Safety of fluconazole in kidney transplant recipients for prevention of coccidioidomycosis

Coccidioides is an endemic fungus that causes infections ranging from mild respiratory illness to life-threatening disease, and immunocompromised hosts such as solid organ transplant recipients are at higher risk for disseminated infection and mortality. Our center administers fluconazole prophylaxis to kidney transplant recipients residing in geographic areas with higher incidences of coccidioidomycosis. However, because drug-drug interactions occur between triazoles and immunosuppressants used in transplant medicine, we undertook a study to ascertain whether fluconazole prophylaxis was associated with any important safety outcomes in kidney transplant recipients. This retrospective study evaluated patients who had undergone kidney transplantation between 2016 and 2019. Data on patient demographics, transplant-related clinical information, use of fluconazole prophylaxis (200 mg daily for 6-12 months post-transplant), and patient outcomes were obtained. The primary outcome was mean estimated glomerular filtration rate (eGFR) at 12 months, comparing those who received fluconazole prophylaxis to those who did not. Secondary outcomes included mean eGFR at 3 months, 6 months, and 9 months post-transplant, patient survival, biopsy-proven graft rejection, graft loss, or a new requirement for post-transplant dialysis, all within 12 months post-transplant. The mean eGFR at 12 months was similar between both groups, with 66.4 ml/min/1.73 m² in the fluconazole prophylaxis group vs. 64.3 ml/min/1.73 m² in the non-fluconazole prophylaxis group (P = 0.55). Secondary outcomes were similar across both groups. Multivariable linear regression found no significant association between fluconazole use and graft function. Fluconazole prophylaxis for prevention of coccidioidomycosis was not associated with adverse graft outcomes in kidney transplant recipients.

Performance of CT With Adrenal-Washout Protocol in Heterogeneous Adrenal Nodules: A Multiinstitutional Study

Background: Adrenal-protocol CT is commonly performed to distinguish adrenal adenomas from other adrenal tumors. However, the technique's utility among heterogeneous nodules is not well established, and the optimal method for placing ROIs in heterogeneous nodules is not clearly defined. Objective: To determine the diagnostic performance of adrenal-protocol CT to distinguish adenomas from non-adenomas among heterogeneous adrenal nodules, and to compare this performance among different methods for ROI placement. Methods: This retrospective study including 164 patients (mean age, 59.1 years; 61 men, 103 women) from seven institutions, with a total of 164 heterogeneous adrenal nodules evaluated by adrenal-protocol CT. All nodules had an available pathologic reference standard. A single investigator at each institution evaluated CT images. ROIs were placed on portal venous phase images using four ROI methods: standard ROI, single large ROI in nodule center; high ROI, single ROI on nodule's highest-attenuation area; low ROI, single ROI on nodule's lowest-attenuation; average ROI: mean of three ROIs on nodule's superior, middle, and inferior thirds using the approach for the standard ROI. ROIs were then placed in identical locations on unenhanced and delayed phases. Absolute washout was determined for all methods. Results: The nodules comprised 82 adenomas and 82 non-adenomas (36 pheochromocytomas, 20 metastases, 12 adrenocortical carcinomas, and 14 with other pathologies). Mean nodule size was 4.5±2.8 cm (range, 1.6-23.0 cm). Unenhanced CT attenuation of 10 HU or less exhibited sensitivity and specificity for adenoma of 22.0% and 96.3% for standard ROI, 11.0% and 98.8% for high ROI, 58.5% and 84.1% for low ROI, and 30.5% and 97.6% for average ROI methods. Adrenal-protocol CT overall (unenhanced attenuation of 10 HU or less, or absolute washout of 60% or greater) exhibited sensitivity and specificity for adenoma of 57.3% and 84.1% for standard ROI, 63.4% and 51.2% for high ROI, 68.3% and 62.2% for low ROI, and 59.8% and 85.4% for average ROI methods. Conclusion: Adrenal-protocol CT has poor diagnostic performance for distinguishing adenomas from non-adenomas among heterogeneous adrenal nodules, regardless of the method used for ROI placement. Clinical Impact: Adrenal-protocol CT has limited utility in the evaluation of heterogeneous adrenal nodules.

Correlation between epidural space depth measured with ultrasound and MRI compared to clinical loss of resistance when performing lumbar epidural steroid injection

BACKGROUND

This prospective study assessed the accuracy of MRI and ultrasound (US) measurements as a preprocedural assessment tool for predicting clinical loss of resistance depth (CLORD) during fluoroscopy-guided lumbar epidural steroid injections (ESIs).

MATERIALS AND METHODS

Sixty patients enrolled received lumbar ESIs at an academic chronic pain clinic. The MRI measurement calculated the distance between the skin and the posterior epidural space, while US measurements included transverse and parasagittal oblique views of the interlaminar space. The epidural space measurements were compared with the CLORD during the performance of the prone epidural injections. The differences in measurements were analyzed using two one-sided tests for equivalency with a 0.5 equivalency margin. The intraclass correlation coefficients between CLORD and the imaging modalities were estimated using mixed effects models.

RESULTS

MRI was equivalent to CLORD with a mean difference of -0.2 cm (95% CI -0.39 to -0.11). US transverse and US parasagittal oblique measurements were not equivalent to and underestimated CLORD with mean differences of -0.98 cm (90% CI -1.8 to -0.77) and -0.79 cm (90% CI -1.0 to -5.9), respectively. The intraclass correlation coefficients between MRI and CLORD were the highest at 0.85, compared with 0.65 and 0.73 for transverse and parasagittal oblique US views, respectively.

CONCLUSIONS

MRI measurements are preferable over US for preprocedural assessment of patients receiving lumbar ESIs for predicting CLORD.

Comparison of coccidioidal complement fixation and quantitative immunodiffusion serology at a reference laboratory

The incidence of coccidioidomycosis continues to increase. The diagnosis frequently relies on non-invasive diagnostic testing with immunodiffusion and complement fixation (CF) testing the current gold standard. A direct comparison of quantitative immunodiffusion and CF for IgG antibodies has not been previously reported. In a comparison of 368 samples, there was close concordance observed (360/368 = 97.8%) (P-value < .001). These tests can be considerably interchangeable in the reference laboratory setting.

Treatment Outcomes With Conservative Management of Frontal Sinus Outflow Tract Fractures

OBJECTIVE

Historically, early surgical management of frontal sinus outflow tract (FSOT) fractures has been standard practice. There has been a paradigm shift toward nonsurgical or delayed management. Unfortunately, clinical indications and treatment outcomes for this approach are poorly understood. This study evaluates radiologic indicators, as well as sinus reaeration and complication rates for FSOT injuries treated nonsurgically.

STUDY DESIGN

A retrospective cohort study of FSOT injuries between 2005 and 2019.

SETTING

Academic, tertiary care medical center.

METHODS

Radiographic fracture patterns of the frontal ostia (FO) and frontal recess (FR) were recorded as either patent, disrupted, or obstructed. Sinus reaeration, surgical rescue, and complication rates were documented. Patients with follow-up imaging >42 days were included. Patients undergoing immediate surgical intervention were excluded.

RESULTS

One hundred patients were identified and 44 met the criteria (88 sinuses). Among nonobstructed FSOT injuries (ie, patent or disrupted), reaeration occurred in 91% of the FO and 98% of FR injuries. Two sinuses required surgical rescue including 1 Draf IIB (1%), and 1 obliteration (1%). Two sinuses had complications including 1 mucocele (1%) and 1 cerebrospinal fluid leak (1%). FO and FR fracture patterns had no identifiable correlation with long-term reaeration rates or the need for surgical intervention.

CONCLUSION

Among nonobstructive injuries to the FSOT, average reaeration rates in observed patients were high (91%-98%). Rescue surgery (2%) and complication rates (2%) were low, suggesting that nonsurgical management of nonobstructed FSOT is a viable strategy. No radiographic features were clearly identified to be predictive of sinus reaeration.

Association of Parity and Previous Birth Outcome With Brachial Plexus Birth Injury Risk

OBJECTIVE

To evaluate the association of maternal delivery history with a brachial plexus birth injury risk in subsequent deliveries and to estimate the effect of subsequent delivery method on brachial plexus birth injury risk.

METHODS

We conducted a retrospective cohort study of all live-birth deliveries occurring in California-licensed hospitals from 1996 to 2012. The primary outcome was recurrent brachial plexus birth injury in a subsequent pregnancy. The exposure was delivery history (parity, shoulder dystocia in a previous delivery, or previously delivering a neonate with brachial plexus birth injury). Multiple logistic regression was used to model adjusted associations of delivery history with brachial plexus birth injury in a subsequent pregnancy. The adjusted risk and adjusted risk difference for brachial plexus birth injury between vaginal and cesarean deliveries in subsequent pregnancies were determined, stratified by delivery history, and the number of cesarean deliveries needed to prevent one brachial plexus birth injury was determined.

RESULTS

Of 6,286,324 neonates delivered by 4,104,825 individuals, 7,762 (0.12%) were diagnosed with a brachial plexus birth injury. Higher parity was associated with a 5.7% decrease in brachial plexus birth injury risk with each subsequent delivery (adjusted odds ratio [aOR] 0.94, 95% CI 0.92-0.97). Shoulder dystocia or brachial plexus birth injury in a previous delivery was associated with fivefold (0.58% vs 0.11%, aOR 5.39, 95% CI 4.10-7.08) and 17-fold (1.58% vs 0.11%, aOR 17.22, 95% CI 13.31-22.27) increases in brachial plexus birth injury risk, respectively. Among individuals with a history of delivering a neonate with a brachial plexus birth injury, cesarean delivery was associated with a 73.0% decrease in brachial plexus birth injury risk (0.60% vs 2.21%, aOR 0.27, 95% CI 0.13-0.55) compared with an 87.9% decrease in brachial plexus birth injury risk (0.02% vs 0.15%, aOR 0.12, 95% CI 0.10-0.15) in individuals without this history. Among individuals with a history of brachial plexus birth injury, 48.1 cesarean deliveries are needed to prevent one brachial plexus birth injury.

CONCLUSIONS

Parity, previous shoulder dystocia, and previously delivering a neonate with brachial plexus birth injury are associated with future brachial plexus birth injury risk. These factors are identifiable prenatally and can inform discussions with pregnant individuals regarding brachial plexus birth injury risk and planned mode of delivery.

The Impact of Surgical Posterior Nasal Nerve Cryoablation on Symptoms and Disease-Specific Quality of Life in Patients With Chronic Rhinitis

OBJECTIVE

Preliminary data have demonstrated long-term efficacy of posterior nasal nerve (PNN) cryoablation in reducing rhinitis symptoms for patients with allergic rhinitis (AR) and nonallergic rhinitis (NAR). We sought to evaluate the impact of procedural cryoablation of the PNN on quality of life (QOL) in patients with AR and NAR.

METHODS

Adult patients undergoing PNN cryoablation for AR or NAR after appropriate medical therapy were included for analysis. Demographics, medical therapies, baseline rhinitis symptom (total nasal symptom score [TNSS]), and disease-specific QOL (mini-rhinoconjunctivitis quality of life questionnaire [mini-RQLQ]) were recorded. The Wilcoxon signed-rank test was used to test for significant changes in baseline test scores posttreatment. Absolute and relative improvement in outcomes was determined for each participant. Secondary outcomes were assessed with univariate and multivariate analyses.

RESULTS

Fourteen patients were enrolled with a mean follow-up of 16.5 weeks. The TNSS and mini-RQLQ scores significantly improved after PNN cryoablation (median δs [interquartile range]: -4 [3] and -1.61 [1.08], respectively; both P = .0002). The minimal clinically important difference for the TNSS and mini-RQLQ was obtained in 92.9% of patients in each category. Relative mean percentage (%) improvement after PNN cryoablation in the TNSS and mini-RQLQ was 40.7% and 40.5% (standard deviation = 24.9 and 29.5, respectively), respectively, for all patients. Patients with NAR (n = 10) reported mean improvement of 41.3% (29.1) as measured by the TNSS and 49.6% (25.9) by mini-RQLQ. Patients with AR reported mean percentage improvement in TNSS and mini-RQLQ scores of 39.5% (12.1) and 24.6% (28.5), respectively. Patients who had been prescribed a nasal anticholinergic for management prior to PNN cryoablation had statistically significantly increased improvement in mini-RQLQ scores from pre- to post-procedure (P = .0387).

CONCLUSION

Surgical cryoablation of the PNN significantly improves both symptoms and disease-specific QOL in majority of patients with AR and NAR.

Characteristics and outcomes of patients undergoing second-trimester dilation and evacuation for intrauterine fetal demise vs induced abortion

OBJECTIVES

Patients with intrauterine fetal demise (IUFD) are at higher risk of complications when undergoing dilation and evacuation (D&E) compared to patients undergoing abortion for other indications. We aimed to compare baseline characteristics and describe outcomes, including frequencies of complications such as disseminated intravascular coagulation (DIC) and hemorrhage, in patients undergoing D&E for IUFD vs induced abortion, with a goal of identifying associated risk factors for complications.

STUDY DESIGN

We conducted a retrospective matched cohort study of patients undergoing nonemergent D&Es for singleton ≥14-0/7-week IUFD January 1, 2019 to May 31, 2021, matched with two patients undergoing induced second-trimester D&Es by cesarean delivery history, patient age, and gestational age (GA). We collected demographics, history, GA, coagulation studies, quantitative blood loss (QBL), and complications. We calculated descriptive statistics and tested for association using chi-square, Fisher's exact, t, and Wilcoxon's rank sum tests.

RESULTS

Of 1390 procedures, 64 patients with IUFD met inclusion criteria and were matched with 128 patients undergoing induced D&E. Eight (12.5%) patients with IUFD and six (4.7%) undergoing induced D&E had hemorrhage (odds ratio [OR] = 2.90, 95% confidence interval [0.96, 8.77]). Six (9.4%) patients with IUFD and none undergoing induced D&E had DIC (OR = 28.56 [1.58, 515.38]). Median QBL was 75.0 mL (50, 162.5) for patients with IUFD vs 110.0 mL (50, 200) for those undergoing induced D&E (p = 0.083). Twelve (18.8%) patients with IUFD vs seven (5.5%) undergoing induced D&E received at least one intervention due to bleeding complications (p = 0.004).

CONCLUSIONS

We found a higher DIC frequency but no significant difference in hemorrhage or QBL in IUFD D&E compared to induced abortion. Our IUFD D&E complication frequency is higher than those previously published.

IMPLICATIONS

Our results affirm current standards of care for D&E in patients with IUFD. Large referral centers may have higher proportions of complications compared to other sites.

Are There Ultrasound Features to Distinguish Small (<3 cm) Peripheral Renal Angiomyolipomas From Renal Cell Carcinomas?

BACKGROUND

Small echogenic renal masses are usually angiomyolipomas (AMLs), but some renal cell carcinomas (RCCs) can be echogenic and confused with an AML.

OBJECTIVES

This is a study to evaluate any distinguishing demographic and sonographic features of small (<3 cm) peripheral AMLs versus peripheral RCCs.

METHODS

This is a HIPAA-compliant retrospective review of the demographics and ultrasound features of peripheral renal AMLs compared with a group of peripheral RCCs. All AMLs had confirmation of macroscopic fat as noted on thin-cut CT or fat-saturation MRI sequence images. All RCCs were pathologically proven. Statistical analysis was used to compare findings in the two groups.

RESULTS

There were a total of 52 patients with 56 AMLs, compared with 42 patients with 42 RCCs. There were 42 females in the AML group versus 10 females in the RCC group (P < .0001). The AML diameters (15.7 mm × 12.0 mm) were statistically significantly smaller (Plargest  = .0085, Psmallest  < .001) than the diameters of the RCCs (19.9 mm × 18.5 mm). Ultrasound features found to be statistically different between the two groups were the ratio of the largest dimension to the smallest dimension (P < .001), a lobulated versus smooth margin of the AML (26 vs 30) compared with the RCC group (3 vs 39) (P = .0012), and an "unusual" versus a round shape (P < .001) of the AML group (45 vs 11) compared with the RCC group (9 vs 33). In the multivariable model, the patient sex, margin, and mass shape were predictive of AML, with an area under the receiver operating characteristic curve of 0.92.

CONCLUSION

For a small (<3 cm) peripheral echogenic mass in a female patient, a lobulated lesion with an unusual shape is highly predictive of being an AML.

Comparison of Time Within Therapeutic Range Using Anti-Factor Xa Versus Activated Partial Thromboplastin Time Monitoring of Unfractionated Heparin in Children

OBJECTIVE

To compare unfractionated heparin (UFH) monitoring using time in therapeutic range of activated partial thromboplastin time (aPTT) versus anti-factor Xa activity (anti-Xa) in children.

METHODS

This retrospective chart review, with data between October 2015 and October 2019, included pediatric patients younger than 18 years on therapeutic UFH infusion with aPTT or anti-Xa monitoring. Patients receiving extracorporeal membrane oxygenation, dialysis, concomitant anticoagulants, prophylactic UFH, no stated goal, and UFH administered for less than 12 hours were excluded. The primary outcome compared the percentage of time in therapeutic range between aPTT and anti-Xa. Secondary outcomes included time to first therapeutic value, UFH infusion rates, mean rate adjustments, and adverse events.

RESULTS

A total of 65 patients were included, with 33 aPTT patients and 32 anti-Xa patients, representing 39 UFH orders in each group. Baseline characteristics were similar between groups, with an overall mean age of 1.4 years and mean weight of 6.7 kg. The anti-Xa cohort demonstrated a statistically significantly higher percentage of time in therapeutic range compared with the aPTT group (50.3% vs 26.9%, p = 0.002). The anti-Xa group also demonstrated a trend toward decreased time to first therapeutic value compared with aPTT (14 vs 23.2 hours, p = 0.12). Two patients in each group experienced new or worsening thrombosis. Six patients in the aPTT cohort experienced bleeding.

CONCLUSIONS

This study demonstrated greater time was spent within therapeutic range for children receiving UFH monitored with anti-Xa compared with aPTT. Future studies should assess clinical outcomes in a larger population.

Maternal Epidemiology of Brachial Plexus Birth Injuries in California: 1996-2012

Objective To evaluate the incidence of brachial plexus birth injury (BPBI) and its associations with maternal demographic factors. Additionally, we sought to determine whether longitudinal changes in BPBI incidence differed by maternal demographics. Methods We conducted a retrospective cohort study of over 8 million maternal-infant pairs using California's Office of Statewide Health Planning and Development Linked Birth Files from 1991-2012. Descriptive statistics were used to determine BPBI incidence and the prevalence of maternal demographic factors (race, ethnicity, age). Multivariable logistic regression was used to determine associations of year, maternal race, ethnicity, and age with BPBI. Excess population level risk associated with these characteristics was determined by calculating population attributable fractions. Results The incidence of BPBI between 1991-2012 was 1.28 per 1000 live births, with peak incidence of 1.84 per 1000 in 1998 and low of 0.9 per 1000 in 2008. Incidence varied by demographic group, with infants of Black (1.78 per 1000) and Hispanic (1.34 per 1000) mothers having higher incidences compared to White (1.25 per 1000), Asian (0.8 per 1000), Native American (1.29 per 1000), Other race (1.35 per 1000), and Non-Hispanic (1.15 per 1000) mothers. After controlling for delivery method, macrosomia, shoulder dystocia, and year, infants of Black (AOR=1.88, 95% CI 1.70, 2.08), Hispanic (AOR=1.25, 95% CI 1.18, 1.32) and advanced-age mothers (AOR=1.16, 95% CI 1.09, 1.25) were at increased risk. Disparities in risk experienced by Black, Hispanic, and advanced-age mothers contributed to a 5%, 10%, and 2% excess risk at the population level, respectively. Longitudinal trends in incidence did not vary among demographic groups. Population-level changes in maternal demographics did not explain changes in incidence over time. Conclusions Although BPBI incidence has decreased in California, demographic disparities exist. Infants of Black, Hispanic, and advanced-age mothers are at increased BPBI risk compared to White, Non-Hispanic, and younger mothers.

Clinical interventions are more accurate than quantitative measurements for defining hemorrhage with dilation and evacuation

OBJECTIVES

To assess if quantitative blood loss (QBL) with dilation and evacuation (D&E) procedures correlated with clinically relevant outcomes or hemorrhage.

STUDY DESIGN

We used a de-identified database to review D&E procedures performed at UC Davis Health from April 2019 through March 2020. Surgeons determined QBL during procedures and estimated blood loss, when excessive, during post-procedure recovery. We extracted patient demographic and procedure-related information. We defined clinically relevant bleeding as cases with bleeding-related interventions within 24 hours post-procedure including use of ≥2 uterotonics, tranexamic acid administration, cervical injury requiring repair, uterine balloon tamponade, blood transfusion, uterine artery embolization, hospitalization, or return to operating room; the latter 5 criteria defined hemorrhage. We used χ2 test for trend to evaluate bleeding outcomes.

RESULTS

We evaluated 431 procedures with a mean gestational age of 19 weeks and 3 days. Clinically relevant bleeding outcomes occurred in 6/319 (2%), 15/97 (15%) and 7/12 (58%) patients with total blood loss <250mL, 250-500mL and >500mL, respectively (p<0.0001); 11 had bleeding related to cervical injuries. Hemorrhage occurred in 0, 4/97 (4%) and 5/12 (42%) patients, respectively (p<0.0001). Patients with relevant bleeding outcomes had QBLs ranging from 150-1800mL (median QBL 312.5mL, interquartile range [IQR] 250-550mL) while those without clinically relevant bleeding ranged from 10-900mL (median QBL 150mL, IQR 75-200mL).

CONCLUSION

Most patients (75%) with clinically relevant bleeding outcomes had QBL ≤500mL. Although higher QBL correlates with clinical interventions, the need for significant interventions rather than a single blood loss amount should be used to define hemorrhage with D&E procedures.

IMPLICATIONS

Clinical hemorrhage is best defined by the necessary clinical interventions required to manage bleeding rather than any quantified amount of blood loss.

The classical and alternative circulating renin-angiotensin system in normal dogs and dogs with stage B1 and B2 myxomatous mitral valve disease

BACKGROUND

The behavior of the comprehensive circulating renin-angiotensin system (RAS) in dogs with myxomatous mitral valve disease (MMVD) before to the onset of congestive heart failure remains largely unexplored.

HYPOTHESIS/OBJECTIVES

The classical and alternative RAS activity and aldosterone concentrations will be significantly higher in dogs with American College of Veterinary Internal Medicine (ACVIM) stage B2 MMVD compared to normal dogs and dogs with ACVIM stage B1 MMVD.

ANIMALS

One-hundred seventeen client-owned dogs (normal = 60; B1 = 31; B2 = 26).

METHODS

Prospective observational study. Angiotensin peptides (AP) and aldosterone concentrations were measured using liquid chromatography and mass spectrometry. Angiotensin converting enzymes 1 and 2 (ACE, ACE2) and renin activity surrogates were calculated from AP concentrations. Equilibrium dialysis (ED) and immediate protease inhibition (PI) methods of AP quantification were compared in 14 healthy dogs.

RESULTS

Core RAS activity and aldosterone concentrations did not differ among the 3 groups. However, the balance between the alternative and classical RAS differed, with dogs with stage B2 MMVD having significantly higher ACE2 activity surrogate (ACE2_surr ) when compared to normal dogs (adjusted P = .02; ratio of medians for ACE2_surr [B2:normal], 1.89; 95% confidence interval [CI]: 1.4-2.6). The ED and PI methods of AP quantification were highly correlated (AngI, r = .9, P < .0001; AngII, r = .8, P = .001).

CONCLUSIONS AND CLINICAL IMPORTANCE

Circulating alternative RAS activity, specifically the surrogate measure of ACE2 activity, was increased in dogs with stage B2 MMVD as compared to normal dogs. Equilibrium dialysis results are analogous to immediate protease inhibition in dogs.

Complex Family Planning fellowship graduates' intended practice plans and barriers to practicing in areas of unmet need

OBJECTIVE

To describe practice patterns and challenges encountered by Complex Family Planning (CFP) fellowship graduates.

STUDY DESIGN

We invited all 110 obstetrics and gynecology physicians who graduated from the CFP fellowship from 2017-2020 via email to complete an anonymous online survey. We inquired about demographics, intended and obtained post-fellowship positions, and successes and challenges in obtaining jobs. We used Fisher exact test to assess if the proportion of graduates who grew up, attended residency, and completed fellowship in a U.S. region (Northeast, Midwest, South, and West) and practiced in that same region differed.

RESULTS

Ninety-nine (90.0%) graduates completed the survey. When entering fellowship, most (n=92 [92.9%]) expected to practice in an academic environment. About half (n=49 [49.5%]) pursued fellowship with the intent to practice in a location with an unmet need for abortion providers, of which 22 (44.9%) did so. Forty-nine (49.5%) respondents did not practice after fellowship where they initially intended, citing common challenges of job availability, family-related concerns, safety concerns, and relationship status changes. We found associations between regions where graduates completed residency and currently practice (p=.004), driven primarily by higher associations in the South (76.9%) and West (70.6%) and a lower association in the Midwest (22.7%). We found no association between current practice region and where graduates grew up (p=.15) or completed fellowship (p=.23).

CONCLUSIONS

CFP fellowship graduates from 2017-2020 primarily intended to practice in academic environments with half planning to practice in underserved locations. However, more than half of those who entered fellowship hoping to fill an unmet need for abortion providers did not do so.

Upper Instrumented Vertebrae, Number of Levels Fused, and Plate Morphology Do Not Affect Severity of Chronic Dysphagia After Anterior Cervical Spine Surgery

BACKGROUND

Disordered swallowing, or dysphagia, is the most common complication after anterior cervical spine (ACS) surgery. Many operative factors are associated with development of dysphagia. The aim of this study was to explore how number of levels instrumented, specific levels fused, and plate morphology affect chronic dysphagia after ACS surgery.

METHODS

Consecutive patients referred to a tertiary center for otolaryngology evaluation for chronic dysphagia after ACS surgery between 2012 and 2017 were enrolled. Basic demographic data were obtained. Plain radiographs were reviewed for number of levels fused, upper instrumented vertebrae, and plate morphology. Plate morphology was categorized as a closed, small window, large window, or no profile plate. The 10-item Eating Assessment Tool (EAT-10) was used to assess dysphagia severity.

RESULTS

Of 171 patients referred for dysphagia, 126 met inclusion criteria; 54% were female, with a mean age of 63 years (range, 32-88 years). Mean EAT-10 score was 18.5 ± 10.1. Mean time from spine surgery to videofluoroscopic swallow study for dysphagia was 58.3 months. Mean number of levels fused was 2.2 ± 0.9. There were no significant differences in EAT-10 scores in single-level versus multilevel fusion (19.0 vs. 18.4, P = 0.76) as well as with regard to upper instrumented vertebrae or plate morphology.

CONCLUSIONS

In this series of patients with chronic dysphagia following ACS surgery, the severity of dysphagia as measured by the EAT-10 was not affected by upper instrumented vertebrae, number of levels fused, or plate morphology.

Identification of Demographic and Clinical Prognostic Factors in Traumatic Intraventricular Hemorrhage

BACKGROUND

The presence of traumatic intraventricular hemorrhage (tIVH) following traumatic brain injury (TBI) is associated with worse neurological outcome. The mechanisms by which patients with tIVH have worse outcome are not fully understood and research is ongoing, but foundational studies that explore prognostic factors within tIVH populations are also lacking. This study aimed to further identify and characterize demographic and clinical variables within a subset of patients with TBI and tIVH that may be implicated in tIVH outcome.

METHODS

In this observational study, we reviewed a large prospective TBI database to determine variables present on admission that predicted neurological outcome 6 months after injury. A review of 7,129 patients revealed 211 patients with tIVH on admission and 6-month outcome data. Hypothesized risk factors were tested in univariate analyses with significant variables (p < 0.05) included in logistic and linear regression models. Following the addition of either the Rotterdam computed tomography or Glasgow Coma Scale (GCS) score, we employed a backward selection process to determine significant variables in each multivariate model.

RESULTS

Our study found that that hypotension (odds ratio [OR] = 0.35, 95% confidence interval [CI] = 0.13-0.94, p = 0.04) and the hemoglobin level (OR = 1.33, 95% CI = 1.09-1.63, p = 0.006) were significant predictors in the Rotterdam model, whereas only the hemoglobin level (OR = 1.29, 95% CI = 1.06-1.56, p = 0.01) was a significant predictor in the GCS model.

CONCLUSIONS

This study represents one of the largest investigations into prognostic factors for patients with tIVH and demonstrates that admission hemoglobin level and hypotension are associated with outcomes in this patient population. These findings add value to established prognostic scales, could inform future predictive modeling studies, and may provide potential direction in early medical management of patients with tIVH.

Breastfeeding Perceptions and Behavior Among Postpartum Women Initiating Different Hormonally Systemic Contraceptive Methods

BACKGROUND

There continues to be controversy regarding the simultaneous encouragement of both breastfeeding and immediate postpartum contraception.

RESEARCH AIM

To explore postpartum women's perspectives about breastfeeding and their breastfeeding behaviors, while using one of three different hormonally systemic contraceptive methods immediately postpartum over a 6 month period of time.

METHODS

This was a retrospective, longitudinal, three group comparative, secondary analysis of a prospective cohort study (N = 471) of immediate postpartum contraception. Breastfeeding, for this study, was defined as providing any human milk to the infant. Participants who chose one of three different hormonally systemic forms of contraception immediately postpartum (a long-acting hormonal reversible contraceptive (n = 200), depot medroxyprogesterone acetate 150 mg (n = 98), or a non-hormonal method (n = 173)) were compared at hospital discharge, 6 weeks, 3 months, and 6 months postpartum. The primary outcome was any breastfeeding at 6 months. Secondary outcomes included any and exclusive breastfeeding, concerns about breastfeeding while using contraception, and reasons for breastfeeding discontinuation.

RESULTS

There was no significant difference in the rate of any breastfeeding between the two hormonal and the non-hormonal contraceptive groups at 6 months postpartum (long-acting hormonal 20.1%, non-hormonal 21.7%, depot medroxyprogesterone acetate 13.9%, p = .77, 0.28, respectively). The number of participants who reported stopping breastfeeding due to decreased milk supply was not significantly different between any groups at all time points (total number who discontinued at 6 months postpartum was long-acting hormonal 24.7%, non-hormonal 25.1%, depot medroxyprogesterone acetate 19.3%, p = .30).

CONCLUSIONS

Breastfeeding perspectives and behavioral outcomes over the first 6 months postpartum were not influenced by participants chosen form of immediate postpartum contraception.

Impact of Vaccination on Cost and Course of Hospitalization Associated with COVID-19 Infection

OBJECTIVE

Examine the impact of vaccination status on hospital cost and course for patients admitted with COVID-19 infection.

DESIGN

Retrospective cohort study characterizing vaccinated and unvaccinated individuals hospitalized for COVID-19 between April 2021 to January 2022.

SETTING

Large academic medical center.

METHODS

Patients were included if they were greater than 18 years old, fully vaccinated or unvaccinated against COVID-19, and admitted for COVID-19 infection.

PATIENTS

437 consecutively admitted patients for COVID-19 infection met inclusion criteria. Of these, 79 were excluded for unknown or partial vaccination status, transfer from an outside hospital, or multiple COVID-19 related admissions.

RESULTS

Overall, 279 (77.9%) unvaccinated patients compared to 79 (22.1%) vaccinated patients were hospitalized with a diagnosis of COVID-19. Average length of stay was significantly lower in the vaccinated group (6.47 days versus 8.92 days, P = 0.03). Vaccinated patients experienced a 70.6% lower risk of ICU admission (OR = 0.29, 95% CI 0.12-0.71, P = 0.006). The unadjusted cost of hospitalization was not found to be statistically significant ($119,630 versus $191,146, P = 0.06). After adjusting for age and comorbidities, vaccinated patients experienced a 26% lower cost of hospitalization compared to unvaccinated patients (P = 0.004). Unvaccinated patients incurred a significantly higher cost of hospitalization per day ($29,425 vs $13,845 P < 0.0001). Unvaccinated patients (n = 118, 42.9%) were more likely than vaccinated patients (n = 16, 20.3%) to require high-flow oxygen or mechanical ventilation (OR = 2.95, 95% CI 1.62-5.38, P = 0.0004).

CONCLUSION

Vaccinated patients experienced a lower cost of hospitalization after adjusting for age and comorbidities and shorter length of stay compared to unvaccinated patients admitted for COVID-19.

Chronic Exposure to Low Levels of Parabens Increases Mammary Cancer Growth and Metastasis in Mice

Methylparaben (MP) and propylparaben (PP) are commonly used as food, cosmetic, and drug preservatives. These parabens are detected in the majority of US women and children, bind and activate estrogen receptors (ER), and stimulate mammary tumor cell growth and invasion in vitro. Hemizygous B6.FVB-Tg (MMTV-PyVT)634Mul/LellJ female mice (n = 20/treatment) were exposed to MP or PP at levels within the US Food and Drug Administration's "human acceptable daily intake." These paraben-exposed mice had increased mammary tumor volume compared with control mice (P < 0.001) and a 28% and 91% increase in the number of pulmonary metastases per week compared with the control mice, respectively (P < 0.0001). MP and PP caused differential expression of 288 and 412 mammary tumor genes, respectively (false discovery rate < 0.05), a subset of which has been associated with human breast cancer metastasis. Molecular docking and luciferase reporter studies affirmed that MP and PP bound and activated human ER, and RNA-sequencing revealed increased ER expression in mammary tumors among paraben-exposed mice. However, ER signaling was not enriched in mammary tumors. Instead, both parabens strongly impaired tumor RNA metabolism (eg, ribosome, spliceosome), as evident from enriched KEGG pathway analysis of differential mammary tumor gene expression common to both paraben treatments (MP, P < 0.001; PP, P < 0.01). Indeed, mammary tumors from PP-exposed mice had an increased retention of introns (P < 0.05). Our data suggest that parabens cause substantial mammary cancer metastasis in mice as a function of their increasing alkyl chain length and highlight the emerging role of aberrant spliceosome activity in breast cancer metastasis.

Utility of combined gadoxetic acid and ferumoxytol-enhanced liver MRI for preoperative detection of colorectal cancer liver metastases: a pilot study

Background

Colorectal cancer (CRC) is the second-leading cause of cancer-related death worldwide and resection of CRC metastases confined to the liver is the treatment of choice when feasible. Ferumoxytol is an off-label contrast agent that opacifies vasculature and may be helpful in distinguishing metastases from small hemangiomas and blood vessels on gadoxetic acid-enhanced magnetic resonance imaging (MRI).

Purpose

To compare the diagnostic accuracy of MRI using a standard gadoxetic acid protocol and a combined gadoxetic acid/ferumoxytol protocol in patients with suspected colorectal hepatic metastases.

Material and Methods

In this institutional review board-approved, single-institution, retrospective study, eight patients underwent gadoxetic acid-enhanced liver MRI, supplemented with additional T1-weighted ferumoxytol enhanced sequences. Two radiologists in consensus identified all metastases using all available sequences, which served as the reference standard. Two different radiologists reviewed each exam twice, once using the standard protocol and once with additional ferumoxytol sequences. The detection rate was estimated as the predicted probability of a metastasis along with the 95% confidence interval (CI) using hierarchical logistic regression models.

Results

A total of 49 metastases were identified. The mean diameter was 10 mm, measured in greatest axial dimension (median=7 mm; range=2–70 mm). Readers 1 and 2 had detection rates of 69.6% (95% CI = 48.2–85.0) and 53.1% (95% CI = 35.2–70.3) for gadoxetic acid alone and 98.0% (95% CI = 86.3–99.7) and 83.5% (95% CI = 59.3–94.7) for combined protocol.

Conclusion

In this preliminary investigation, adding ferumoxytol-enhanced sequences to gadoxetic acid liver MRI protocol increased the detection rate of CRC hepatic metastases and may aid in preoperative decision making.

Natural history of pulmonary coccidioidomycosis: Further examination of the VA-Armed Forces Database

There are still many limitations related to the understanding of the natural history of differing forms of coccidioidomycosis (CM), including characterizing the spectrum of pulmonary disease. The historical Veterans Administration-Armed Forces database, recorded primarily before the advent of antifungal therapy, presents an opportunity to characterize the natural history of pulmonary CM. We performed a retrospective cohort study of 342 armed forces service members who were diagnosed with pulmonary CM at VA facilities between 1955 to 1958, followed through 1966, who did not receive antifungal therapy. Patients were grouped by predominant pulmonary finding on chest radiographs. The all-cause mortality was low for all patients (4.6%). Cavities had a median size of 3-3.9 cm (IQR: 2-2.9-4-4.9 cm), with heterogeneous wall thickness and no fluid level, while nodules had a median size of 1-1.19 cm (Interquartile range [IQR] 1-1.9-2-2.9 cm) and sharp borders. The majority of cavities were chronic (85.6%), and just under half were found incidentally. Median complement fixation titers in both the nodular and cavitary groups were negative, with higher titers in the cavitary group overall. This retrospective cohort study of non-disseminated coccidioidomycosis, the largest to date, sheds light on the natural history, serologic markers, and radiologic characteristics of this understudied disease. These findings have implications for the evaluation and management of CM.

Effect of Delay and Disruption in Venous Thromboembolism Prophylaxis in Trauma Patients: Case-Control Study

BACKGROUND

Trauma patients are at high risk for venous thromboembolism (VTE) and bleeding. The purpose of this study was to characterize percentage of VTE chemoprophylaxis given to trauma patients with and without a VTE.

STUDY DESIGN

This retrospective case-control study evaluated trauma patients admitted to a Level I trauma center. Adult patients were included when hospitalized at least 2 days and had a head abbreviated injury score of 1 or less. Non-VTE patients were matched by decade of life and injury severity score (ISS). The primary outcome was percentage of VTE chemoprophylaxis received over the first 14 days of admission. Descriptive statistics, chi-squared test, Student's t-test, and Cox proportional hazard were used for analysis.

RESULTS

A total of 44 VTE patients were included with 125 matched non-VTE patients. Baseline demographics included age in years (50.7 ± 19.6 vs 49.6 ± 19.4), ISS (18.9 ± 11.3 vs 19 ± 11.6), and lower extremity fracture (54.5% vs 40%), for VTE and non-VTE groups, respectively. The primary outcome of VTE chemoprophylaxis doses given was significantly lower for VTE patients than non-VTE patients (49.3% vs 59.3%, p = 0.0069). Significant predictors of VTE were percentage of VTE chemoprophylaxis doses given (p < 0.0001) and weight (p = 0.0042) based on regression analysis. Notably, there was a 7% decrease in the hazard for VTE for every 1% increase in VTE chemoprophylaxis given.

CONCLUSIONS

Patients who developed VTE were more likely to have delays and disruptions in VTE chemoprophylaxis, even after controlling for age, sex, ISS, lower extremity fractures, and number of operations.

Relationship Between Age at Menopause, Obesity, and Incident Heart Failure: The Atherosclerosis Risk in Communities Study

Background The mechanisms linking menopausal age and heart failure (HF) incidence are controversial. We investigated for heterogeneity by obesity on the relationship between menopausal age and HF incidence. Methods and Results Using postmenopausal women who attended the Atherosclerosis Risk in Communities Study Visit 4, we estimated hazard ratios of incident HF associated with menopausal age using Cox proportional hazards models, testing for effect modification by obesity and adjusting for HF risk factors. Women were categorized by menopausal age: <45 years, 45 to 49 years, 50 to 54 years, and ≥55 years. Among 4441 postmenopausal women, aged 63.5±5.5 years, there were 903 incident HF events over a mean follow-up of 16.5 years. The attributable risk of generalized and central obesity for HF incidence was greatest among women who experienced menopause at age ≥55 years: 11.09/1000 person-years and 7.38/1000 person-years, respectively. There were significant interactions of menopausal age with body mass index and waist circumference for HF incidence, Pinteraction 0.02 and 0.001, respectively. The hazard ratios of incident HF for a SD increase in body mass index was elevated in women with menopausal age <45 years [1.39 (1.05-1.84)]; 45-49 years [1.33, (1.06-1.67)]; and ≥55 years [2.02, (1.41-2.89)]. The hazard ratio of incident HF for a SD increase in waist circumference was elevated only in women with menopausal age ≥55 years [2.93, (1.85-4.65)]. Conclusions As obesity worsened, the risk of developing HF became significantly greater when compared with women with lower body mass index and waist circumference, particularly among those who had experienced menopause at age ≥55 years.

Segmented assimilation as a mechanism to explain the dietary acculturation paradox

Latinos have disproportionately high rates of diet-related diseases which are associated with acculturation to the U.S. This negative shift in dietary quality is paradoxical in light of gains in income and education that would be expected to lead to better diet. We examined the extent to which the dietary acculturation paradox among Mexican Americans can be explained by segmented assimilation, a theory that considers how immigrants' and their descendants' trajectories of integration are influenced by a complex interplay of individual, social, and structural factors. First, we performed confirmatory cluster analysis to identify three assimilation segments (classic, underclass, and selective) based on education, income, and an acculturation proxy derived from language, nativity, and time in the U.S. among Mexican-origin participants (N = 4475) of the 2007-2016 National Health and Nutrition Examination Survey (NHANES). These segments were then used as independent variables in linear regression models to estimate the relationship between cluster and dietary quality (assessed by the Health Eating Index (HEI)) and the interaction between cluster and gender, controlling for marital status. There were strong effects of cluster on dietary quality, consistent with hypotheses per segmented assimilation theory. The classic assimilation segment had the poorest diet, despite having higher income and education than the underclass segment. The selective segment had higher or similar dietary quality to the underclass segment. Consistent with expectations, this difference was driven by the relatively higher consumption of greens and beans and whole grains of those in the selective and underclass segments. Overall, women had better diets than men; however, the strongest gender contrast was in the underclass segment. This study advances understanding of dietary acculturation and potential disparities in diet-related health outcomes.

The Impact of Medical Comorbidities on Patient Satisfaction in Chronic Rhinosinusitis

BACKGROUND

Patient satisfaction has a significant bearing on medical therapy compliance and patient outcomes. The purpose of this study was to (1) describe patient satisfaction, as characterized by the Patient Satisfaction Questionnaire-18 (PSQ-18), in the care of patients with chronic rhinosinusitis (CRS) and (2) analyze the impact of comorbidities on satisfaction using the functional comorbidity index (FCI).

METHODS

Patient demographics, disease severity measures, and PSQ-18 scores for patients with CRS presenting to a tertiary rhinology clinic between November 2019 and April 2020 were collected and analyzed. FCI was calculated retrospectively using the electronic medical record; individual comorbidities were tabulated. Spearman's correlations followed by multivariate regression was used to assess the relationship between medical comorbidities and PSQ-18.

RESULTS

Sixty-nine patients met criteria for analysis. There were no significant differences in age, gender, and Sinonasal Outcomes Test-22 scores between CRS patients with (CRSwNP) and without (CRSsNP) nasal polyps. There was no significant difference in the mean FCI for patients with CRSwNP versus CRSsNP (5.1 and 4.3, respectively) (P = .843). Similarly, there was no significant difference in the mean sum PSQ-18 score (78/100 in both) between these cohorts (P = .148). The mean sum PSQ-18 score was not significantly associated with anxiety (P = .728), depression (P = .624), or FCI (P = .282), but was significantly associated with hearing impairment (P < .001).

CONCLUSION

Patient satisfaction in the care of CRS is generally high with a diagnosis of comorbid hearing impairment demonstrating a negative association with satisfaction in this cohort.

NT-pro B-type natriuretic peptide, early menopause, and incident heart failure in postmenopausal women of the ARIC study

OBJECTIVE

N-Terminal pro B-type Natriuretic Peptide (NT-proBNP), a biomarker of heart failure (HF) has been associated with early menopause. We evaluated the modifying role of early menopause on the association of NT-proBNP with incident HF, and separately for HF subtypes, HF with preserved ejection fraction (HFpEF) and HF with reduced ejection fraction (HFrEF).

METHODS

We included 4,352 postmenopausal women including 1,174 with early menopause, ages 63.5 ± 5.5 years, without prevalent HF at the Atherosclerosis Risk in Communities study Visit 4. Binary log-transformation was performed for NT-proBNP. Cox proportional hazards models were used to examine the association of NT-proBNP with incident HF, and separately for incident HFpEF and incident HFrEF, testing for effect modification by early menopause and adjusting for HF risk factors.

RESULTS

We observed 881 HF events over a mean follow-up of 16.5 years. The interaction terms of NT-proBNP and early menopause were not significant for incident HF (Pinteraction 0.95) and incident HFpEF (Pinteraction 0.17) but were significant for incident HFrEF (Pinteraction 0.03). The adjusted hazard ratios resulting from each doubling of NT-proBNP levels amongst women with and without early menopause were 1.33 (1.20-1.47) and 1.34 (1.24-1.44), respectively, for incident HF; 1.57 (1.34-1.86) and 1.38 (1.24-1.54), respectively, for incident HFpEF; and 1.68 (1.42-1.99) and 1.36 (1.22-1.52), respectively, for incident HFrEF.

CONCLUSIONS

The association of NT-proBNP with incident HFpEF is similar irrespective of early menopause status. However, the association of NT-proBNP with incident HFrEF is greater among women with early menopause when compared to those without early menopause.

Complex family planning and pediatric hematology oncology integrated clinic for young people with blood disorders and heavy or abnormal menstrual bleeding

OBJECTIVES

To describe practice patterns of an integrated complex family planning-pediatric hematology oncology clinic for patients with blood disorders STUDY DESIGN: : We retrospectively evaluated the outcomes of patients who had an initial consultation for blood disorders impacting menstrual bleeding in an integrated complex family planning-pediatric hematology oncology clinic from October 2015 to September 2020. We reviewed all charts to extract medical and gynecologic history, blood disorder diagnosis, hormonal treatment prior to and following initial consultation, subsequent visits to the integrated clinic, and hormonal treatment up to 24 months after initial consultation.

RESULTS

We saw 47 patients; their most common blood disorder diagnosis was protein defect (14/47, 30%). Most patients (30/47, 64%) were not using any hormonal treatment prior to their initial consultation. After the initial consultation, 26 (55%) elected to start, change, or discontinue hormonal treatment for abnormal menstrual bleeding, the most common treatment being combined hormonal contraception (CHC, 22/47, 47%), alone or as dual therapy. Over the study duration, 36 patients (77%) initiated, changed, or discontinued their hormone treatment, 22 (61%) of whom changed their treatment plan more than once. CHC usage decreased from 19/47 (40%) to 8/37 (22%) and hormonal device usage, particularly the implant, increased from 9/47 (19%) to 11/37 (30%) over the 24 months from initial consultation.

CONCLUSION

Most patients in an integrated complex family planning-pediatric hematology oncology clinic will change their menstrual bleeding hormone treatment with initial consultation, although management may require multiple changes. The most common treatment 24 months following the initial consultation was hormonal devices.

IMPLICATIONS

Patients with blood disorders affecting menstrual bleeding have complex needs that could be addressed by an integrated complex family planning-pediatric hematology oncology clinic. Most patients require multiple changes in treatment to achieve adequate control of their bleeding, and patients were more likely to choose hormonal devices for management over time.

Sex and Genotype Modulate the Dendritic Effects of Developmental Exposure to a Human-Relevant Polychlorinated Biphenyls Mixture in the Juvenile Mouse

While many neurodevelopmental disorders (NDDs) are thought to result from interactions between environmental and genetic risk factors, the identification of specific gene-environment interactions that influence NDD risk remains a critical data gap. We tested the hypothesis that polychlorinated biphenyls (PCBs) interact with human mutations that alter the fidelity of neuronal Ca²⁺ signaling to confer NDD risk. To test this, we used three transgenic mouse lines that expressed human mutations known to alter Ca²⁺ signals in neurons: (1) gain-of-function mutation in ryanodine receptor-1 (T4826I-RYR1); (2) CGG-repeat expansion in the 5′ non-coding portion of the fragile X mental retardation gene 1 (FMR1); and (3) a double mutant (DM) that expressed both mutations. Transgenic and wildtype (WT) mice were exposed throughout gestation and lactation to the MARBLES PCB mix at 0.1, 1, or 6 mg/kg in the maternal diet. The MARBLES mix simulates the relative proportions of the twelve most abundant PCB congeners found in serum from pregnant women at increased risk for having a child with an NDD. Using Golgi staining, the effect of developmental PCB exposure on dendritic arborization of pyramidal neurons in the CA1 hippocampus and somatosensory cortex of male and female WT mice was compared to pyramidal neurons from transgenic mice. A multilevel linear mixed-effects model identified a main effect of dose driven by increased dendritic arborization of cortical neurons in the 1 mg/kg PCB dose group. Subsequent analyses with genotypes indicated that the MARBLES PCB mixture had no effect on the dendritic arborization of hippocampal neurons in WT mice of either sex, but significantly increased dendritic arborization of cortical neurons of WT males in the 6 mg/kg PCB dose group. Transgene expression increased sensitivity to the impact of developmental PCB exposure on dendritic arborization in a sex-, and brain region-dependent manner. In conclusion, developmental exposure to PCBs present in the gestational environment of at-risk humans interfered with normal dendritic morphogenesis in the developing mouse brain in a sex-, genotype- and brain region-dependent manner. Overall, these observations provide proof-of-principle evidence that PCBs interact with heritable mutations to modulate a neurodevelopmental outcome of relevance to NDDs.

Surgeon education through a surgical cost feedback system reduces supply cost in endoscopic skull base surgery

OBJECTIVE

A large proportion of healthcare expense is operating room (OR) costs. As a means of cost mitigation, several institutions have implemented surgeon education programs to bring awareness about supply costs. This study evaluates the impact of a surgical cost feedback system (surgical receipt) on the supply costs of endoscopic skull base surgery (ESBS) procedures.

METHODS

The supply costs of each ESBS surgical case were prospectively collected and analyzed before and after the implementation of a nonincentivized, automated, and itemized weekly surgical receipt system between January 2017 and December 2019. Supply cost data collected 15 months prior to intervention were compared with cost data 21 months after implementation of the surgical receipt system. Demographics, surgical details, and OR time were collected retrospectively.

RESULTS

Of 105 ESBS procedures analyzed, 36 preceded and 69 followed implementation of cost feedback. There were no significant differences in patient age (p = 0.064), sex (p = 0.489), surgical indication (p = 0.389), or OR anesthesia time (p = 0.51) for patients treated before and after implementation. The mean surgical supply cost decreased from $3824.41 to $3010.35 (p = 0.002) after implementation of receipt feedback. Usage of dural sealants (p = 0.043), microfibrillar collagen hemostat (p = 0.007), and oxidized regenerated cellulose hemostat (p < 0.0001) and reconstructive technique (p = 0.031) significantly affected cost. Mediation analysis confirmed that the overall cost reduction was predominantly driven by reduced use of dural sealant; this cost saving exceeded the incremental cost of greater use of packing materials such as microfibrillar collagen hemostat.

CONCLUSIONS

Education of surgeons regarding surgical supply costs by a surgical receipt feedback system can reduce the supply cost per case of ESBS operations.

Predictors of Aspiration Pneumonia and Mortality in Patients with Dysphagia

OBJECTIVES/HYPOTHESIS

To identify risk factors for pneumonia incidence in patients with dysphagia undergoing a videofluoroscopic swallow study (VFSS) in an outpatient tertiary-care center.

STUDY DESIGN

Historical cohort study.

METHODS

All individuals undergoing a VFSS between 10/02/13 and 07/30/15 were identified and followed historically for 2 years. Demographic information, medical history, and fluoroscopic data were collected. The 2-year incidence of pneumonia was obtained from the medical records and telephone interview. The incidence of pneumonia and death were calculated and risk factors for pneumonia and mortality were ascertained.

RESULTS

689 patients were followed for 2 years. The mean age (±standard deviation) of the cohort was 65 (±15.5) years. 49% (338/689) were female. The most common causes of dysphagia were cricopharyngeus muscle dysfunction (270/689), head and neck cancer (175/689), and neurodegenerative disease (56/689). The incidence of pneumonia was 22% (153/689). The incidence of death was 11%. Multivariable logistic regression revealed that chronic obstructive pulmonary disorder [COPD] (odds ratio [OR] = 2.36, 95% confidence interval [CI]: 1.33-4.19), hypertension (OR = 1.82, 95% CI: 1.23-2.73), tracheotomy status (OR = 2.96, 95% CI: 1.09-7.99), and vallecular residue (OR = 1.88, 95% CI: 1.24-2.85) were all significantly associated with an elevated risk of pneumonia. Kidney disease (OR = 1.27, 95% CI: 1.02-9.9), COPD (OR = 3.27, 95% CI: 1.65-6.49), vallecular residue (OR = 2.35, 95% CI: 1.35-4.1), male gender (OR = 2.21, 95% CI: 1.25-3.92), and low body mass index (OR: 1.12, 95% CI: 1.06-1.19) were independent adjusted risk factors for death.

CONCLUSIONS

The incidence of aspiration pneumonia (22%) and death (11%) within 2-years of a VFSS was high. The greatest adjusted risk factors for incident pneumonia were tracheotomy (OR = 3.0), COPD (OR = 2.4) and vallecular residue (OR = 1.9). The greatest adjusted risk factors for death were COPD (OR = 3.3), vallecular residue (OR = 2.3), and male gender (OR = 2.2).

LEVEL OF EVIDENCE

4 Laryngoscope, 2021.

Racial and Ethnic Diversity Among Obstetrics and Gynecology, Surgical, and Nonsurgical Residents in the US From 2014 to 2019

This cross-sectional study examines racial and ethnic diversity among obstetrics and gynecology (OBGYN), surgical, and nonsurgical residents in the US.

Postoperative Opioid Prescribing and Consumption after Hysterectomy: A Prospective Cohort Study

STUDY OBJECTIVE

To examine opioid prescribing and consumption patterns after hysterectomy and identify factors associated with postoperative opioid consumption.

DESIGN

Prospective cohort study.

SETTING

Single university medical center.

PATIENTS

Women undergoing hysterectomy for benign, nonobstetric indications.

INTERVENTIONS

Participant preoperative and surgical characteristics were obtained through chart review and patient report of baseline pain score. During the third postoperative week, participants completed a telephone interview, including a direct count of remaining opioid pills and assessment of satisfaction with pain management. We assessed factors associated with opioid consumption in oral morphine equivalents (OME) using a linear regression model.

MEASUREMENTS AND MAIN RESULTS

Of the 129 participants, 113 (88%) completed the postoperative survey after hysterectomy: 16 vaginal, 43 robotic-assisted, 42 conventional laparoscopic, and 12 abdominal hysterectomies. The median amount of opioid prescribed was 150 OME (interquartile range [IQR] 113-200), while the median amount consumed was 75 (IQR 10-135), reflecting an average consumption of about 50% of the prescription. Opioid prescription size was associated with consumption; for every additional oral morphine equivalent prescribed, on average, an additional 0.5 was consumed (p <.001). If the indication for hysterectomy was related to pain, participants consumed 25.3 additional OME (p = .04). The amount of opioid prescribed was inversely correlated with pain management satisfaction; every additional point on a 1 through 5 Likert scale of increasing satisfaction was associated with 44 fewer OME prescribed (standard error 9 OME, p <.001). For the 1464 total unused pills among the 104 participants with leftover opioids, only 20% reported an Food and Drug Administration -compliant opioid disposal plan.

CONCLUSION

Gynecologic surgeons can respond to the opioid epidemic by reducing excess opioid pills after hysterectomy by providing both the smallest effective prescription size and concrete resources for safe opioid disposal. These actions may contribute to a reduction in opioid use disorder cases or overdose deaths.

Markedly elevated hepatic arterial velocity-HAV greater than 200 cm/s-is not specific to hepatobiliary disease

OBJECTIVE

The aim of the study was to review the different etiologies and outcomes of patients with hepatic artery velocities greater than 200 cm/s.

METHODS

This retrospective study included 88 hospitalized patients in whom angle-corrected proper hepatic artery flow velocities greater than 200 cm/s were obtained during an abdominal ultrasonographic examination. Peak systolic hepatic artery flow velocities, hepatic artery resistance index, and portal vein flow velocities were evaluated. The patients were then allocated to one of four groups based on their primary underlying diagnosis: structural liver disease, nonstructural liver disease, generalized infection, or miscellaneous.

RESULTS

The median hepatic artery velocity was similar for all groups, ranging from 226 to 238 cm/s. The maximum portal venous velocities were not significantly different between groups. No lab values were statistically different between the groups, except total bilirubin that was greater in the nonstructural liver disease group (8 mg/dL). Overall, 9/88 (10.2%) of patients with elevated hepatic artery velocity died within 30 days of their ultrasonographic examination.

CONCLUSION

Elevated hepatic artery velocity greater than 200 cm/s in hospitalized patients is not specific to primary hepatobiliary disease but may indicate acute hepatic dysfunction from other causes such as infection or sepsis.

Telemedicine, Patient Satisfaction, and Chronic Rhinosinusitis Care in the Era of COVID-19

BACKGROUND

Telemedicine has become increasingly popular in the care of rhinologic patients during the COVID-19 pandemic. This change in practice patterns may place patients at risk of a perceived lower-quality exchange with their healthcare provider, which may in turn impact satisfaction.

OBJECTIVE

This study compares patient satisfaction scores between in-person clinic visits and telemedicine video visits in patients with chronic rhinosinusitis (CRS).

METHODS

Sixty-nine patients with CRS presenting to an academic rhinology clinic between March to April 2020 were retrospectively divided into video visits (VV) and clinic visits (CV) groups based on mandated state quarantine orders on March 19. Patient demographics, disease severity measures, and Patient Satisfaction Questionnaire-18 (PSQ-18) scores were collected and analyzed. Chi square test and Fisher's exact test were performed.

RESULTS

There were no significant differences in age (p = 0.81), gender (p = 0.55), CRS phenotype (p = 0.16), and disease severity measures (Sinonasal Outcomes Test-22 (SNOT-22) (p = 0.92); Lund-Mackay score (p = 0.96)) between the video and clinic visit groups. There were no significant differences in PSQ-18 total scores (VV PSQ-18 mean score = 78.1, CV PSQ-18 mean score = 78.4; p = 0.67) or the following subdomain scores between the two groups: general satisfaction (p = 0.73), technical quality (p = 0.62), interpersonal manner (p = 0.41), communication (p = 0.31), financial aspects (p = 0.89), time spent with doctor (p = 0.88), and accessibility and convenience (p = 0.47).

CONCLUSION

Patient satisfaction with telemedicine in the COVID-19 pandemic parallels that of traditional in-person visits. Video visits can serve as a viable alternative to clinic visits, while still maintaining high satisfaction.

Natural History of Disseminated Coccidioidomycosis: Examination of the VA-Armed Forces Database

BACKGROUND

The natural history of non-central nervous system (CNS) disseminated coccidioidomycosis (DCM) has not been previously characterized. The historical VA-Armed Forces coccidioidomycosis patient group provides a unique cohort of patients not treated with standard antifungal therapy allowing for characterization of the natural history of coccidioidomycosis.

METHODS

We conducted a retrospective study of 531 VA-Armed Forces coccidioidomycosis patients diagnosed between 1955-1958 and followed to 1966. Groups were identified as non-disseminated coccidioidomycosis (non-DCM, 462 patients), DCM (44 patients), and CNS (25 patients). The duration of initial infection, fate of primary infection, all-cause mortality and mortality secondary to coccidioidomycosis were assessed and compared between groups.

RESULTS

Mortality due to coccidioidomycosis at last known follow up was significantly different across the groups: 0.65% in non-DCM, 25% in DCM, and 88% in CNS (P<0.001). The primary fate of pulmonary infection demonstrated key differences with pulmonary nodules observed in 39.61% in non-DCM, 13.64% in DCM, and 20% in CNS (P<0.001). There were differences in cavity formation with 34.20% in non-DCM, 9.09% DCM, and 8 % in CNS (P <0.001). Forty-one percent and 56% of patients in the non-CNS DCM and CNS groups, respectively, developed dissemination as the presenting manifestation or concurrent with initial infection.

CONCLUSIONS

This large retrospective cohort study helps characterize the natural history of DCM, provides insight into the host immunologic response, and has direct clinical implications for the management and follow-up of patients.

Surgeon cost feedback through a surgical receipt program reduces cost in sinonasal surgery

BACKGROUND

Operating room (OR) costs are a large portion of healthcare expenses. This study evaluates the impact of a surgeon-targeted surgical receipt cost feedback system on OR supply costs in sinonasal surgery and individual components contributing to procedural cost.

METHODS

Itemized weekly surgical receipts detailing individual case supply costs were analyzed before and after the implementation of a non-incentivized surgeon cost feedback system between January 2017 and June 2019. Supply cost data collected 15 months prior to intervention was compared to cost data 15 months after implementation of the weekly automated receipt dissemination to surgeons. Chi square test was used for categorical data and the Wilcoxon test was used to compare change in cost. Univariate and mediation analyses were performed to assess variables impacting cost.

RESULTS

Of 502 sinonasal procedures analyzed, 239 were before and 264 after cost feedback implementation. There were no significant differences in age/gender, or indication for surgery. The median OR supply cost decreased from $1229.64 to $1097.22 (p = 0.02) after receipt implementation. There were effects of procedure type (p = 0.02), circulating nurse specialization (p < 0.001), steroid eluting stent (p = 0.002), and sinus drill (p < 0.001) on cost. Mediation analysis confirmed full mediation by decreasing use of steroid-eluting stents.

CONCLUSION

Surgeon cost feedback in the form of individualized OR surgical receipts is an effective model to reduce supply cost per case in sinonasal surgery.

Impact of preoperative pectoralis plane nerve blocks for mastectomy on perioperative opioid consumption: a retrospective study

Aim: To compare perioperative opioid consumption for patients undergoing mastectomy surgery with or without pectoralis nerve (PECS) plane blocks. Patients & methods: Retrospective study evaluating 152 adult females with mastectomies. Demographics, postanesthesia care unit stay duration and opioid consumption data at three time points were collected and analyzed for statistical significance. Results: 98 patients were included in the PECS block group, 54 patients were in the general anesthesia only group. Age and BMI were comparable. Total perioperative intravenous opioid consumption was less in the PECS block group (50.88 mg) compared with the general anesthesia only group (67.83 mg), p < 0.001. Conclusion: Acute pain after mastectomy is often severe. PECS plane block may decrease perioperative opioid consumption after mastectomy surgery compared with general anesthesia alone.

Underwater versus conventional endoscopic resection of nondiminutive nonpedunculated colorectal lesions: a prospective randomized controlled trial (with video)

BACKGROUND AND AIMS

Incomplete resection of colorectal neoplasia decreases the efficacy of colonoscopy. Conventional resection (CR) of polyps, performed in a gas-distended colon, is the current standard, but incomplete resection rates of approximately 2% to 30% for nondiminutive (>5 mm), nonpedunculated lesions are reported. Underwater resection (UR) is a novel technique. The aim of this study was to determine the incomplete resection rates of colorectal lesions removed by UR versus CR.

METHODS

In a randomized controlled trial, patients with small (6-9 mm) and large (≥10 mm) nonpedunculated lesions were assigned to CR (gas-distended lumen) or UR (water-filled, gas-excluded lumen). Small lesions in both arms were removed with a dedicated cold snare. For CR, large lesions were removed with a hot snare after submucosal injection. For UR, large lesions were removed with a hot snare without submucosal injection. Four-quadrant biopsy samples around the resection sites were used to evaluate for incomplete resection.

RESULTS

Four hundred sixty-two eligible polyps (248 UR vs 214 CR) from 255 patients were removed. Incomplete resection rates for UR and CR were low and did not differ (2% vs 1.9%, P = .91). UR was performed significantly faster for lesions ≥10 mm in size (10-19 mm, 2.9 minutes vs 5.6 minutes, P < .0001); ≥20 mm, 7.3 minutes vs 9.5 minutes, P = .015).

CONCLUSIONS

Low incomplete resection rates are achievable with UR and CR. UR is effective and safe with the advantage of faster resection and potential cost savings for removal of larger (≥10 mm) lesions by avoiding submucosal injection. As an added approach, UR has potential to improve the cost-effectiveness of colonoscopy by increasing efficiency and reducing cost while maintaining quality. (Clinical trial registration number: NCT02889679.).

Risk of developing an abdominal aortic aneurysm after ectatic aorta detection from initial screening

OBJECTIVE

Current abdominal aortic aneurysm (AAA) surveillance guidelines lack any follow-up recommendations after initial abdominal aortic screening diameter of less than 3.0 cm. Some reports have demonstrated patients with late AAA formation and late ruptures after initial ultrasound screening detection of patients with an aortic diameter of 2.5 to 2.9 cm (ectatic aorta). The purpose of this study was to determine ectatic aorta prevalence, AAA development, rupture risk, and risk factor profile in patients with detected ectatic aortas in a AAA screening program.

METHODS

A retrospective chart review of all patients screened for AAA from January 1, 2007, to December 31, 2016, within a regional health care system was conducted. Screening criteria were men 65 to 75 years of age that smoked a minimum of 100 cigarettes in their lifetime. An ectatic aorta was defined as a maximum aortic diameter from 2.5 to 2.9 cm. An AAA was defined as an aortic diameter of 3 cm or greater. Patients screened with ectatic aortas who had subsequent follow-up imaging of the aorta with a minimum of 1-year follow-up were analyzed for associated clinical and cardiovascular risk factors. All data were collected through December 3,/2018. A logistic regression of statistically significant variables from univariate and χ² analyses were performed to identify risks associated with the development of AAA from an initially diagnosed ectatic aorta. A Cox proportional hazard model was used to assess survival data. A P value of less than .05 was considered statistically significant.

RESULTS

From a screening pool of 19,649 patients, 3205 (16.3%) with a mean age of 72.1 ± 5.3 years were identified to have an ectatic aorta from January 1, 2007, to December 31, 2016. The average screening ectatic aortic diameter was 2.6 ± 0.1 cm. There were 672 patients (21.0%) with a mean age of 73.0 ± 5.7 years who received subsequent imaging for other clinical indications and 193 of these patients (28.7%) with ectatic aortas developed an AAA from the last follow-up scan (4.2 ± 2.5 years). The average observation length of all patients was 6.4 ± 2.9 years. No ruptures were reported, but 27.8% of deaths were of unknown cause. One patient had aortic growth to 5.5 cm or greater (0.15%). Larger initial screening diameter (P < .01), presence of chronic obstructive pulmonary disease (P < .01), and active smoking (P = .01) were associated with AAA development.

CONCLUSIONS

Patients with diagnosed ectatic aortas from screening who are active smokers or have chronic obstructive pulmonary disease are likely to develop an AAA.

Assessment of an e-training tool for college students to improve accuracy and reduce effort associated with reading nutrition labels

Objective: Nutrition labels are often underutilized due to the time and effort required to read them. We investigated the impact of label-reading training on effort, as well as accuracy and motivation. Participants: Eighty college students (21 men and 59 women). Methods: The training consisted of a background tutorial on nutrition followed by three blocks of practice reading labels to decide which of two foods was the relatively better choice. Label-reading effort was assessed using an eye tracker and motivation was assessed using a 6-item scale of healthy food-choice empowerment. Results: Students showed increases in label-reading accuracy, decreases in label-reading effort, and increases in empowerment. Conclusions: The nutrition label e-training tool presented here, whether used alone or as part of other wellness and health programs, may be an effective way to boost students' label-reading skills and healthy food choices, before they settle into grocery shopping habits.

A prospective RCT comparing combined chromoendoscopy with water exchange (CWE) vs water exchange (WE) vs air insufflation (AI) in adenoma detection in screening colonoscopy

Background

A low adenoma detection rate (ADR) increases risks of interval cancers (ICs). Proximal colon flat polyps, e.g. serrated lesions (SLs), are difficult to find. Missed proximal colon flat lesions likely contribute to IC.

Aims

We compared chromoendoscopy with water exchange (CWE), water exchange (WE) and air insufflation (AI) in detecting adenomas in screening colonoscopy.

Methods

After split-dose preparation, 480 veterans were randomized to AI, WE and CWE.

Results

Primary outcome of proximal ADR (55.6% vs 53.4% vs 52.2%, respectively) were similar in all groups. Adenoma per colonoscopy (APC) and adenoma per positive colonoscopy (APPC) were comparable. Detection rate of proximal colon SLs was significantly higher for CWE and WE than AI (26.3%, 23.6% and 11.3%, respectively, p = 0.002). Limitations: single operator; SLs only surrogate markers of but not IC.

Conclusions

When an endoscopist achieves high-quality AI examinations with overall ADR twice (61.6%) the recommended standard (30%), use of WE and CWE does not produce further improvement in proximal or overall ADR. Comparable APC and APPC confirm equivalent withdrawal inspection techniques. WE alone is sufficient to significantly improve detection of proximal SLs. The impact of increased detection of proximal SLs by WE on prevention of IC deserves to be studied. This study is registered at ClinicalTrial.gov (NCT#01607255).

Genetic mutations in Ca2+ signaling alter dendrite morphology and social approach in juvenile mice

Dendritic morphology is a critical determinant of neuronal connectivity, and calcium signaling plays a predominant role in shaping dendrites. Altered dendritic morphology and genetic mutations in calcium signaling are both associated with neurodevelopmental disorders (NDDs). In this study we tested the hypothesis that dendritic arborization and NDD-relevant behavioral phenotypes are altered by human mutations that modulate calcium-dependent signaling pathways implicated in NDDs. The dendritic morphology of pyramidal neurons in CA1 hippocampus and somatosensory cortex was quantified in Golgi-stained brain sections from juvenile mice of both sexes expressing either a human gain-of-function mutation in ryanodine receptor 1 (T4826I-RYR1), a human CGG repeat expansion (170-200 CGG repeats) in the fragile X mental retardation gene 1 (FMR1 premutation), both mutations (double mutation; DM), or wildtype mice. In hippocampal neurons, increased dendritic arborization was observed in male T4826I-RYR1 and, to a lesser extent, male FMR1 premutation neurons. Dendritic morphology of cortical neurons was altered in both sexes of FMR1 premutation and DM animals with the most pronounced differences seen in DM females. Genotype also impaired behavior, as assessed using the three-chambered social approach test. The most striking lack of sociability was observed in DM male and female mice. In conclusion, mutations that alter the fidelity of calcium signaling enhance dendritic arborization in a brain region- and sex-specific manner and impair social behavior in juvenile mice. The phenotypic outcomes of these mutations likely provide a susceptible biological substrate for additional environmental stressors that converge on calcium signaling to determine individual NDD risk.

Variation in outcomes among 24/7 percutaneous coronary intervention centres for patients resuscitated from out-of-hospital cardiac arrest

BACKGROUND

Patients treated at 24/7 percutaneous coronary intervention (PCI) centres following out-of-hospital cardiac arrest (OHCA) have better outcomes than those treated at non-24/7 PCI centres. However, variation in outcomes between 24/7 PCI centres is not well studied.

OBJECTIVES

To evaluate variation in outcomes among 24/7 PCI centres and to assess stability of 24/7 PCI centre performance.

METHODS

Adult patients in the California Office of Statewide Health Planning and Development Patient Discharge Database with a "present on admission" diagnosis of cardiac arrest admitted to a 24/7 PCI centre from 2011 to 2015 were included. Primary outcome was good neurologic recovery at hospital discharge. Secondary outcomes were survival to hospital discharge, cardiac catheterisation, and DNR orders within 24 h. Data were analysed using mixed effects logistic regression models. Hospitals were ranked each year and overall.

RESULTS

Of 27,122 patients admitted to 128 24/7 PCI centres, 41% (11,184) survived and 27% (7188) had good neurologic recovery. Adjusted rates of good neurologic recovery (18%-39%; p,0.001), survival (32%-51%; p < 0.0001), cardiac catheterisation (11%-49%; p < 0.0001) and DNR orders within 24 h (4.8%-49%; p < 0.0001) varied between 24/7 PCI centres. For the 26 hospitals with mean good neurologic rankings in the top or bottom tenth during 2011-2013, 14 (54%) remained in their respective tenth for 2014-2015.

CONCLUSION

Significant variation exists between 24/7 PCI centres in good neurologic recovery following OHCA and persists over time. Future studies should evaluate hospital-level factors that contribute to these differences in outcomes between 24/7 PCI centres.

Nutrition Label Use and Its Association With Dietary Quality Among Latinos: The Roles of Poverty and Acculturation

OBJECTIVE

To investigate how acculturation and poverty are independently and jointly associated with the use of the Nutrition Facts panel (nutrition label) and to examine the extent to which nutrition label use moderates the association of poverty and acculturation on dietary quality among Latinos.

DESIGN

Cross-sectional analysis of the 2007/2008 and 2009/2010 waves of the National Health and Nutrition Examination Survey.

PARTICIPANTS

A total of 3,696 adults (aged >19 years) self-identified as Latino/Hispanic with food label use data from the most recent Consumer Behavior Phone Follow-Up Modules.

MAIN OUTCOME MEASURE(S)

Nutrition label use and dietary quality.

ANALYSIS

Logistic regression.

RESULTS

Acculturation moderated the association of income on the likelihood of using nutrition labels, such that lower-income English-speaking Latinos were half as likely as higher-income English-speakers to use nutrition labels (P = .01, odds ratio [OR] = 0.44, 95% confidence interval [CI], 0.24-0.81); however, Spanish speakers were equally likely to use nutrition labels across income levels (P = .99; OR = 1.00; 95% CI, 0.77-1.31). Nutrition label use moderated the association of acculturation on diet. Among English-speaking Latinos, those who read nutrition labels had less than half the risk for poor diet (P =.001; OR = 0.43; 95% CI, 0.26-0.69); however, label use was not significantly associated with the diet quality of Spanish speakers (P = .07; OR = 0.82; 95% CI, 0.67-1.02). Nutrition label use decreased the risk for poor dietary quality regardless of poverty status.

CONCLUSIONS AND IMPLICATIONS

Overall, results demonstrated a positive association between the use of the Nutrition Facts panel for Latinos and dietary quality. An important nutrition education strategy among bicultural Latinos at risk for a poor diet as a result of acculturation may include label reading comprehension. This approach may also address the low rates of label use. The study provides evidence of segmented assimilation in which low-income, bicultural Latinos follow an underclass pattern of acculturation demonstrated by a lower likelihood of reading nutrition labels and higher-income, bicultural Latinos follow the more successful selective pattern.

Utility of Shear Wave Elastography for Assessing Allograft Fibrosis in Renal Transplant Recipients: A Pilot Study

OBJECTIVES

To evaluate the utility of ultrasound-based shear wave elastography (SWE) as a noninvasive method to accurately detect and potentially stage the severity of renal allograft fibrosis and assess its user reproducibility.

METHODS

In this Institutional Review Board-approved, Health Insurance Portability and Accountability Act-compliant prospective study, 70 renal transplant recipients underwent an SWE evaluation of their allograft followed directly by biopsy. Two radiologists performed separate SWE measurement acquisitions and the mean, median, and standard deviation of 10 SWE measurements, obtained separately within the cortex and the medulla, were automatically computed. Each patient's SWE results were subsequently compared to their histologic fibrosis scores. The Fisher exact test and univariate logistic regression models were fit to test for associations between the presence of fibrosis (yes/no) as well as categorical SWE results based on the fibrosis severity, ranging from F0 (no fibrosis) to F3 (severe fibrosis), correlating with histologic scores according to the 2007 Banff classification system. Interobserver and intraobserver correlations were also examined.

RESULTS

Our median medulla SWE values reached statistical significance (P = .04) in association with fibrosis. Furthermore, for every unit increase in the median medulla SWE measurement, the odds of fibrosis increased by approximately 20%. No statistical significance was found for mean cortical, median cortical, or mean medullary SWE values (P = .32, .37, and .06, respectively) in association with fibrosis.

CONCLUSIONS

The use of SWE for assessing renal allograft fibrosis is challenging but promising. Further investigation with a larger sample size remains to validate our initial results and establish clinical relevance.

Comparison of Self-Reported and Behavioral Pain Assessment Tools in Critically Ill Patients

BACKGROUND

Self-reported and behavioral pain assessment scales are often used interchangeably in critically ill patients due to fluctuations in mental status. The correlation between scales is not well elucidated. The purpose of this study was to describe the correlation between self-reported and behavioral pain scores in critically ill patients.

METHODS

Pain was assessed using behavioral and self-reported pain assessment tools. Behavioral pain tools included Critical Care Pain Observation Tool (CPOT) and Behavioral Pain Scale (BPS). Self-reported pain tools included Numeric Rating Scale (NRS) and Wong-Baker Faces Pain Scales. Delirium was assessed using the confusion assessment method for the intensive care unit. Patient preference regarding pain assessment method was queried. Correlation between scores was evaluated.

RESULTS

A total of 115 patients were included: 67 patients were nondelirious and 48 patients were delirious. The overall correlation between self-reported (NRS) and behavioral (CPOT) pain scales was poor (0.30, P = .018). In patients without delirium, a strong correlation was found between the 2 behavioral pain scales (0.94, P < .0001) and 2 self-reported pain scales (0.77, P < .0001). Self-reported pain scale (NRS) and behavioral pain scale (CPOT) were poorly correlated with each other (0.28, P = .021). In patients with delirium, there was a strong correlation between behavioral pain scales (0.86, P < .0001) and a moderate correlation between self-reported pain scales (0.69, P < .0001). There was no apparent correlation between self-reported (NRS) and behavioral pain scales (CPOT) in patients with delirium (0.23, P = .12). Most participants preferred self-reported pain assessment.

CONCLUSION

Self-reported pain scales and behavioral pain scales cannot be used interchangeably. Current validated behavioral pain scales may not accurately reflect self-reported pain in critically ill patients.

An Evaluation of an eHealth Tool Designed to Improve College Students' Label-Reading Skills and Feelings of Empowerment to Choose Healthful Foods

Objective

College students are at risk for poor dietary choices. New skills can empower individuals to adopt healthful behaviors, yet eHealth tools designed to develop food-choice skills, such as label-reading skills, are uncommon. We investigated the effects of web-based label-reading training on college students’ perceptions of healthful food-choice empowerment.

Methods

Students completed label-reading training in which they practiced selecting the more healthful food using nutrition labels. We examined improvements in label-reading accuracy (correct healthfulness decisions) and perceptions of empowerment, using a 6-item scale. Repeated measures ANOVAs and paired-samples t-tests were used to examine changes in accuracy and empowerment across the training session.

Results

In addition to increases in label-reading accuracy with training, we found increases in healthful food-choice empowerment scores. Specifically, the proportion of correct (i.e., more healthful) food choices increased across the three blocks of practice (p = 0.04) and food-choice empowerment scores were about 7.5% higher on average after training (p < 0.001).

Conclusion and implications

Label-reading training was associated with increased feelings of empowerment associated with making healthful food choices. Skill focused eHealth tools may offer an important avenue for motivating behavior change through skill development.

Aggressive Versus Conservative Initial Diuretic Dosing in the Emergency Department for Acute Decompensated Heart Failure

Background:Intravenous (IV) loop diuretics are recommended to relieve vascular congestion in patients with acute decompensated heart failure (ADHF); however, initial dosing is often empirical. Strong evidence supporting individualized diuretic dosing in the emergency department (ED) is lacking. Objective: The purpose of this study was to compare the efficacy and safety of aggressive (≥2 daily home doses) and conservative (<2 daily home doses) initial doses of loop diuretic. Methods: This was a retrospective cohort study in adult patients presenting to the ED with ADHF at an academic medical center from Apri 2015 to September 2015. The primary outcome was time to transition from IV to oral diuretics. Results: A total of 91 patients were included (aggressive dosing, n = 44; conservative dosing, n = 47). Mean time to transition from IV to oral diuretics was 67.9 hours in the aggressive group compared with 88.1 hours in the conservative group ( P = 0.049). Mean hospital length of stay (LOS) was 119.5 hours in the aggressive group versus 123.0 hours in the conservative group ( P = 0.799). No differences were observed between the mean urine output ( P = 0.829), change in body weight ( P = 0.528), or serum creatinine ( P = 0.135). Conclusion: Patients who received an aggressive initial diuretic dose in the ED had a significantly faster time to oral diuretic therapy without any significant differences in hospital LOS, urine output, change in body weight, and renal function when compared with conservative dosing.