 24 + 0 and 32 + 6 weeks of gestation from 2012-2019 and admitted to the Neonatal Unit at Mercy Hospital for Women (MHW). Infants were categorized according to whether FGR was listed as an antenatal complication in the medical records and whether they were SGA (<10th centile on Fenton chart) or appropriate for gestational age (AGA) at birth, and comparisons for neonatal outcomes were made.

RESULTS

371/2126 preterm infants (17.5%) had antenatal suspicion of FGR, and 166 (7.8%) were SGA at birth. No differences in any neonatal outcomes were found between infants with or without suspected FGR, except decreased intraventricular hemorrhage (IVH) in the FGR group. SGA classification was associated with increased rates of all morbidities other than IVH, including bronchopulmonary dysplasia, retinopathy of prematurity, and necrotizing enterocolitis, compared with the AGA group. Death was significantly higher in the SGA group (7.2%) compared with the AGA group (3.5%).

CONCLUSION

SGA by Fenton chart more reliably identified neonates at risk of adverse neonatal outcomes than antenatal suspicion of FGR, suggesting it is a reasonable clinical proxy. This most likely reflects the much lower tenth centile weight cutoffs on the Fenton charts compared to in-utero charts used antenatally to diagnose FGR based on ultrasound estimated fetal weight. SGA classification by Fenton approximately equates to <3rd centile on in-utero charts at our institution, therefore identifying the most severe FGR cases.

Association of fat mass and fat-free mass with all-cause and cause-specific mortality in Asian individuals: A prospective cohort study

OBJECTIVE

The study's objective was to investigate the association of fat mass index (FMI) and fat-free mass index (FFMI) with all-cause mortality and cause-specific mortality in the Chinese population.

METHODS

A total of 422,430 participants (48.1% men and 51.9% women) from the Taiwan MJ Cohort with an average follow-up of 9 years were included.

RESULTS

The lowest (Q1) and highest (Q5) quintiles of FMI and FFMI were associated with increased all-cause mortality. Compared with those in the third quintile (Q3) group of FMI, participants in Q1 and Q5 groups of FMI had hazard ratios and 95% CI of 1.32 (1.24-1.40) and 1.13 (1.06-1.20), respectively. Similarly, compared with those in Q3 group of FFMI, people in Q1 and Q5 groups of FFMI had hazard ratios of 1.14 (1.06-1.23) and 1.16 (1.10-1.23), respectively. In the restricted cubic spline models, both FMI and FFMI showed a J-shaped association with all-cause mortality. People in Q5 group of FFMI had a hazard ratio of 0.72 (0.58-0.89) for respiratory disease.

CONCLUSIONS

The mortality risk increases in those with excessively high or low FMI and FFMI, yet the associations between FMI, FFMI, and the risk of death varied across subgroups and causes of death.

Developing Leaders and Fighting Burnout: An Interview With Sharon Pappas

This year, Sharon Pappas, PhD, RN, NEA-BC, FAAN, Chief Nurse Executive (CNE) at Emory Healthcare (EHC), Atlanta, Georgia, received the American Organization for Nursing Leadership (AONL) prestigious Lifetime Achievement Award, which honors an AONL member recognized by the nursing community as a significant leader in the nursing profession and who has served AONL in an important leadership capacity. As CNE of Georgia's largest healthcare system, she leads and supports a Magnet® nursing culture across EHC, with the goal of achieving Magnet designation for the entire EHC system. Dr Pappas was commended for her leadership in leading the EHC incident command during COVID-19 where she focused on providing exceptional patient care and supporting clinical nurses caring for critically ill patients.

Use of the Heterosexist Harassment, Rejection, and Discrimination Scale With Different Sexual Orientation, Gender, and Racial/Ethnic Groups: An Examination of Measurement Invariance

The Heterosexist Harassment, Rejection, and Discrimination Scale (HHRDS) is one of the most commonly used measures of sexual orientation-related discrimination, but little is known about its psychometric properties across different sexual orientations, gender, and racial/ethnic groups. A three-factor model was initially obtained, but most studies treat the HHRDS unidimensionally. Therefore, we tested whether the HHRDS exhibited measurement invariance across sexual orientation, gender, and racial/ethnic groups among 792 sexual minority young adults (aged 18-29) who participated in an online study. Across models, the three-factor solution fit better than the one-factor solution. All models achieved configural invariance and most achieved metric invariance; none of the considered models achieved scalar invariance (1-3 items were not equivalent across groups, depending on the comparison). Findings suggest that the HHRDS generally functions equivalently across sexual orientation, gender, and racial/ethnic groups, but some caution in interpreting scores is warranted.

Trends in the prevalence of intellectual disability among children in Taiwan

BACKGROUND

Intellectual disability (ID) is a major developmental disability. However, data on changes in the prevalence over time at the national level are limited.

METHOD

Using data from the national disability registry, we conducted an ecological study to evaluate the time trends of ID among children in Taiwan. We calculated the prevalence of ID by age, sex and severity, from 2000 to 2011, and assessed the time trends.

RESULTS

During the study period, the overall prevalence of ID in children aged 3-17 years increased from 3.60 to 5.91 per 1000 (β = 0.22, P < 0.001, r2  = 0.97). The prevalence of mild ID (MID, intelligence quotient: 50-69) increased from 1.30 to 3.60 per 1000 (β = 0.21, P < 0.001, r2  = 0.98). However, the prevalence of severe ID (SID, intelligence quotient: <50) was relatively constant, between 2.22 and 2.38 per 1000 (β = 0.01, P = 0.076, r2  = 0.96). Boys had a higher prevalence than girls, and the average boy-to-girl prevalence ratio was 1.42 for MID and 1.31 for SID. The boy-to-girl prevalence ratios of MID and SID decreased over time (β = -0.01, P < 0.001, r2  = 0.99 for MID; β = -0.01, P < 0.001, r2  = 1.00 for SID).

CONCLUSION

The prevalence of ID in Taiwanese children increased from 2000 to 2011 and was largely attributable to increases in MID. Boys had a higher prevalence of ID and were more likely to have MID.

Individual, interpersonal and environmental correlates of sedentary behaviours in adults with intellectual disabilities

BACKGROUND

Sedentary behaviours have adverse health outcomes and adults with intellectual disabilities are at a higher risk of unhealthy lifestyle behaviours. The lack of knowledge relating to sedentary behaviours in adults with intellectual disabilities has impeded the development of effective interventions. This study aimed to investigate individual, interpersonal and environmental correlates that are associated with sedentary behaviours in adults with intellectual disabilities.

METHOD

A secondary analysis of data from The UK Household Longitudinal Study (Understanding Society; collected 2011-2013) was conducted. Twenty-two predictor variables were included in a stepwise logistic regression, with TV hours during weekdays (≤3 and >3 h/day) used as a proxy for sedentary behaviours. A sample of 266 adults, with mean age of 37.9 and range from 18 to 49 years old, with intellectual disabilities were identified. Because 63.9% were female, 62.4% had children and 28.2% were employed, the sample is likely to be most representative of more able adults with intellectual disabilities.

RESULTS

A significant interaction term between having children and neighbourhood status was found in the initial model so separate models for good and poor-quality neighbourhoods are reported. Having children only had a significant effect to lower the odds of high TV time among participants living in good quality neighbourhoods (OR 0.10, 95% CI 0.03, 0.25). However, for people living in poor quality neighbourhoods it was better quality leisure services that was associated with lower odds of high TV time (OR 0.48, 95% CI 0.23, 0.90). Being employed only significantly reduced the odds of high TV time in the good quality neighbourhood model (OR 0.35, 95% CI 0.12, 0.78). These effects highlight the importance of environmental effects on lifestyle behaviours of adults with intellectual disabilities.

CONCLUSIONS

Future research should aim to expand our understanding of environmental effects on the sedentary behaviours and other lifestyle behaviours of adults with intellectual disabilities.

Trimester-specific reference intervals for thyroid function parameters in pregnant Caucasian women using Roche platforms: a prospective study

BACKGROUND

Standard thyroid function parameters reference intervals (RI) are unsuitable during pregnancy, potentially resulting in incongruous treatments that may cause adverse effects on pregnancy outcomes. We aimed at defining trimester-specific TSH, FT4 and FT3 RI, using samples longitudinally collected from healthy Caucasian women.

MATERIALS AND METHODS

Blood samples from 150 healthy Caucasian women, who had a physiological gestation and a healthy newborn at term, were collected in each trimester and at around six months post-partum. They showed mild iodine deficiency. After excluding women with overt TSH abnormalities (> 10 mU/L) and/or TPO antibodies, data from 139 pregnant women were analyzed by means of widely used Roche platforms, and TSH, FT4 and FT3 trimester-specific RI were calculated. Post-partum data were available for 55 subjects.

RESULTS

Serum TSH RI were 0.34-3.81 mU/L in the first trimester, and changed slightly to 0.68-4.07 U/L and 0.63-4.00 mU/L in the second and third trimester, respectively. Conversely, both FT4 and FT3 concentrations progressively decreased during pregnancy, the median values in the third trimester being 14.8% and 13.2% lower, respectively, than in the first trimester. Thyroid function parameters in the first trimester were similar to those measured after the end of pregnancy.

CONCLUSIONS

This study calculates trimester-specific RI for thyroid function parameters in pregnancy, and proposes the reference limits that should be adopted when using Roche platforms in Caucasian women.

Turnbull-Cutait Pull-Through Procedure Is an Alternative to Permanent Ostomy in Patients With Complex Pelvic Fistulas

BACKGROUND

A permanent stoma is frequently recommended in the setting of complex or recurrent rectovaginal fistulas because of the high failure rate of reconstructive procedures. The Turnbull-Cutait pull-through procedure is a salvage operation for motivated patients desiring to avoid permanent fecal diversion.

OBJECTIVE

To analyze the cure rates of complex rectovaginal fistulas after the Turnbull-Cutait pull-through procedure based on cause.

DESIGN

After the institutional review approval board, a retrospective review of women who underwent the procedure (1993-2018) for a rectovaginal fistula was conducted. Patients' demographics, cause, and postoperative outcomes were analyzed.

SETTING

Colorectal surgery department at a tertiary center in the United States.

PATIENTS

Adult women with a rectovaginal fistula who underwent a colonic pull-through procedure were included.

MAIN OUTCOME MEASURES

Recurrence after the colonic pull-through procedure.

RESULTS

There were 81 patients who underwent colonic pull-through; of those, 26 patients had a rectovaginal fistula, had a median age of 51 (43-57) years, and had a mean BMI of 28 ± 3.2 kg/m 2 . A total of 4 patients (15%) had a recurrence and 85% of the patients healed. Ninety-three percent of the patients healed after the prior anastomotic leak. Patients with a Crohn's disease-related fistula had a 75% cure rate. The Kaplan-Meier analysis showed a cumulative incidence of recurrence of 8% (95% CI, 0%-8%) within 6 months after surgery and 12% at 12 months.

LIMITATIONS

Retrospective design.

CONCLUSIONS

The Turnbull-Cutait pull-through procedure may be the last option to preserve intestinal continuity and successfully treat rectovaginal fistulas in 85% of cases.

EL PROCEDIMIENTO PULLTHROUGH DE TURNBULLCUTAIT ES UNA ALTERNATIVA A LA OSTOMA PERMANENTE EN PACIENTES CON FSTULAS PLVICAS COMPLEJAS

ANTECEDENTES:Con frecuencia se recomienda un estoma permanente en el contexto de una fístula rectovaginal compleja o recurrente debido a la alta tasa de fracaso de los procedimientos reconstructivos. El procedimiento de extracción de Turnbull-Cutait es una operación de rescate para pacientes motivados que desean evitar la desviación fecal permanente.OBJETIVO:Analizar las tasas de curación de la fístula rectovaginal compleja después del procedimiento de extracción de Turnbull-Cutait según la etiología.DISEÑO:Después de la junta de aprobación de revisión institucional, se realizó una revisión retrospectiva de mujeres que se sometieron a un procedimiento (1993-2018) por fístula rectovaginal. Se analizaron los datos demográficos, la etiología y los resultados posoperatorios de los pacientes.AJUSTE:Departamento de cirugía colorrectal en un centro terciario en los Estados Unidos.PACIENTES:Mujeres adultas con fístula rectovaginal que se sometieron a extracción del colon.RESULTADO PRINCIPAL:recurrencia después de la extracción del colon.RESULTADOS:Hubo 81 pacientes que tenían extracción colónica, de esas 26 fístulas rectovaginales con una mediana de edad de 51 (43 - 57) años, y un índice de masa corporal promedio de 28 ± 3,2 kg/m2. Un total de 4 (15%) pacientes tuvieron una recurrencia y el 85% de los pacientes se curaron. El noventa y tres por ciento de los pacientes se curaron después de la fuga anastomótica previa. Los pacientes con fístula relacionada con EC tuvieron una tasa de curación del 75%. El análisis de Kaplan Meier mostró una incidencia acumulada de recurrencia del 8% [95% intervalo de confianza 0%-18%] dentro de los 6 meses posteriores a la cirugía y del 12% a los 12 meses.LIMITACIONES:Diseño retrospectivo.CONCLUSIONES:El procedimiento de extracción de Turnbull-Cutait puede ser la última opción que se puede ofrecer para preservar la continuidad intestinal y tratar la fístula rectovaginal con éxito en el 85% de los casos. (Traducción-Yesenia.Rojas-Khalil).

Comparison of Olympic-Style Weightlifting Performances of Elite Athletes: Scaling Models Account for Body Mass

PURPOSE

We developed a scale for comparison of performances by weightlifters of different body mass and compare this scaling formula to current systems.

METHODS

Data from Olympics and World and Continental Championships from 2017 to 2021 were obtained; results from athletes with doping violations were excluded, resulting in performances from 1900 athletes from 150 countries for use in analysis. Functional relationships between performance and body mass were explored by testing various transformations of body mass in the form of fractional polynomials that include a wide range of nonlinear relationships. These transformations were evaluated in quantile regression models to determine the best fit, examine sex differences, and distinguish fits for different performance levels (90th, 75th, and 50th percentiles).

RESULTS

The resulting model used a transformation of body mass with powers -2 and 2 for males and females and was used to specify a scaling formula. The small percentage deviations between modeled and actual performances confirm the high accuracy of the model. In the subset of medalists, scaled performances were comparable across different body masses, whereas both Sinclair and Robi scalings, currently used in competitions, were more variable. The curves had similar shapes for the 90th and 75th percentile levels but were less steep for the 50th percentile.

CONCLUSIONS

The scaling formula we derived to compare weightlifting performances across a range of body mass can easily be implemented in the competition software to determine the overall best lifters. This is an improvement over current methods that do not accurately account for differences in body mass and result in bias or yield large variations even with small differences in body mass despite identical performances.

Completion of Fetal Anatomy Evaluations in Women With Body Mass Index ≥ 50 kg/m2

OBJECTIVES

As maternal body mass index (BMI) increases, fetal anatomy ultrasound becomes more challenging, less sensitive, and less likely to be complete. We sought to report our experience of incomplete evaluation of anatomy in patients with BMI of 50 kg/m2 or greater.

METHODS

This is a retrospective cohort of singleton gestations in mothers with BMI of 50 kg/m2 or greater, undergoing anatomy evaluations between 2017 and 2021 at 9 maternal-fetal-medicine sites in Houston, TX. Patient variables and scan results were collected throughout pregnancy to provide a longitudinal assessment of the primary outcome, completion rate (percent of all scans which optimally captured 24 American Institute of Ultrasound in Medicine-recommended images). Secondary outcomes included the rate of optimal capture of each individual structure.

RESULTS

In total, 293 patients with BMI ≥50 kg/m2 were identified. Only 28% of initial scans were complete, but over the entire pregnancy, a complete anatomic evaluation was achieved in 76% of women, largely due to weekly ultrasounds done for antenatal testing later in pregnancy. Neither BMI, placental location, nor amniotic fluid volume affected completion rate. The most difficult views are the outflow tracts, 4-chamber view, and spine.

CONCLUSIONS

One quarter of women with BMI of 50 kg/m2 or greater will not have a complete fetal anatomic evaluation by the end of pregnancy, since even basic fetal anatomic views are technically challenging to complete. Solutions deserve further attention, and may include first trimester imaging, transvaginal imaging, and optimization of ultrasound machine settings.

Cleft Lip and Cleft Palate: Time to Include Orofacial Ultrasound Markers Into the First-Trimester Anatomy Scan?

Orofacial clefts are one of the most common congenital malformations. The prenatal diagnosis is often made in the second trimester of pregnancy as result of ultrasound examination of the midface on coronal and axial planes. However, the diagnosis in the first trimester is elusive due to the small size of the facial structures and technical limitations present at this early gestational age. In this Commentary, we suggest the routine systematic ultrasound identification of easy-to-obtain landmarks to improve the detection of cleft lip and cleft palate in the first trimester. These include, but are not limited to, visualization of the primary palate using the coronal plane of the face looking for disruption at the base of the retronasal triangle, and visualization of the palate using the sagittal plane looking for the maxillary gap and loss of the superimposed line. Early prenatal detection of orofacial clefts would allow a more detailed search for associated chromosomal anomalies or genetic syndromes.

Adherence, Safety, and Feasibility of HIV Pre-Exposure Prophylaxis Among Adolescent Men Who Have Sex With Men and Transgender Women in Brazil (PrEP1519 Study)

PURPOSE

To evaluate the adherence, safety, and feasibility of pre-exposure prophylaxis (PrEP) in real-world settings among adolescent men who have sex with men (AMSM) and transgender women (ATGW).

METHODS

PrEP1519 is a single-arm, multicentric demonstration cohort study of daily oral PrEP among AMSM and ATGW aged 15 to 19 years in Brazil. Study visits occurred at baseline, weeks 4, 12, and then quarterly until 96 weeks. Descriptive statistics and a mixed logistic model for longitudinal data evaluated the factors associated with high adherence.

RESULTS

One thousand sixteen AMSM and ATGW accessed the PrEP1519 clinics. Of those, 998 (98.2%) underwent clinical triage. Forty one were diagnosed with human immunodeficiency viruses (HIV) at baseline (4.0%) and 79 (7.9%) were not eligible for PrEP. Of the 878, 795 (90.5%) enrolled in PrEP, 82 (10.3%) were lost to follow-up, and 713 were included. There was no significant decrease in creatinine clearance; only two participants had grade-III aspartate aminotransferase elevation. Incident HIV infection occurred in eight participants (incidence rate [IR] = 1.64 per 100 person-years [PY]): two in 15-17 years (IR = 2.24 per 100 PY) and six in 18-20 years (IR = 1.51 per 100 PY). PrEP adherence was higher among those with more years of schooling, those reporting no difficulties in PrEP use due to side effects, and who had low HIV risk perception in the past three months.

DISCUSSION

PrEP for AMSM and ATGW was safe and feasible in real-world settings. However, a higher IR among young adolescents and a higher adherence among less vulnerable people indicate the need for greater care, considering the specificities of this age group.

Incidence and risk factors for anxiety disorders in young adults: A population-based prospective cohort study

Anxiety disorders are among the most common psychiatric disorders in the general population. Our objective was to describe the cumulative incidence and risk factors of anxiety disorders, including obsessive-compulsive disorder (OCD) and posttraumatic stress disorder (PTSD), in a follow-up of young adults over a five-year period. This is a prospective cohort conducted in two waves. The first took place from 2007 to 2009, in which 1,560 young adults aged between 18 and 24 years were evaluated using the Mini-International Neuropsychiatric Interview (MINI). Subjects were invited to participate in the second wave, which wave took place from 2012 to 2014, where 1,244 young adults were evaluated using the MINI-Plus. Our findings showed a cumulative incidence of 10.9% for any anxiety disorder, 6.5% for generalized anxiety disorder, 6.0% for agoraphobia, 2.0% for OCD, 1.6% for panic disorder, 1.1% for social anxiety and 0.7% for PTSD. Being female and having had a depressive episode were risk factors to develop any anxiety disorder. We observed a high cumulative incidence of anxiety disorders in a population-based sample of young adults. Our data highlights the importance of the early identification of these disorders as this could lead to early illness detection, early illness management and a reduced burden of disease.

Changes in Perception of Cure Among Patients With Genitourinary Cancers Initiating Immune Checkpoint Inhibitors: A Longitudinal Study

BACKGROUND

We explored changes in perceptions of cure among patients with genitourinary (GU) cancers starting Immune checkpoint inhibitors (ICIs) therapy.

MATERIALS AND METHODS

This longitudinal study assessed patients before starting therapy and 3-months later with a questionnaire that included patient perceptions of ICIs and the Patient-Reported Outcomes Measurement Information System (PROMIS) Anxiety scale. General linear modeling was used to investigate changes in expectation of cure over time, and chi-square tests were used to determine the association between expectation of cure and perceptions of ICIs and anxiety.

RESULTS

A total of 45 patients were recruited (73% male, 84% diagnosed with renal cell carcinoma). The proportion of patients who possessed an accurate expectation of cure increased over time (55.6%-66.7%, P = .001). An accurate expectation of cure was associated with lower rates of anxiety over time. Patients with inaccurate expectation of cure reported more severe side effects and worse self-reported ECOG score at the follow-up assessment (P = .04).

CONCLUSION

We found that patients with GU metastatic cancer treated with ICI therapy have increasingly accurate expectations of cure over time. Accurate expectation of cure is associated with decreased anxiety. Further research is needed to fully explore this dynamic over time and help inform interventions that can help patients develop accurate expectations.

[Discrimination, stigma and identity: A literature review]

OBJECTIVE

This study aimed to update the scientific knowledge concerning the relationship between discrimination, stigma and self-concept.

METHODS

A review was conducted and allowed to include 15 peer-reviewed articles for qualitative analysis, consisting of 13 unique samples (n=2830; Mage=37.6). The search was conducted on Pubmed and PsychInfo following this research protocol: "de stigmatization" ([Title/Abstract] or "destigmatization" [Title/Abstract] or "self-stigma" [Title/Abstract] or "Perceived stigma" [Title/Abstract] or "anticipated discrimination" [Title/Abstract] or "experienced discrimination" [Title/Abstract]) and (identi*[Title] or "self-concept" [Title]). The search resulted in 43 articles, plus three articles identified from other sources. Thirty-one articles were excluded because they did not align with the aim of the review.

RESULTS

Among the 15 articles included, there were 11 quantitative studies, two qualitative studies, one literature review and one theoretical article. The stigma was related to a mental disorder (n=8), a physiological or ethnic difference (n=5) or sexual orientation and gender identity (n=2). Among the 11 quantitative studies based on unique samples, all included both males and females (n=2616; Mage=36.7; 61.1% of women). Four studies established a significant impact of perceived stigma on social identity. This impact was negative when there was at least one other parallel social identity perceived favorably by the individual, and positive otherwise. In two studies, this impact was moderated by the importance of the stigmatized social identity in the self-concept. In one study, social identity was correlated to psychological distress. The sign, positive or negative, of this correlation depended on self-stigma. When self-stigma was high (i.e., self-concept is strongly perceived through the prism of negative stereotypes associated with the social identity), then social identity was positively associated with psychological distress. Otherwise, the sign of this association was negative. In one study, four distinct variables were predictors of suicidal ideation: experienced discrimination, perceived stigma, anticipated discrimination and self-stigma. Experienced discrimination predicted suicidal ideation through anticipatory discrimination and self-stigma; and perceived stigma predicted suicidal ideation through anticipated discrimination. Self-stigma and anticipatory discrimination predicted suicidal ideation at the same level.

CONCLUSIONS

The results suggest that a key variable to address in order to reduce the negative consequences of discrimination and stigmatization is self-stigma, i.e., the fact of conceiving the self-concept through the filter of the negative stereotypes associated with the characteristic perceived as discriminated. The altered self-concept should therefore be a main transnosographic diagnostic and therapeutic target. An easy-to-use proxy to detect the altered self-concept is the propensity to feel the emotion of shame, which is correlated to self-stigma.

Pentobarbital coma for management of intracranial hypertension following traumatic brain injury: Lack of early response to treatment portends poor outcomes

INTRODUCTION

Traumatic brain injury (TBI) results in the death of over 50,000 and the permanent disability of 80,000 individuals annually in the United States. Much of the permanent disability is the result of secondary brain injury from intracranial hypertension (ICH). Pentobarbital coma is often instituted following the failure of osmotic interventions and sedation to control intracranial pressure (ICP). The goal of this study was to evaluate the efficacy of pentobarbital coma with respect to ICP management and long-term functional outcome.

METHODS

Traumatic brain injury patients who underwent pentobarbital coma at a level 1 trauma center between 2014 and 2021 were identified. Patient demographics, injury characteristics, Glasgow Coma Scale (GCS) scores, intracranial pressures (ICPs), and outcomes were obtained from the trauma registry as well as inpatient and outpatient medical records. The proportion of ICPs below 20 for each hospitalized patient-day was calculated. The primary outcome measured was GCS score at the last follow-up visit.

RESULTS

25 patients were identified, and the majority were male (n ​= ​23, 92%) with an average age of 30.0 years ​± ​12.9 and median injury severity score of 30 (21.5-33.5). ICPs were monitored for all patients with a median of 464 (326-1034) measurements. The average hospital stay was 16.9 days ​± ​11.5 and intensive care stay was 16.9 ​± ​10.8 days. 9 (36.0%) patients survived to hospital discharge. Mean follow-up time in months was 36.9 ​± ​28.0 (min-max 3-80). 7 of the 9 surviving patients presented as GCS 15 on follow-up and the remaining were both GCS 9. Patients presenting at last follow-up with GCS 15 had a significantly higher proportion of controlled ICPs throughout their hospitalization compared to patients who expired or with follow-up GCS <15 (GCS 15: 88% ​± ​10% vs. GCS <15 or dead: 68% ​± ​22%, P ​= ​0.006). A comparison of the daily proportion of controlled ICPs by group revealed negligible differences prior to pentobarbital initiation. Groups diverged nearly immediately upon pentobarbital coma initiation with a higher proportion of controlled ICPs for patients with follow-up GCS of 15.

CONCLUSION

Patients that do not have an immediate response to pentobarbital coma therapy for ICH universally had poor outcomes. Alternative therapy or earlier palliation should be considered for such patients. In contrast, patients whose ICPs responded quickly to pentobarbital had excellent long-term outcomes.

Placental fetal vascular malperfusion, neonatal neurologic morbidity, and infant neurodevelopmental outcomes: a systematic review and meta-analysis

OBJECTIVE

This study aimed to evaluate the association of placental fetal vascular malperfusion lesions with neonatal brain injury and adverse infant neurodevelopmental outcomes.

DATA SOURCES

PubMed and Medline, Scopus, and Cochrane databases were searched from inception to July 2022.

STUDY ELIGIBILITY CRITERIA

We included cohort and case-control studies reporting the associations of fetal vascular malperfusion lesions with neonatal encephalopathy, perinatal stroke, intracranial hemorrhage, periventricular leukomalacia, and infant neurodevelopmental and cognitive outcomes.

METHODS

Data were analyzed by including fetal vascular malperfusion lesions as an exposure variable and brain injuries or neurodevelopmental impairment as outcomes using random-effects models. The effect of moderators, such as gestational age or study type, was assessed by subgroup analysis. Study quality and risk of bias were assessed by applying the Observational Study Quality Evaluation method.

RESULTS

Out of the 1115 identified articles, 26 were selected for quantitative analysis. The rates of neonatal central nervous system injury (neonatal encephalopathy or perinatal stroke) in term or near-term infants were more common among fetal vascular malperfusion cases (n=145) than among controls (n=1623) (odds ratio, 4.00; 95% confidence interval, 2.72-5.90). In premature deliveries, fetal vascular malperfusion lesions did not influence the risk of intracranial hemorrhage or periventricular leukomalacia (odds ratio, 1.40; 95% confidence interval, 0.90-2.18). Fetal vascular malperfusion-associated risk of abnormal infant neurodevelopmental outcome (314 fetal vascular malperfusion cases and 1329 controls) was modulated by gestational age being higher in term infants (odds ratio, 5.02; 95% confidence interval, 1.59-15.91) than in preterm infants (odds ratio, 1.70; 95% confidence interval, 1.13-2.56). Abnormal infant cognitive development and mental development were more common among fetal vascular malperfusion cases (n=241) than among controls (n=2477) (odds ratio, 2.14; 95% confidence interval, 1.40-3.27). The type of study (cohort vs case-control) did not influence the association between fetal vascular malperfusion and subsequent infant brain injury or abnormal neurodevelopmental outcome.

CONCLUSION

The findings of cohort and case-control studies indicate a considerable association between fetal vascular malperfusion placental lesions and increased risk of brain injury in term neonates, and neurodevelopmental impairment in both term and preterm infants. A diagnosis of placental fetal vascular malperfusion should be taken into consideration by both pediatricians and neurologists during the follow-up of infants at risk of adverse neurodevelopmental outcomes.

Glycemic control and neonatal outcomes in twin pregnancies with gestational diabetes mellitus

BACKGROUND

Preliminary data suggest that strict glycemic control in twin pregnancies with gestational diabetes mellitus may not improve outcomes but might increase the risk of fetal growth restriction.

OBJECTIVE

This study aimed to investigate the association of maternal glycemic control with the risk of gestational diabetes mellitus-related complications and small for gestational age in twin pregnancies complicated by gestational diabetes mellitus.

STUDY DESIGN

This was a retrospective cohort study of all patients with a twin pregnancy complicated by gestational diabetes mellitus in a single tertiary center between 2011 and 2020, and a matched control group of patients with a twin pregnancy without gestational diabetes mellitus in a 1:3 ratio. The exposure was the level of glycemic control, described as the proportion of fasting, postprandial, and overall glucose values within target. Good glycemic control was defined as a proportion of values within target above the 50th percentile. The first coprimary outcome was a composite variable of neonatal morbidity, defined as at least 1 of the following: birthweight >90th centile for gestational age, hypoglycemia requiring treatment, jaundice requiring phototherapy, birth trauma, or admission to the neonatal intensive care unit at term. A second coprimary outcome was small for gestational age, defined as birthweight <10th centile or <3rd centile for gestational age. Associations between the level of glycemic control and the study outcomes were estimated using logistic regression analysis and were expressed as adjusted odds ratio with 95% confidence interval.

RESULTS

A total of 105 patients with gestational diabetes mellitus in a twin pregnancy met the study criteria. The overall rate of the primary outcome was 32.4% (34/105), and the overall proportion of pregnancies with a small for gestational age newborn at birth was 43.8% (46/105). Good glycemic control was not associated with a reduction in the risk of composite neonatal morbidity when compared with suboptimal glycemic control (32.1% vs 32.7%; adjusted odds ratio, 2.06 [95% confidence interval, 0.77-5.49]). However, good glycemic control was associated with higher odds of small for gestational age compared with nongestational diabetes mellitus pregnancies, especially in the subgroup of diet-treated gestational diabetes mellitus (65.5% vs 34.0%, respectively; adjusted odds ratio, 4.17 [95% confidence interval, 1.74-10.01] for small for gestational age <10th centile; and 24.1% vs 7.0%, respectively; adjusted odds ratio, 3.97 [95% confidence interval, 1.42-11.10] for small for gestational age <3rd centile). In contrast, the rate of small for gestational age in gestational diabetes mellitus pregnancies with suboptimal control was not considerably different when compared with non-gestational diabetes mellitus pregnancies. In addition, in cases of diet-treated gestational diabetes mellitus, good glycemic control was associated with a left-shift of the distribution of birthweight centiles, whereas the distribution of birthweight centiles among gestational diabetes mellitus pregnancies with suboptimal control was similar to that of nongestational diabetes mellitus pregnancies.

CONCLUSION

In patients with gestational diabetes mellitus in a twin pregnancy, good glycemic control is not associated with a reduction in the risk of gestational diabetes mellitus-related complications but may increase the risk of a small for gestational age newborn in the subgroup of patients with mild (diet-treated) gestational diabetes mellitus. These findings further question whether the gestational diabetes mellitus glycemic targets used in singleton pregnancies also apply to twin pregnancies and support the concern that applying the same diagnostic criteria and glycemic targets in twin pregnancies may result in overdiagnosis and overtreatment of gestational diabetes mellitus and potential neonatal harm.

Is magnesium sulfate therapy warranted in all cases of late postpartum severe hypertension? A suggested approach to a clinical conundrum

Magnesium sulfate reduces the risk for eclamptic seizures antepartum, intrapartum, and in the immediate postpartum period, however, there are no studies that have evaluated the benefits and risks of magnesium sulfate among women with late postpartum severe hypertension only. Juxtaposed on this clinical uncertainty is the increased incidence of severe hypertension owing to a rise in pregnancies complicated by advanced maternal age, obesity, chronic hypertension, diabetes, and recent protocols for intensive monitoring of blood pressure in the postpartum period. These factors have led to a significant increase in postpartum presentations for the evaluation and management of severe hypertension, in some cases leading to postpartum readmissions for administration of antihypertensive therapy and magnesium sulfate without data demonstrating clear clinical benefit. Postpartum readmissions can have several negative consequences, including interfering with early bonding with a newborn, breastfeeding, and use of scarce healthcare resources. In addition, magnesium sulfate is associated with risks for serious cardiorespiratory depression and bothersome side effects and can delay determining the optimal antihypertensive regimen, which is typically the most pressing clinical need during postpartum presentations of late-postpartum severe hypertension. Eclampsia that occurs more than 48 hours after delivery is rare (constitutes 16% of all cases of eclampsia) and is most commonly preceded by headaches or other cerebral symptoms. In this commentary, we propose an approach to evaluating and managing patients with late postpartum severe hypertension aimed at identifying those women at highest risk for end-organ injury. We recommend that the short- and long-term focus for all patients with severe hypertension should be the optimal management of blood pressures with a goal of close outpatient monitoring when logistically feasible and clinically appropriate. We suggest reserving magnesium sulfate therapy for the subset of patients with neurologic symptoms who may be at highest risk for an eclamptic seizure.

Is chronotype linked with adherence to the Mediterranean diet among adolescents? The EHDLA study

BACKGROUND

No previous study has evaluated the relationship between chronotype and adherence to the Mediterranean diet among adolescents. The aim of the present study was to assess the association between chronotype and adherence to the Mediterranean diet in a sample of Spanish adolescents aged 12-17 years.

METHODS

This study examined secondary data from 820 adolescents (55.5% girls) from the Eating Healthy and Daily Life Activities (EHDLA) study, which included a representative sample of adolescents aged 12-17 years from the Valle de Ricote (Region of Murcia, Spain). Adolescents' chronotype was evaluated with the Morningness/Eveningness Scale in Children. Adherence to the Mediterranean diet was determined through the Mediterranean Diet Quality Index for Children and Teenagers.

RESULTS

The proportion of adolescents with an optimal Mediterranean diet was 37.6%. In relation to chronotype, we found that 24.5%, 69.4%, and 6.1% of the adolescents were classified as morning, intermediate, and evening types, respectively. After adjusting for several covariates, both evening- and intermediate-type adolescents showed lower odds of having optimal adherence to the Mediterranean diet (evening-type: odds ratio [OR] = 0.30, confidence interval [CI] 95% 0.12-0.72; intermediate-type: OR = 0.62, CI 95% 0.44-0.87) than morning-type adolescents.

CONCLUSIONS

Chronotype could affect adherence to the Mediterranean Diet in adolescents, so it should be a factor to be considered in future studies assessing eating habits.

IMPACT

No previous study has evaluated the relationship between chronotype and adherence to the Mediterranean diet among adolescents. Both evening- and intermediate-type adolescents showed lower odds of having optimal Mediterranean diet adherence than morning-type adolescents. These findings may indicate a need to promote eating healthy habits based on a more holistic approach, not only on the total energy expenditure or in specific food groups but also on the chronotype.

Panx1 knockout promotes preneoplastic aberrant crypt foci development in a chemically induced model of mouse colon carcinogenesis

Colorectal cancer, which is the third leading cause of cancer-related deaths worldwide, is a multistep disease, featuring preneoplastic aberrant crypt foci (ACF) as the early morphological manifestation. The roles of hemichannel-forming transmembrane Pannexin 1 (Panx1) protein have not been investigated in the context of colon carcinogenesis yet, although it has contrasting roles in other cancer types. Thus, this study was conducted to examine the effects of Panx1 knockout (Panx1-/- ) on the early events of chemically induced colon carcinogenesis in mouse. Wild type (WT) and Panx1-/- female C57BL6J mice were submitted to a chemically induced model of colon carcinogenesis by receiving six intraperitoneal administrations of 1,2-dimethylhydrazine (DMH) carcinogen. Animals were euthanized 8 h (week 7) or 30 weeks (week 37) after the last DMH administration in order to evaluate sub-acute colon toxicity outcomes or the burden of ACF, respectively. At week 7, Panx1 genetic ablation increased DMH-induced genotoxicity in peripheral blood cells, malondialdehyde levels in the colon, and apoptosis (cleaved caspase-3) in colonic crypts. Of note, at week 37, Panx1-/- animals showed an increase in aberrant crypts (AC), ACF mean number, and ACF multiplicity (AC per ACF) by 56%, 57% and 20%, respectively. In essence, our findings indicate that Panx1 genetic ablation promotes preneoplastic ACF development during chemically induced mouse colon carcinogenesis, and a protective role of Panx1 is postulated.