Safety of percutaneous versus transjugular liver biopsy: A propensity score matched analysis

PURPOSE

This study sought to identify the complication, mortality, and readmission rates of patients undergoing either percutaneous (PCLB) or transjugular liver biopsy (TJLB) when propensity matched for demographics and hepatic comorbidities.

METHODS

A retrospective review of New York's Statewide Planning and Research Cooperative System ICD9 coded database from the years 2009-2013 was conducted. Patients over the age of 18 undergoing either PCLB or TJLB were included. Patients with hepatic neoplasm or metastasis were excluded. 2:1 PCLB:TJLB propensity match for age, race, payment, coagulopathy, thrombocytopenia/purpura, hypercoagulability, ascites, acute liver failure, chronic hepatitis, cirrhosis, and bone marrow disease was conducted. Univariate analysis compared demographics, complications, readmissions, and mortality.

RESULTS

1467 patients met inclusion criteria (PCLB = 978, TJLB = 489). Propensity match was successful in that there were no significant differences in demographics or hepatic comorbidities. TJLB had significantly lower rates of hematoma (0.20 % vs 1.20 %, p = 0.049) and higher rates of cardiac complications (0.40 % vs 0.00 %, p = 0.045). Other complication, readmission, and mortality rates did not differ significantly. Logistic regression found no significant predictors of readmission within 7 days or any complication within 5 days.

CONCLUSION

This retrospective, multi-center database review of adult patients undergoing PCLB or TJLB propensity matched for demographics and hepatic comorbidities found that TJLB patients had a significantly higher rate of cardiac complications while PCLB patients had a significantly higher rate of hematoma. These findings support prior literature suggesting a trend towards safety of TJLB compared to PCLB in patients with hemostatic disorders and/or advanced liver disease.

Investigation of common, low-frequency and rare genome-wide variation in anorexia nervosa

Anorexia nervosa (AN) is a complex neuropsychiatric disorder presenting with dangerously low body weight, and a deep and persistent fear of gaining weight. To date, only one genome-wide significant locus associated with AN has been identified. We performed an exome-chip based genome-wide association studies (GWAS) in 2158 cases from nine populations of European origin and 15 485 ancestrally matched controls. Unlike previous studies, this GWAS also probed association in low-frequency and rare variants. Sixteen independent variants were taken forward for in silico and de novo replication (11 common and 5 rare). No findings reached genome-wide significance. Two notable common variants were identified: rs10791286, an intronic variant in OPCML (P=9.89 × 10-6), and rs7700147, an intergenic variant (P=2.93 × 10-5). No low-frequency variant associations were identified at genome-wide significance, although the study was well-powered to detect low-frequency variants with large effect sizes, suggesting that there may be no AN loci in this genomic search space with large effect sizes.

Genetic and environmental aspects in the association between attention-deficit hyperactivity disorder symptoms and binge-eating behavior in adults: a twin study

BACKGROUND

Prior research demonstrated that attention-deficit hyperactivity disorder (ADHD) is associated with binge-eating behavior, binge-eating disorder (BED), and bulimia nervosa (BN). The aim of this study was to investigate these associations in an adult twin population, and to determine the extent to which ADHD symptoms and binge-eating behavior share genetic and environmental factors.

METHODS

We used self-reports of current ADHD symptoms and lifetime binge-eating behavior and associated characteristics from a sample of over 18 000 adult twins aged 20-46 years, from the population-based Swedish Twin Registry. Mixed-effects logistic regression was used to examine the association between ADHD and lifetime binge-eating behavior, BED, and BN. Structural equation modeling was used in 13 773 female twins to determine the relative contribution of genetic and environmental factors to the association between ADHD symptoms and binge-eating behavior in female adult twins.

RESULTS

ADHD symptoms were significantly associated with lifetime binge-eating behavior, BED, and BN. The heritability estimate for current ADHD symptoms was 0.42 [95% confidence interval (CI) 0.41-0.44], and for lifetime binge-eating behavior 0.65 (95% CI 0.54-0.74). The genetic correlation was estimated as 0.35 (95% CI 0.25-0.46) and the covariance between ADHD and binge-eating behavior was primarily explained by genetic factors (91%). Non-shared environmental factors explained the remaining part of the covariance.

CONCLUSIONS

The association between adult ADHD symptoms and binge-eating behavior in females is largely explained by shared genetic risk factors.

Risk of eating disorders in immigrant populations

OBJECTIVE

The risk of certain psychiatric disorders is elevated among immigrants. To date, no population studies on immigrant health have addressed eating disorders. We examined whether risk of eating disorders in first- and second-generation immigrants differs from native-born Danes and Swedes.

METHOD

All individuals born 1984-2002 (Danish cohort) and 1989-1999 (Swedish cohort) and residing in the respective country on their 10th birthday were included. They were followed up for the development of eating disorders based on out-patient and in-patient data.

RESULTS

The risks of all eating disorder types were lower among first-generation immigrants compared to the native populations: Incidence-rate ratio (95% confidence interval) was 0.39 (0.29, 0.51) for anorexia nervosa, 0.60 (0.42, 0.83) for bulimia nervosa, and 0.62 (0.47, 0.79) for other eating disorders in Denmark and 0.27 (0.21, 0.34) for anorexia nervosa, 0.30 (0.18, 0.51) for bulimia nervosa, and 0.39 (0.32, 0.47) for other eating disorders in Sweden. Likewise, second-generation immigrants by both parents were at lower risk, whereas those with only one foreign-born parent were not.

CONCLUSION

The decreased risk of eating disorders among immigrants is opposite to what has been observed for other psychiatric disorders, particularly schizophrenia. Possible explanations include buffering sociocultural factors and underdetection in health care.

Paternal age at childbirth and eating disorders in offspring

BACKGROUND

Advanced paternal age at childbirth is associated with psychiatric disorders in offspring, including schizophrenia, bipolar disorder and autism. However, few studies have investigated paternal age's relationship with eating disorders in offspring. In a large, population-based cohort, we examined the association between paternal age and offspring eating disorders, and whether that association remains after adjustment for potential confounders (e.g. parental education level) that may be related to late/early selection into fatherhood and to eating disorder incidence.

METHOD

Data for 2 276 809 individuals born in Sweden 1979-2001 were extracted from Swedish population and healthcare registers. The authors used Cox proportional hazards models to examine the effect of paternal age on the first incidence of healthcare-recorded anorexia nervosa (AN) and all eating disorders (AED) occurring 1987-2009. Models were adjusted for sex, birth order, maternal age at childbirth, and maternal and paternal covariates including country of birth, highest education level, and lifetime psychiatric and criminal history.

RESULTS

Even after adjustment for covariates including maternal age, advanced paternal age was associated with increased risk, and younger paternal age with decreased risk, of AN and AED. For example, the fully adjusted hazard ratio for the 45+ years (v. the 25-29 years) paternal age category was 1.32 [95% confidence interval (CI) 1.14-1.53] for AN and 1.26 (95% CI 1.13-1.40) for AED.

CONCLUSIONS

In this large, population-based cohort, paternal age at childbirth was positively associated with eating disorders in offspring, even after adjustment for potential confounders. Future research should further explore potential explanations for the association, including de novo mutations in the paternal germline.

A genome-wide association study of anorexia nervosa

Anorexia nervosa (AN) is a complex and heritable eating disorder characterized by dangerously low body weight. Neither candidate gene studies nor an initial genome-wide association study (GWAS) have yielded significant and replicated results. We performed a GWAS in 2907 cases with AN from 14 countries (15 sites) and 14 860 ancestrally matched controls as part of the Genetic Consortium for AN (GCAN) and the Wellcome Trust Case Control Consortium 3 (WTCCC3). Individual association analyses were conducted in each stratum and meta-analyzed across all 15 discovery data sets. Seventy-six (72 independent) single nucleotide polymorphisms were taken forward for in silico (two data sets) or de novo (13 data sets) replication genotyping in 2677 independent AN cases and 8629 European ancestry controls along with 458 AN cases and 421 controls from Japan. The final global meta-analysis across discovery and replication data sets comprised 5551 AN cases and 21 080 controls. AN subtype analyses (1606 AN restricting; 1445 AN binge-purge) were performed. No findings reached genome-wide significance. Two intronic variants were suggestively associated: rs9839776 (P=3.01 × 10(-7)) in SOX2OT and rs17030795 (P=5.84 × 10(-6)) in PPP3CA. Two additional signals were specific to Europeans: rs1523921 (P=5.76 × 10(-)(6)) between CUL3 and FAM124B and rs1886797 (P=8.05 × 10(-)(6)) near SPATA13. Comparing discovery with replication results, 76% of the effects were in the same direction, an observation highly unlikely to be due to chance (P=4 × 10(-6)), strongly suggesting that true findings exist but our sample, the largest yet reported, was underpowered for their detection. The accrual of large genotyped AN case-control samples should be an immediate priority for the field.

Cannabis use in the last year in a US national sample of twin and sibling pairs

BACKGROUND

Three prior population-based twin studies, none of which was nationally representative, suggested that both genetic and familial-environmental factors contribute to family resemblance for lifetime cannabis use. We seek to replicate these results in a US national probability sample of twin and sibling pairs examining only last year cannabis use.

METHODS

Cannabis use in the last year was assessed by self-report questionnaire. Biometrical twin analyses were performed.

RESULTS

Twin and sibling resemblance for last-year cannabis use was substantial, and much higher in monozygotic pairs than in dizygotic and sibling pairs, where levels of resemblance were similar. Modeling suggested that sibling resemblance was due to genetic factors--with a heritability of at least 60% and probably family environmental factors. No evidence was found that cannabis use was influenced by a special twin environment.

CONCLUSIONS

Consistent with prior studies, use of cannabis is substantially influenced by genetic factors but family-environment is also possibly of importance.

Gender differences in the rates of exposure to stressful life events and sensitivity to their depressogenic effects

OBJECTIVE

Women are at greater risk for major depression than men. The authors sought to determine whether the gender difference in prevalence for major depression was due to more frequent exposure to stressful life events and/or greater sensitivity to their depressogenic effects.

METHOD

Male-male, female-female, and male-female twin pairs from a population-based registry were personally interviewed. Each interview assessed the occurrence, to the nearest month, of 18 personal and social network classes of stressful life events and episode onsets of major depression. Standard logistic regression analyses were conducted for the same-sex pairs, and each female twin in the opposite-sex pairs was compared with her male co-twin by using conditional logistic regression.

RESULTS

Women consistently reported higher rates of housing problems, loss of confidant, crises and problems getting along with individuals in their proximal network, and illness of individuals within their distal network. In both the same-sex and opposite-sex samples, men reported higher rates of job loss, legal problems, robbery, and work problems. Consistent sex differences in the depressogenic effect of stressful life events were seen for three event categories: men were more sensitive to the depressogenic effects of divorce or separation and work problems; women were more sensitive to the depressogenic effects of problems getting along with individuals in their proximal network. None of the gender difference in prevalence of major depression could be explained by differing rates of or sensitivities to stressful life events.

CONCLUSIONS

Women reported more interpersonal whereas men reported more legal and work-related stressful life events. Most life event categories influenced the risk for major depression similarly in the two sexes. The results suggest that the greater prevalence of major depression in women versus men is due neither to differences in the rates of reported stressful life events nor to differential sensitivity to their pathogenic effect.

Genetic risk, number of previous depressive episodes, and stressful life events in predicting onset of major depression

OBJECTIVE

The association between stressful life events and the onset of major depression decreases as the number of previous depressive episodes increases. How do genetic risk factors for major depression impact on this "kindling" phenomenon? In particular, do those at high genetic risk exhibit an increase in the speed of kindling, or are they "prekindled"?

METHOD

Using discrete-time survival analysis, the authors examined the interaction between genetic risk, number of previous depressive episodes, and life event exposure in the prediction of episodes of major depression in female-female twin pairs from a population-based registry. The twins were interviewed four times over a 9-year period, producing 92,521 person-months of exposure.

RESULTS

The decline in the association between stressful life events and risk for major depression as the number of previous depressive episodes increased was strongest in those at low genetic risk and was weak to absent in those at high genetic risk. In the absence of previous depressive episodes, those at high genetic risk frequently experienced depressive episodes without major environmental stressors.

CONCLUSIONS

Genetic risk factors for depression produce a "prekindling" effect rather than increase the speed of kindling. The "kindled" state, wherein depressive episodes occur with little provocation, may be reached by two pathways: many previous depressive episodes, perhaps driven by multiple adversities, and high genetic risk.

Sexual orientation in a U.S. national sample of twin and nontwin sibling pairs

OBJECTIVE

Although previous studies have suggested that sexual orientation is influenced by familial factors, which may be partly genetic, these studies have relied on unrepresentative and potentially biased samples. The authors attempted to estimate the role of genetic and environmental factors in the determination of sexual orientation in a more representative sample.

METHOD

Sexual orientation was assessed by a single item on a self-report questionnaire in a U.S. national sample of twin and nontwin sibling pairs. Sexual orientation was classified as heterosexual or nonheterosexual (bisexual or homosexual). The authors compared the similarity of sexual orientation in the monozygotic twins to the similarity in the same-sex dizygotic twins, all dizygotic twins, the same-sex dizygotic twins and sibling pairs, and all dizygotic twins and sibling pairs. Biometrical twin analyses were performed.

RESULTS

All analyses demonstrated familial resemblance for sexual orientation. Resemblance was greater in the monozygotic twins than in the dizygotic twins or in the dizygotic twins plus nontwin siblings. Biometrical twin modeling suggested that sexual orientation was substantially influenced by genetic factors, but family environment may also play a role. No evidence was found for a violation of the equal-environment assumption regarding monozygotic and dizygotic twin pairs.

CONCLUSIONS

Familial factors, which are at least partly genetic, influence sexual orientation. The results of these analyses should be interpreted in the context of low statistical power and the use of a single item to assess the complex phenotype of sexual orientation.

Tobacco consumption in Swedish twins reared apart and reared together

BACKGROUND

Prior studies of twins reared together suggest that regular tobacco use (RTU) is substantially heritable. However, strong social influences on RTU might have biased these results.

METHODS

We examine the self-report lifetime history of RTU in members of 778 male-male and female-female twin pairs, raised together and apart, born from 1890 to 1958 and ascertained through the population-based Swedish Twin Registry.

RESULTS

In men, the pattern of twin resemblance for RTU suggested both genetic and rearing-environmental effects, which, in the best-fit biometrical model, accounted for 61% and 20% of the variance in liability to RTU, respectively. For women, overall results were hard to interpret, but became clearer when divided by birth cohort. In women born before 1925, rates of RTU were low and twin resemblance was environmental in origin. In later cohorts, rates of RTU in women increased substantially, as did heritability. For women born after 1940, heritability of RTU was similar to that seen in men (63%).

CONCLUSIONS

Genetic factors play an important etiologic role in RTU. In women, the impact of genetic factors increased in more recent cohorts, suggesting that, as social restrictions on female tobacco use relaxed over time, heritable influences increased in importance.

Stressful life events and previous episodes in the etiology of major depression in women: an evaluation of the "kindling" hypothesis

OBJECTIVE

Although previous evidence has suggested that the etiologic role of stressful life events in major depression is reduced in recurrent versus first-onset cases, this question deserves reexamination because of potential methodological limitations of the previous studies.

METHOD

Members of female-female twin pairs from a population-based registry (N=2,395), who were interviewed four times over a period of 9 years, formed a study group that contained 97,515 person-months and 1,380 onsets of major depression. Discrete-time survival, proportional hazards model, and piece-wise regression analyses were used to examine the interaction between life event exposure and number of previous depressive episodes in the prediction of episodes of major depression.

RESULTS

For those with zero to nine previous depressive episodes, the depressogenic effect of stressful life events declined substantially with increasing episode number. However, the association between stressful life events and major depression was not substantially influenced by additional episodes. This pattern of results was robust to the addition of indices of event severity, measures of genetic risk, and restriction to independent stressful life events. The same pattern was also seen upon examining within-person changes in number of episodes.

CONCLUSIONS

The association between previous number of depressive episodes and the pathogenic impact of stressful life events on major depression is likely causal and biphasic. Through approximately nine episodes, the association between stressful life event exposure and risk of major depression progressively declines but is largely unchanged with further episodes. These results are consistent with the kindling hypothesis but suggest a threshold at which the mind/brain is no longer additionally sensitized to the depressive state.

Nursing algorithms

The search for creative approaches to staffing never ceases. What is correct staffing planning? How do you achieve control over your staffing budget? How do you justify your budget to the hospital's financial officer? This article presents one hospital's modeling technique for projecting labor component budgets, establishing a flexible staffing assignment system, and instituting reporting systems for control.