Hospital characteristics associated with nurse staffing during labor and birth: Inequities for the most vulnerable maternity patients

BACKGROUND

Evidence is limited on nurse staffing in maternity units.

PURPOSE

To estimate the relationship between hospital characteristics and adherence with Association of Women's Health, Obstetric and Neonatal Nurses nurse staffing guidelines.

METHODS

We enrolled 3,471 registered nurses in a cross-sectional survey and obtained hospital characteristics from the 2018 American Hospital Association Annual Survey. We used mixed-effects linear regression models to estimate associations between hospital characteristics and staffing guideline adherence.

FINDINGS

Overall, nurses reported strong adherence to AWHONN staffing guidelines (rated frequently or always met by ≥80% of respondents) in their hospitals. Higher birth volume, having a neonatal intensive care unit, teaching status, and higher percentage of births paid by Medicaid were all associated with lower mean guideline adherence scores.

DISCUSSION AND CONCLUSIONS

Important gaps in staffing were reported more frequently at hospitals serving patients more likely to have medical or obstetric complications, leaving the most vulnerable patients at risk.

Combined analysis of clinical features, human chorionic gonadotropin (hCG) value, and hCG ratios for early prediction of postmolar gestational trophoblastic neoplasia

PURPOSE

To investigate factors predicting postmolar gestational trophoblastic neoplasia (GTN) by combined analysis of clinical features, human chorionic gonadotropin (hCG) value, and hCG ratios.

METHODS

This retrospective study enrolled patients with histopathologically proven molar pregnancy. Patients lost to follow-up before remission or developing postmolar GTN were excluded. Demographic and clinical characteristics and hCG data obtained before and after molar evacuation were collected. Area under the receiver operating characteristic curve (AUC) analysis was used to identify the hCG and hCG ratio cutoff values that predict postmolar GTN. Multivariate analysis was employed to identify independent predictors of GTN.

RESULTS

There were 113 complete moles, 11 partial moles, and 52 unspecified moles included in the final analysis. Of the 176 cases, 90 achieved remission and 86 developed post-molar GTN. The incidence of postmolar GTN was 48.9%, with a median time to GTN development of 5 weeks. Univariate analysis showed age, molar evacuation performed elsewhere, pre-evacuation hCG, hCG at 2nd week post-evacuation, and ratio of hCG at 2nd week post-evacuation to post-evacuation hCG significantly predict GTN. Multivariate analysis revealed an hCG value ≥ 1400 IU/L at 2nd week post-evacuation (AUC: 0.92, aOR: 6.51, 95% CI 1.28-33.16; p = 0.024) and a ratio of hCG at 2nd week post-evacuation to post-evacuation hCG of ≥ 0.02 (AUC: 0.88, aOR: 12.27, 95% CI 2.15-70.13; p = 0.005) to independently predict GTN.

CONCLUSIONS

An hCG value ≥ 1400 IU/L at 2nd week post-evacuation and a ratio of hCG at 2nd week post-evacuation to post-evacuation hCG of ≥ 0.02 independently and reliably predict postmolar GTN.

Implementation of Early Detection and Intervention for Cerebral Palsy in High-Risk Infant Follow-Up Programs: U.S. and Global Considerations

Early detection and intervention for cerebral palsy is best practice for all high-risk infants according to international guidelines, consensus statements and research-supported evidence. It allows support for families and optimization of developmental trajectories into adulthood. All phases of implementation of CP early detection can be found across the world in high-risk infant follow-up programs, demonstrating feasibility and acceptability through standardized implementation science. The largest clinical network for CP early detection and intervention in the world has now sustained an average age at detection less than 12 months corrected age for more than 5 years. Targeted referrals and interventions for CP can now be offered to patients in optimal periods of neuroplasticity, and new therapies researched as the age of detection decreases. Implementation of guidelines and incorporation of rigorous CP research studies both allow high-risk infant follow-up programs to fulfill their mission of improving outcomes of those with the most vulnerable developmental trajectories from birth.

Preeclampsia: Narrative review for clinical use

Aim

Preeclampsia is a very complex multisystem disorder characterized by mild to severe hypertension.

Methods

PubMed and the Cochrane Library were searched from January 1, 2002 to March 31, 2022, with the search terms "pre-eclampsia" and "hypertensive disorders in pregnancy". We also look for guidelines from international societies and clinical specialty colleges and we focused on publications made after 2015.

Results

The primary issue associated with this physiopathology is a reduction in utero-placental perfusion and ischemia. Preeclampsia has a multifactorial genesis, its focus in prevention consists of the identification of high and moderate-risk clinical factors. The clinical manifestations of preeclampsia vary from asymptomatic to fatal complications for both the fetus and the mother. In severe cases, the mother may present renal, neurological, hepatic, or vascular disease. The main prevention strategy is the use of aspirin at low doses, started from the beginning to the end of the second trimester and maintained until the end of pregnancy.

Conclusion

Preeclampsia is a multisystem disorder; we do not know how to predict it accurately. Acetylsalicylic acid at low doses to prevent a low percentage, especially in patients with far from term preeclampsia. There is evidence that exercising for at least 140 min per week reduces gestational hypertension and preeclampsia. Currently, the safest approach is the termination of pregnancy. It is necessary to improve the prediction and prevention of preeclampsia, in addition, better research is needed in the long-term postpartum follow-up.

Roles and reported practices of paediatricians in the early identification and monitoring of hearing impairment in high-risk newborns and infants

BACKGROUND

The paediatrician is often the first professional who provides care for the infant and their families, hence having a vital role in the early identification and intervention of hearing impairment.

OBJECTIVE

This study aimed to identify the role and reported practices of paediatricians in the early identification and monitoring of hearing impairment in high-risk newborns and infants.

METHODS

The sample comprised 30 paediatricians in South Africa. Data were collected by means of an online survey and analysed using descriptive statistics.

RESULTS

Variability was noted in the early identification protocols, with most participants conducting objective measures. Although most participants refer newborns and infants for audiological evaluation when hearing impairment is suspected, there is variability with regard to the age at which they are referred. Approximately 98% of participants believe that they form part of the multidisciplinary team; however, only 69% reported that they have actually been part of a multidisciplinary team.

CONCLUSIONS

Paediatricians had sufficient knowledge regarding the assessment of hearing impairment and their role in the early hearing detection and intervention programme. There is however a need for information sharing regarding appropriate hearing screening measures.

Disrupted white matter microstructure correlates with impulsivity in children and adolescents with bipolar disorder

Altered white matter (WM) microstructure likely occurs in children with bipolar disorder (BD) with impulsivity representing one of the core features. However, altered WM microstructures and their age-related trendlines in children with BD and those at high-risk of developing BD, as well as correlations of WM microstructures with impulsivity, have been poorly investigated. In this study, diffusion MRI, cognitive, and impulsivity assessments were obtained from children/adolescents diagnosed with BD, offspring of individuals with BD (high-risk BD) and age-matched healthy controls. A novel atlas-based WM skeleton measurement approach was used to quantify WM microstructural integrity with all diffusion-tensor-imaging (DTI) metrics including fractional anisotropy, axial, mean and radial diffusivity to survey entire WM tracts and ameliorate partial volume effects. Among all DTI-derived metric measures, radial diffusivity quantifying WM myelination was found significantly higher primarily in corpus callosum and in the corona radiata in children with BD compared to controls. Distinguished from age-related progressively decreasing diffusivities and increasing fractional anisotropy in healthy controls, flattened age-related trendlines were found in BD group, and intermediate developmental rates were observed in high-risk group. Larger radial diffusivity in the corpus callosum and corona radiata significantly correlated with shorter response times to affective words that indicate higher impulsivity in the BD group, whereas no such correlation was found in the healthy control group. This work corroborates the progressive nature of pediatric BD and suggests that WM microstructural disruption involved in affective regulation and sensitive to impulsivity may serve as a biomarker of pediatric BD progression.

A nomogram for the preoperative estimation of neuroblastoma risk despite inadequate biopsy information

BACKGROUND AND PURPOSE

If the preoperative pathological information is inadequate, a risk classification may not be able to be determined for some patients with neuroblastoma. Our objectives were to include imaging factors, serum biomarkers, and demographic factors in a nomogram to distinguish high-risk patients before surgical resection based on the COG classification.

METHOD

A total of 106 patients were included in the study. Of these, patients with clinicopathologically confirmed neuroblastoma at Tianjin Children's Hospital from January 2013 to November 2021 formed the training cohort (n = 82) for nomogram development, and those patients from January 2010 to December 2013 formed the validation cohort (n = 24) to confirm the model's performance.

RESULT

On multivariate analysis of the primary cohort, independent factors for high risk were the presence of distant metastasis (p = 0.004), lactate dehydrogenase (LDH) (p = 0.009), and tumor volume (p = 0.033), which were all selected into the nomogram. The calibration curve for probability showed good agreement between prediction by nomogram and actual observation. The C-index of the nomogram was 0.95 95% [0.916-0.99]. Application of the nomogram in the validation cohort still gave good discrimination and good calibration.

CONCLUSION

Three independent factors including the presence of distant metastasis, lactate dehydrogenase (LDH), and tumor volume are associated with high-risk neuroblastoma and selected into the nomogram. The novel nomogram has the flexibility to apply a clinically suitable cutoff to identify high-risk neuroblastoma patients despite inadequate preoperative pathological information. The nomogram can allow these patients to be offered suitable induction chemotherapy regimens and surgical plans.

LEVELS OF EVIDENCE

Level III.

Association of Brachytherapy Boost with Overall Survival for Gleason 9-10 Prostate Cancer: The Impact of Primary versus Secondary Pattern 5

PURPOSE

The addition of a brachytherapy (BT) boost to external beam radiotherapy (EBRT) reduces recurrence risk in men with high-risk prostate cancer (PCa) and may reduce PCa-mortality for Gleason grade group 5 (GG5). Whether the extent of pattern five, a risk factor for distant metastases, impacts the benefit of a BT boost is unclear.

METHODS

Men with localized GG5 PCa treated with (1) EBRT or (2) EBRT+BT between 2010 and 2016 were identified in the National Cancer Database. EBRT monotherapy group received conventionally fractionated (1.8-2.0 Gy per fraction) ≥74 Gy or moderately hypofractionated (2.5-3.0 Gy per fraction) ≥60 Gy. EBRT + BT group received conventionally fractionated ≥45 Gy or moderately hypofractionated ≥37.5 Gy, and either LDR or HDR BT. All patients received concomitant ADT; none received chemotherapy, immunotherapy, or surgery. OS was compared using Kaplan-Meier, log-rank test, and multivariable Cox proportional hazards in the overall cohort, followed by subgroups based on primary versus secondary pattern 5. Propensity score- and exact-matching was used to corroborate results.

RESULTS

A total of 8260 men were eligible: EBRT alone (89%) versus EBRT + BT (11%). 5-year OS for EBRT versus EBRT + BT was 76.3% and 85.0%, respectively (p = 0.002; multivariable adjusted HR 0.84, 95% CI 0.65-0.98; p = 0.04). These results remained consistent after propensity score and exact matching. The OS advantage of a BT boost was more prominent in men with Gleason 4 + 5 PCa (p = 0.001) and not observed in men with Gleason 5 + 5 or 5 + 4 PCa.

CONCLUSIONS

Extent of pattern five may be useful in appropriately selecting men for EBRT+BT and should be considered as a pre-randomization stratification variable for future clinical trial design.

Anatomical and functional outcomes of Boston type I keratoprosthesis as primary penetrating corneal procedure in high-risk and non-high-risk cases

PURPOSE

To analyze the anatomical and functional results of Boston type I keratoprosthesis (B1-KPro) as a primary corneal procedure in high-risk (HR) cases and non-high-risk (NHR) cases.

METHODS

In this retrospective interventional case series, all patients who underwent B1-KPro at a single center between January 2006 and March 2021 were reviewed and identified. Cases were classified according to the primary diagnosis. Anatomical failure was considered in the case of prosthesis extrusion or phthisis bulbi. Functional failure was a postoperative corrected distance visual acuity (CDVA) ≥ 1.3 LogMAR (≤ 0.05 decimal) at the end of the follow-up period.

RESULTS

Twenty-three eyes were included for analysis. Thirteen eyes were classified as HR and 10 as NHR. The mean age was 46.5 ± 26.5 years (5-84 years) in the HR group and 49.5 ± 26.9 years (2-78 years) in the NHR group. The mean follow-up was 42.0 ± 35.9 months (1.5-118 months) in HR and 44.8 ± 38.8 months (1-107 months) in NHR. Three eyes in the HR and none in the NHR group showed anatomical failure. Functional failure was reported in 5/13 eyes in the HR and 8/10 in the NHR group. Functional cumulative survival probability was 92% and 82% for the HR group at 1 and 2 years, respectively. In the NHR group, it was 27% at both times. No significant differences were found between groups, except for functional survival in the HR group due to better visual potential of the eyes.

CONCLUSIONS

B1-KPro as a primary corneal procedure is a valid option for visual rehabilitation in high-risk cases.

The 2022 Updated European Association of Urology Guidelines on the Use of Adjuvant Immune Checkpoint Inhibitor Therapy for Renal Cell Carcinoma

In KEYNOTE-564, adjuvant pembrolizumab, a PD-1 antibody, significantly improved disease-free survival (DFS) in localised clear-cell renal cell carcinoma (ccRCC) with a high risk of relapse. In 2021, the European Association of Urology RCC Guidelines Panel issued a weak recommendation for adjuvant pembrolizumab for high-risk ccRCC as defined by the trial until final overall survival data and results from other trials were available. Meanwhile, the primary DFS endpoints were not met for adjuvant atezolizumab (PD-L1 inhibitor; IMmotion010), adjuvant nivolumab plus ipilimumab (CheckMate 914), or perioperative nivolumab (PROSPER). Owing to heterogeneity, a meta-analysis is not recommended. Pembrolizumab remains the only immune checkpoint inhibitor currently recommended in this setting. Overall survival data are immature and biomarkers to predict outcome are lacking. Uncertainty exists and overtreatment is occurring. Treatment decisions should be made with caution and with the involvement of each patient. PATIENT SUMMARY: New results from three trials of immunotherapy after surgery for kidney cancer to reduce the risk of recurrence showed no improvement with these treatments. These results are in contrast to an earlier study that showed that the antibody pembrolizumab did extend the time before kidney cancer recurrence, even though it is not yet clear if overall survival is longer. Thus, we cautiously recommend pembrolizumab as additional treatment in high-risk kidney cancer after surgery, but patient preference should be carefully considered and the risk of overtreatment should be discussed.

Social COmmunication Program supported by E-health (SCOPE) for infants and toddlers at elevated likelihood of autism spectrum disorder: study design of a cluster randomized controlled trial

BACKGROUND

Although the importance of early detection and early intervention of autism spectrum disorders (ASD) is widely recognized, multiple barriers exist in accessing early intervention services. As an alternative to these barriers, the SCOPE project presents a new, easy accessible and blended intervention called BEAR (Blended E-health for children at eArly Risk). This paper describes this BEAR intervention and study design of an ongoing two arm cluster randomized controlled trial (RCT).

METHODS

BEAR (Blended E-health for children at eArly Risk) is a blended e-health intervention, based on evidence-based naturalistic developmental behavioral interventions (NDBI's) and can be offered to parents and infants/toddlers at high likelihood for ASD. During the ongoing RCT, N = 88 high risk infants and toddlers will be cluster randomized over the BEAR intervention and care-as-usual (CAU) conditions. The finalized version of the intervention protocol and study design are presented in this paper. The primary outcome measure is joint engagement measured by the Joint Engagement Rating Inventory (JERI) during videotaped parent-child interaction. Secondary outcome measures include severity of ASD symptoms, global level of adaptive functioning, parental well-being, parental skills and satisfaction with healthcare. Also, costs will be estimated from society's perspective. Assessments take place at the start of the study (T1), after eight weeks (T2) and after six months (T3) and include behavioral home observations and parental questionnaires.

DISCUSSION

The SCOPE project aims to contribute to improved early identification and timely start of suitable interventions for infants and toddlers at elevated likelihood for ASD. This ongoing RCT will offer insight in the feasibility, short-term and six months effects of the innovative BEAR intervention. It is estimated that inclusion for the trial (N = 88) is completed in spring 2023.

TRIAL REGISTRATION

Dutch Trial Register, NTR7695. Registered at December 17^th, 2018, www.trialregister.nl .

Osteoporosis treatment in Austria-assessment of FRAX-based intervention thresholds for high and very high fracture risk

The adoption of the management pathway proposed by the National Osteoporosis Guideline Group (NOGG), UK applied using the Austrian FRAX® tool in a referral population of Austrian women categorises 22-29% of women age 40 years or more eligible for treatment of whom 28-34% are classified at very high risk.

PURPOSE

The aim of this study is to provide a reference document for the further development of existing guidelines for the management of osteoporosis in Austria, considering FRAX-based intervention thresholds for high and very high fracture risk.

METHODS

The model development was based on two Austrian hospital referral cohorts. Baseline information was collected to compute the 10-year probability (using the Austrian FRAX model) of a major osteoporotic fracture (MOF) and hip fracture both with and without the inclusion of femoral neck bone mineral density (BMD). Assessment thresholds for BMD testing were defined, as well as intervention thresholds. In addition, thresholds that characterise men and women at high and very high fracture risk were established. The management pathway followed that currently recommended by the UK National Osteoporosis Guideline Group (NOGG).

RESULTS

The two cohorts comprised a total of 1306 women and men with a mean age of 66.7 years. Slightly more than 50% were eligible for treatment by virtue of a prior fragility fracture. In those women without a prior fracture, 22% (n = 120) were eligible for treatment based on MOF probabilities. Of these, 28% (n = 33) were found to be at very high risk. When both MOF and hip fracture probabilities were used to characterise risk, 164 women without a prior fracture were eligible for treatment (29%). Of these, 34% (n = 56) were found to be at very high risk. Fewer men without prior fracture were eligible for treatment compared with women.

CONCLUSION

The management pathway as currently outlined is expected to reduce inequalities in patient management. The characterisation of very high risk may aid in the identification of patients suitable for treatment with osteoanabolic agents.

Underscreening, overscreening, and guideline-adherent cervical cancer screening in a national cohort

OBJECTIVE

To explore rates of under- and overscreening for cervical cancer among a national cohort.

METHODS

The MarketScan database, a national administrative database of employee-sponsored insurance, was queried for elements relevant to cervical cancer screening among women aged 21-65 with 6 years of continuous enrollment (2015-2019). Average-risk women were defined as those without high-risk medical conditions or abnormal screening histories, and without evidence of hysterectomy with removal of the cervix for benign indications. Average-risk women were considered adequately screened if they had Pap tests alone at 2.5-3.5 year intervals, or HPV tests or co-tests at 4.5-5.5 year intervals. Logistic regressions were used to predict the odds of receiving guideline-adherent screening, underscreening, and overscreening.

RESULTS

Among 1,872,809 eligible patients, 1,471,063 (78.5%) qualified for routine screening. Of these, only 18.1% received guideline-adherent screening, and 25.4% were unscreened during the 6-year period. Younger women (aged 21-39) were more likely to be overscreened [OR 1.46]. Older women (aged 50-64) were more likely to be underscreened or unscreened during the study period [OR 2.54]. Guideline-adherent screening was highest with HPV testing alone (80%) followed by co-testing (44%), and lowest with cytology alone (15%). A total of 329,062 women in this general population sample (18%) met high-risk criteria that required increased frequency of screening.

CONCLUSIONS

High rates of both underscreening and overscreening indicate a need for additional strategies to improve guideline-adherent care.

CLINICAL TRIAL REGISTRATION

N/A.

Editor's Choice - Endovascular Aneurysm Repair in High Risk Patients: A Systematic Review and Meta-Analysis

OBJECTIVE

To investigate outcomes of endovascular aneurysm repair (EVAR) in high risk patients.

METHODS

Bibliographic sources (MEDLINE, EMBASE, CINAHL, and CENTRAL) were searched using combinations of thesaurus and free text terms. The review protocol was registered in PROSPERO (CRD42021287207) and reported according to PRISMA 2020. Pooled estimates were calculated using odds ratio (OR) or hazard ratio (HR) and 95% confidence interval (CI) applying the Mantel-Haenszel or inverse variance method. EVAR peri-operative mortality in high risk patients over time was examined with mixed effects meta-regression. The GRADE framework was used to rate the certainty of evidence.

RESULTS

The pooled peri-operative mortality in 18 416 high risk patients who underwent EVAR was 3% (95% CI 2.3 - 4%) and has significantly reduced over time (year of publication p = .003; median study point p = .023). The peri-operative mortality was significantly lower in high risk patients treated with EVAR compared with open repair (OR 0.64; 95% CI 0.45 - 0.92), but no significant difference was found in overall (HR 1.06; 95% CI 0.76 - 1.49) or aneurysm related mortality (HR 0.57; 95% CI 0.21 - 1.55). No significant difference was found in overall mortality between high risk patients treated with EVAR vs. no intervention (HR 0.42; 95% CI 0.14 - 1.26), but the aneurysm related mortality was significantly lower in the former (HR 0.30; 95% CI 0.14 - 0.63). The peri-operative mortality was higher in high risk than normal risk patients treated with EVAR (OR 2.33; 95% CI 1.75 - 3.10), as was the overall mortality (HR 3.50; 95% CI 2.55 - 4.80). The certainty of evidence was very low for EVAR vs. open surgery or no intervention and low for high vs. normal risk patients.

CONCLUSION

The EVAR peri-operative mortality in high risk patients has improved over time. Even though the aneurysm related mortality of EVAR is lower compared with no intervention, EVAR may confer no overall survival benefit.

Dim light melatonin patterns in unaffected offspring of parents with bipolar disorder: A case-control high-risk study

BACKGROUND

Circadian dysregulation has long been thought to be a key component in the pathophysiology of bipolar disorder (BD). However, it remains unclear whether this dysregulation constitutes a risk factor, manifestation, or consequence of BD. This study aimed to compare dim light melatonin secretion patterns between unaffected offspring of parents with BD (OBD) and offspring of control parents (OCP).

METHODS

This case-control study included unaffected OBD (mean age 14.0 years; male 50.0 %) and age- and sex-matched OCP (mean age 13.0 years; male: 43.5 %). Seventeen saliva samples were collected in dim light conditions. Dim light melatonin onset (DLMO), phase angles, and area under the curve (AUC) were calculated.

RESULTS

185 saliva samples from 12 OBD (n = 12) and 741 from OCP (n = 46) were collected. Unaffected OBD had a significant lower nocturnal melatonin level (14.8 ± 4.6 vs. 20.3 ± 11.7 pg/mL) and a smaller melatonin AUC within two hours after DLMO (35.5 ± 11.3 vs. 44.6 ± 18.1 pg/mL) but a significant larger phase angle between DLMO and sleep onset (2.2 ± 1.0 vs. 1.4 ± 1.2 h) than OCP. There was no significant between-group difference in DLMO. The graphic illustrations showed a considerably flattened melatonin secretion in unaffected OBD.

LIMITATIONS

The main limitations include lack of 24-h dim melatonin secretion measurement, large age range of participants, and small sample size.

CONCLUSIONS

These findings suggest that unaffected OBD already presented with circadian rhythm dysregulations. Future investigations are needed to clarify the role of abnormal melatonin secretion in the onset of BD.

Aortic wrapping is life-saving in high-risk acute aortic dissection and intramural haematoma

Aortic wrapping is a controversial repair in patients presenting with acute type A aortic dissection or intramural haematoma, but this method may be a potential alternative to medical treatment or conventional repair in patients aged >80 years and in those presenting with prohibitive co-morbidities such as stroke, circulatory collapse, full oral anticoagulation with the last generation drugs. We report on 5 high-risk and/or patients over 80 years who received external aortic wrapping with or without cardiopulmonary bypass during the last 18 months. All survived the procedure and could be extubated early postoperatively. No patient remained on the intensive care longer than 2 days and all were discharged without additional complications. Postoperative radiological control was acceptable and no patient had any new aortic event up to 18 months postoperatively.

Nomogram Predicting Downgrading in National Comprehensive Cancer Network High-risk Prostate Cancer Patients Treated with Radical Prostatectomy

BACKGROUND

Some high-risk prostate cancer (PCa) patients may show more favorable Gleason pattern at radical prostatectomy (RP) than at biopsy.

OBJECTIVE

To test whether downgrading could be predicted accurately.

DESIGN, SETTING, AND PARTICIPANTS

Within the Surveillance, Epidemiology and End Results database (2010-2016), 6690 National Comprehensive Cancer Network (NCCN) high-risk PCa patients were identified.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSES

We randomly split the overall cohort between development and validation cohorts (both n = 3345, 50%). Multivariable logistic regression models used biopsy Gleason, prostate-specific antigen, number of positive prostate biopsy cores, and cT stage to predict downgrading. Accuracy, calibration, and decision curve analysis (DCA) tested the model in the external validation cohort.

RESULTS AND LIMITATIONS

Of 6690 patients, 50.3% were downgraded at RP, and of 2315 patients with any biopsy pattern 5, 44.1% were downgraded to RP Gleason pattern ≤4 + 4. Downgrading rates were highest in biopsy Gleason pattern 5 + 5 (84.1%) and lowest in 3 + 4 (4.0%). In the validation cohort, the logistic regression model-derived nomogram predicted downgrading with 71.0% accuracy, with marginal departures (±3.3%) from ideal predictions in calibration. In DCA, a net benefit throughout all threshold probabilities was recorded, relative to treat-all or treat-none strategies and an algorithm based on an average downgrading rate of 50.3%. All steps were repeated in the subgroup with any biopsy Gleason pattern 5, to predict RP Gleason pattern ≤4 + 4. Here, a second nomogram (n = 2315) yielded 68.0% accuracy, maximal departures from ideal prediction of ±5.7%, and virtually the same DCA pattern as the main nomogram.

CONCLUSIONS

Downgrading affects half of all high-risk PCa patients. Its presence may be predicted accurately and may help with better treatment planning.

PATIENT SUMMARY

Downgrading occurs in every second high-risk prostate cancer patients. The nomograms developed by us can predict these probabilities accurately.

Impact of Type 2 Diabetes Mellitus with a Focus on Asian Indians Living in India and Abroad: A Systematic Review

BACKGROUND

Diabetes is a highly prevalent disease in the world. Type 2 diabetes mellitus (T2DM) is growing at an alarming rate due to rapid urbanization, migration, aging population, and lifestyle changes.

INTRODUCTION

We have summarized the global T2DM distribution in specific International Diabetes Federation (IDF)-defined regions and various countries and highlighted the high risk of T2DM prevalence in Asian Indians living in India and worldwide.

METHOD

A systematic review was conducted using combinations of the following key concepts 'T2DM' ; 'global distribution' ; 'Asian Indians' ; 'high risk' and 'prevalence' by searching PubMed and EMBASE databases for articles describing the global distribution of T2DM. From 430 searched articles, 54 full-text articles were reviewed to study the distribution, risk, and prevalence of diabetes in various countries.

RESULT

As per IDF Atlas, 463 million people in 2019 have diabetes worldwide, and it is expected to rise to 700 million by 2045. The global distribution of T2DM differs from various countries to various regions. Asia is the epicenter of diabetes, where 60% of people with diabetes live, mainly in China (139.9 million) and India (65 million). South Asians are more susceptible to developing T2DM as compared to ethnic Europeans. Asian Indians living worldwide are at a high risk of developing T2DM. Those who have migrated to various countries (USA, UK, Australia, Singapore, Mauritius, New Zealand, Fiji, etc.) have a higher prevalence of T2DM than the native population and even more significant than those Indians living in India due to being more insulin resistant. Indians develop T2DM at a younger age and at a lower BMI due to genetic makeup and behavioral and environmental determinants, including diet and sedentary lifestyle and westernization.

CONCLUSION

In conclusion, insulin levels were found to be higher not only in adults but also in adolescents and young adults. In addition, rapid urbanization, migration, industrial modernization, and lifestyle changes are other factors responsible for the develvement of T2DM.

Aromatase inhibitors and contralateral breast cancer in BRCA mutation carriers

BACKGROUND

Deleterious BRCA mutations confer a significant lifetime risk of breast cancer (BC) as well as contralateral BC (CBC) in patients who do not undergo prophylactic mastectomy. Prior reports have suggested that tamoxifen reduces the risk of CBC in BRCA mutation carriers. Whether aromatase inhibitors (AI) have the same effect is unknown.

METHODS

This is a retrospective review of patients diagnosed with non-metastatic ER+ BC between 2004 and 2014 with known BRCA mutation status. Patients were followed from primary diagnosis until CBC diagnosis or death. Median follow-up was 11.5 years. Risk of CBC was evaluated as time to event.

RESULTS

935 subjects were included in this analysis, with 53 BRCA1 mutation carriers, and 94 BRCA2 mutation carriers. Median age at diagnosis was 42.7 years. Seventy-two percent (676) received tamoxifen and 43% (405) received AI. A total of 66 CBCs occurred, of which 10% (15/147) occurred in BRCA mutation carriers vs 6.5% (51/788) in BRCA wild type. Multivariate analyses indicated that BRCA status and AI use were significantly associated with CBC risk. AI use resulted in a significant reduction in risk of CBC (HR 0.44, p = 0.004) regardless of the BRCA mutation status. Tamoxifen use was not associated with reduced risk of CBC.

CONCLUSIONS

This is the first report showing that AIs reduce the risk of CBC in BRCA mutation carriers. The potential role of AIs as chemoprevention should be validated in larger independent cohorts.

Initial screening of gastric cancer using oral contrast-enhanced trans-abdominal ultrasonography in rural asymptomatic individuals

BACKGROUND & AIMS

Initial screening for high-risk population of gastric cancer (GC) is needed in rural areas of large-population countries. This study aims to explore the feasibility of applying noninvasive ultrasonography as an initial screening strategy to improve the early diagnosis and prevention of GC.

METHODS

Oral contrast-enhanced trans-abdominal ultrasonography (OCTU) was initially applied to screen around 15,000 residents from 24 different rural villages of Changxing Island in Shanghai, China, facilitating the identification of high-risk population for further endoscopy examination.

RESULTS

176 subjects (1.18 %) were initially identified with gastric diseases using OCTU while 14,787 ones (98.93 %) were normal with negative results. 145 out of 176 individuals (82.39 %) took further endoscopy examination, and 16 were diagnosed with GC with biopsy examination, with 9 of them at the early stage. We followed up with the Center for Disease Control and Prevention, and identified another 6 GC cases occurred within one year among OCTU-negative population, serving as an adjustment factor for sensitivity analysis. As a result, with a total of 22 GC cases included in this cohort, the positive predictive rate, the negative predictive value, sensitivity, and specificity were 9.09％, 99.96 %, 75.5 %, and 98.93 %, respectively.

CONCLUSIONS

OCTU is feasible, non-invasive, low-cost, and widely acceptable in rural area, thus we proposed that OCTU is practicable to serve as a supplementary screening method to improve the early detection of GC in rural area of China and other developing countries with large population.

Predictive models for first-onset and persistence of depression and anxiety among university students

BACKGROUND

Depression and anxiety are both prevalent among university students. They frequently co-occur and share risk factors. Yet few studies have focused on identifying students at highest risk of first-onset and persistence of either of these conditions.

METHODS

Multicenter cohort study among Spanish first-year university students. At baseline, students were assessed for lifetime and 12-month Major Depressive Episode and/or Generalized Anxiety Disorder (MDE-GAD), other mental disorders, childhood-adolescent adversities, stressful life events, social support, socio-demographics, and psychological factors using web-based surveys; 12-month MDE-GAD was again assessed at 12-month follow-up.

RESULTS

A total of 1253 students participated in both surveys (59.2% of baseline respondents; mean age = 18.7 (SD = 1.3); 56.0% female). First-onset of MDE-GAD at follow-up was 13.3%. Also 46.7% of those with baseline MDE-GAD showed persistence at follow-up. Childhood/Adolescence emotional abuse or neglect (OR= 4.33), prior bipolar spectrum disorder (OR= 4.34), prior suicidal ideation (OR=4.85) and prior lifetime symptoms of MDE (ORs=2.33-3.63) and GAD (ORs=2.15-3.75) were strongest predictors of first-onset MDE-GAD. Prior suicidal ideation (OR=3.17) and prior lifetime GAD symptoms (ORs=2.38-4.02) were strongest predictors of MDE-GAD persistence. Multivariable predictions from baseline showed AUCs of 0.76 for first-onset and 0.81 for persistence. 74.9% of first-onset MDE-GAD cases occurred among 30% students with highest predicted risk at baseline.

LIMITATIONS

Self-report data were used; external validation of the multivariable prediction models is needed.

CONCLUSION

MDE-GAD among university students is frequent, suggesting the need to implement web-based screening at university entrance that identify those students with highest risk.

[High risk localized and locally advanced prostate cancer: Long-term oncological outcomes after prostatectomy]

INTRODUCTION

High risk localized and locally advanced forms are responsible for the vast majority of specific deaths from prostate cancer among non-metastatic diseases at diagnosis. No randomized study has yet been published to establish the best local treatment in terms of survival.

AIM

Conduct a large-volume cohort study with long-term follow-up to analyze specific and overall survival outcomes after surgery.

METHOD

A single-center retrospective study of all patients operated on for localized high-risk and locally advanced prostate cancer was performed. Actuarial survival analyses and multivariate analyses were performed to discern predictive risk factors.

RESULTS

Five hundred patients were included. MRI stage was≥iT3a in 40.7% of cases and 50.2% of patients had a Gleason score≥8 on biopsy. The mean follow-up was 63.1 months. The overall, specific and biological recurrence-free survival were respectively 77.6%, 93.9% and 26.8% at 10 years. A PSA level≥20, a Gleason score on biopsy≥9 and a MRI stage≥iT3a were significantly associated with the 10-years biological recurrence risk.

CONCLUSION

This study shows very good long-term oncological results. In the absence of a randomized controlled trial, these results suggest the primary role of surgery in this indication and support the evolution of current practices. We pointed out very pejorative features that might help selection of the best candidates for surgical treatment.

LEVEL OF EVIDENCE: 4

Extrastriatal Dopamine D2/3 Receptor Availability in Alcohol Use Disorder and Individuals at High Risk

INTRODUCTION

Reduced striatal dopamine D2/3 receptor availability in alcohol use disorder (AUD) has been demonstrated in recent clinical studies and meta-analyses. However, only a limited number of studies investigated extrastriatal D2/3 availability in AUD or in at-risk populations. In line with a dimensional understanding of addiction, extrastriatal dopaminergic neuroadaptations have been suggested to be relevant from a pathobiological perspective.

METHODS

We investigated D2/3 receptor availability via 18F-fallypride positron emission tomography applying a region of interest (ROI) approach. We selected ROIs for the prefrontal cortex (PFC) and the anterior cingulate cortex (ACC). Our sample included 19 healthy controls (low risk [LR]), 19 individuals at high risk (HR) to develop addiction, and 20 recently detoxified AUD patients.

RESULTS

We found significantly higher D2/3 receptor availability of HR compared to AUD in the left and right rostral ACC (rACC), as well as in the left ventrolateral PFC (vlPFC). We did not observe a significant difference between AUD and LR. After corrections for multiple comparisons none of the ROIs reached significance throughout the group comparison. The D2/3 receptor availability in the left rACC was inversely correlated with symptom severity assessed with the Alcohol Dependency Scale.

DISCUSSION

To our knowledge, the present work is the first study investigating extrastriatal D2/3 receptor availabilities in individuals at HR and patients with AUD. The observation that D2/3 receptor availabilities are highest in HR might suggest that their pathobiology differs from subjects with AUD. Future studies are necessary to clarify the intraindividual course of this biomarker over different disease stages and its possible role as a risk or protective factor.

Rate of breast biopsy referrals in female BRCA mutation carriers aged 50 years or more: a retrospective comparative study and matched analysis

PURPOSE

To evaluate the total biopsy and positive biopsy rates in women at high risk of breast cancer compared to the general population.

METHODS

The study group consisted of 330 women with pathogenic variants (PVs) in BRCA1/2 attending the dedicated multidisciplinary breast cancer clinic of a tertiary medical center in Israel. Clinical, genetic, and biopsy data were retrieved from the central healthcare database and the medical files. Patients aged 50 years or older during follow-up were matched 1:10 to women in the general population referred for routine breast cancer screening at the same age, as recommended by international guidelines. The groups were compared for rate of biopsy studies performed and percentage of positive biopsy results. Matched analysis was performed to correct for confounders.

RESULTS

The total biopsy rate per 1000 follow-up years was 61.7 in the study group and 22.7 in the control group (p < 0.001). The corresponding positive biopsy rates per 1000 follow-up years were 26.4 and 2.0 (p < 0.001), and the positive biopsy percentages, 42.9% and 8.7% (p < 0.0001).

CONCLUSION

Women aged 50 + years with PVs in BRCA1/2 attending a dedicated clinic have a 2.7 times higher biopsy rate per 1000 follow-up years, a 13.2 times higher positive biopsy rate per 1000 follow-up years, and a 4.9 times higher positive biopsy percentage than same-aged women in the general population.

Identification of high-risk stage I colon and rectal cancer patients: a retrospective analysis of a large Japanese cohort

PURPOSE

Data regarding risk factors for recurrence in stage I colorectal cancer patients are limited. The aim of this study was to clarify the existence of a high-recurrence-risk population among stage I colorectal cancer patients.

METHODS

This analysis included 7,539 stage I colorectal cancer patients treated between 1997 and 2012 at 24 leading hospitals in Japan. Risk factors for time to recurrence were evaluated using a Cox proportional hazards model, and a high-risk group for recurrence was identified. Prognostic outcomes of high-risk stage I colorectal cancer patients were compared with those of low-risk stage I and stage II patients.

RESULTS

Multivariable analyses identified left-sided location (hazard ratio [HR]: 1.65, 95% confidence interval [CI]: 1.09-2.58), T2 tumors (HR: 1.80, 95% CI: 1.21-2.66), and lymphatic invasion (HR: 1.55, 95% CI: 1.05-2.28) as risk factors for recurrence in stage I colon cancer, and patients with these three risk factors were classified as high risk. For stage I rectal cancer, patients with poor differentiation (HR: 2.86, 95% CI: 1.21-5.69), T2 tumors (HR: 1.53, 95% CI: 1.07-2.23), and venous invasion (HR: 1.51, 95% CI: 1.08-2.13) were identified as high risk. The Kaplan-Meier analysis of cumulative recurrence rate and recurrence-free survival revealed that the high-risk stage I colorectal cancer patients have poorer clinical outcomes than the low-risk patients.

CONCLUSION

Although stage I colorectal cancer patients generally have a favorable prognosis after curative surgery, poorer prognosis was observed in high-risk stage I colorectal cancer patients than in low-risk patients.