Nevin Manimala

Pediatrics. 2021 Jun 2:e2020030007. doi: 10.1542/peds.2020-030007. Online ahead of print.

ABSTRACT

BACKGROUND AND OBJECTIVES: The Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network recently proposed new, severity-based diagnostic criteria for bronchopulmonary dysplasia (BPD). This study provides the first benchmark epidemiological data applying this definition.

METHODS: Retrospective cohort study of infants born from 22 to 29 weeks’ gestation in 2018 at 715 US hospitals in the Vermont Oxford Network. Rates of BPD, major neonatal morbidities, and common respiratory therapies, stratified by BPD severity, were determined.

RESULTS: Among 24 896 infants, 2574 (10.3%) died before 36 weeks’ postmenstrual age (PMA), 12 198 (49.0%) did not develop BPD, 9192 (36.9%) developed grade 1 or 2 BPD, and 932 (3.7%) developed grade 3 BPD. Rates of mortality before 36 weeks’ PMA and grade 3 BPD decreased from 52.7% and 9.9%, respectively, among infants born at 22 weeks’ gestation to 17.3% and 0.8% among infants born at 29 weeks’ gestation. Grade 1 or 2 BPD peaked in incidence (51.8%) among infants born at 25 weeks’ gestation. The frequency of severe intraventricular hemorrhage or cystic periventricular leukomalacia increased from 4.8% among survivors without BPD to 23.4% among survivors with grade 3 BPD. Similar ranges were observed for late onset sepsis (4.8%-31.4%), surgically treated necrotizing enterocolitis (1.4%-17.1%), severe retinopathy of prematurity (1.2%-23.0%), and home oxygen therapy (2.0%-67.5%).

CONCLUSIONS: More than one-half of very preterm infants born in the United States died before 36 weeks’ PMA or developed BPD. Greater BPD severity was associated with more frequent development of major neonatal morbidities, in-hospital mortality, and use of supplemental respiratory support at discharge.

PMID:34078747 | DOI:10.1542/peds.2020-030007

Saudi Med J. 2021 Jun;42(6):666-672. doi: 10.15537/smj.2021.42.6.20200733.

ABSTRACT

OBJECTIVES: To evaluate direct cost of in-vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI) cycle and reproductive outcomes among infertile women with different body mass index (BMI).

METHODS: A retrospective study of 826 subfertility patients who had IVF or IVF-ICSI in 2017 to 2018 were reviewed. The patients were divided into 4 groups bestowing to BMI to normal weight (18.5-24.9 kg/m²), underweight (<18.5 kg/m²), overweight(25-29.9 kg/m²), and obese(≥30 kg/m²). Data on treatment costs of IVF/ICSI and reproductive outcomes were collected and analyzed. A total of 338 patients (40.9%) were overweight, and 300 (36.3%) patients were obese. A bottom-up methodology was used to measure the resource utilization. The capital inputs needed for individual procedures were defined and calculated by consulting with appropriate clinicians and priced using market prices for 2017-2018.

RESULTS: There was no statistical significant difference for live birth rate (LBR) among the BMI groups, with the occurrence of LBR in 23 women with normal BMI (13.1%), in 48 (14.2%) women who were overweight, in 48 (16%) in women who were obese (p=0.7). The median cost for IVF/ICSI treatment cycle did not differ across BMI groups; the cost was 10,380 SAR for women of normal weight, 10,440 SAR for women who are overweight and obese (p=0.6).

CONCLUSION: Our results suggest that costs of IVF/IVF-ICSI is not significantly affected in women who are overweight or obese.

PMID:34078730 | DOI:10.15537/smj.2021.42.6.20200733

Clin Cancer Res. 2021 Jun 2:clincanres.0641.2021. doi: 10.1158/1078-0432.CCR-21-0641. Online ahead of print.

ABSTRACT

PURPOSE: Patient derived xenografts (PDXs) are a research tool for studying cancer biology and drug response phenotypes. While engraftment rates are higher for tumors with more aggressive characteristics, it is uncertain whether engraftment is prognostic for cancer recurrence.

EXPERIMENTAL DESIGN: In a prospective study of breast cancer patients treated with neoadjuvant chemotherapy (NAC) with taxane+/-trastuzumab followed by anthracycline-based chemotherapy, we report the association between breast cancer events and PDX engraftment using tumors derived from treatment naïve (pre-NAC biopsies from 113 patients) and treatment resistant (post-NAC at surgery from 34 patients). Gray’s test was used to assess whether the cumulative incidence of a breast cancer event differs with respect to either pre-NAC PDX engraftment or post-NAC PDX engraftment.

RESULTS: With a median follow up of 5.7 years, the cumulative incidence of breast cancer relapse did not differ significantly according to pre-NAC PDX engraftment (5-year rate: 13.6% versus 13.4%; p=0.89). However, the incidence of a breast event was greater for patients with post-NAC PDX engraftment (5-year rate: 50.0% versus 19.6%), but this did not achieve significance (p=0.11).

CONCLUSIONS: In treatment-naive breast cancer receiving standard NAC, PDX engraftment was not prognostic for breast cancer recurrence. Further study is needed to establish whether PDX engraftment in the treatment-resistant setting is prognostic for cancer recurrence.

PMID:34078650 | DOI:10.1158/1078-0432.CCR-21-0641

J Plast Reconstr Aesthet Surg. 2021 Apr 18:S1748-6815(21)00218-7. doi: 10.1016/j.bjps.2021.03.114. Online ahead of print.

ABSTRACT

INTRODUCTION: There is limited evidence for appropriate post-operative opioid prescribing in breast reconstruction patients. We sought to describe postoperative outpatient prescription opioid use patterns (quantity and duration) following discharge after immediate breast reconstruction with tissue expanders (TE) and to identify demographic and/or clinical risk factors associated with postoperative outpatient opioid use.

METHODS: Patients 18 years and older undergoing immediate TE-based breast reconstruction were given a 28-day postoperative pain medication log book. Descriptive statistics were performed to describe the quantity and duration of opioid use. Preoperative, intraoperative, and postoperative characteristics were examined and tested for their associations with postoperative opioid use.

RESULTS: A total of 45 logbooks were completed. On average, patients used opioids for 7.42 days (SD = 6.45) after discharge home and used 15.9 (SD = 18.71) oxycodone 5 mg tablet equivalents (119.3 morphine milligram equivalents, SD = 140.31). The total number of oxycodone 5 mg equivalents consumed prior to discharge was associated with the amount of post-discharge opioid consumption (IRR=1.08, p<0.01). Each additional year of age was associated with a reduction in the days-to-opioid cessation by a factor of 0.97 (p=0.01). Each additional oxycodone 5mg equivalent consumed prior to hospital discharge was associated with an increase in the days-to-cessation after discharge by a factor of 1.04 (p=0.026).

CONCLUSIONS: These patient-reported data will provide a benchmark which plastic surgeons can use to minimize narcotic use in patients and will help prevent issues of dependence, misuse, and diversion, while being mindful of adequate pain control. For patients discharging home after a one-night stay for immediate TE breast reconstruction, we recommend a prescription for 10 oxycodone 5 mg tablets, or 15 tablets if they are less than age 49 or have had high inpatient opioid use. Patients should also be counseled that the expected duration of outpatient opioid use is 7-11 days, and that 20 % of patients did not use any opioids following hospital discharge, making nonnarcotic pain regimens a real possibility.

PMID:34078588 | DOI:10.1016/j.bjps.2021.03.114

Urol Oncol. 2021 May 31:S1078-1439(21)00193-9. doi: 10.1016/j.urolonc.2021.04.036. Online ahead of print.

ABSTRACT

PURPOSE: Provider and hospital factors influence healthcare quality, but data are lacking to assess their impact on renal cancer surgery. We aimed to assess factors related to surgeon and hospital volume and study their impact on 30-day outcomes after radical nephrectomy.

MATERIALS AND METHODS: Renal surgery data were abstracted from Maryland’s Health Service Cost Review Commission from 2000 to 2018. Patients ≤18 years old, without a diagnosis of renal cancer, and concurrently receiving another major surgery were excluded. Volume categories were derived from the mean annual cases distribution. Multivariable logistic and linear regression models assessed the association of volume on length of stay, intensive care days, cost, 30-day mortality, readmission, and complications.

RESULTS: 7,950 surgeries, completed by 573 surgeons at 48 hospitals, were included. Demographic, surgical, and admission characteristics differed between groups. Radical nephrectomies performed by low volume surgeons demonstrated increased post-operative complication frequency, mortality frequency, length of stay, and days spent in intensive care relative to other groups. However, after logistic regression adjusting for clinical risk and socioeconomic factors, only increased length of stay and ICU days remained associated with lower surgeon volume. Similarly, after adjusted logistic regression, hospital volume was not associated with the studied outcomes.

CONCLUSIONS: Surgeons and hospitals differ in regards to patient demographic and clinical factors. Barriers exist regarding access to high-volume care, and thus some volume-outcome trends may be driven predominantly by disparities and case mix.

PMID:34078583 | DOI:10.1016/j.urolonc.2021.04.036

Thromb Haemost. 2021 Jun 2. doi: 10.1055/a-1522-4131. Online ahead of print.

ABSTRACT

Objectives Pulmonary thrombus formation is a hallmark of coronavirus disease 2019 (COVID-19). A dysregulated immune response culminating in thromboinflammation has been described, but the pathomechanisms remain unclear. Methods We studied 41 adult COVID-19 patients with positive results on reverse-transcriptase polymerase-chain-reaction assays and 37 sex-and age-matched healthy controls. Number and surface characteristics of extracellular vesicles (EV) and citrullinated histone H 3 levels were determined in plasma upon inclusion by flowcytometry and immunoassay. Results 20 patients had severe and 21 non-severe disease. The number of EV [median, (25th, 75th percentile)] was significantly higher in patients compared with controls [658.8 (353.2, 876.6) vs 435.5 (332.5, 585.3), geometric mean ratio (95% confidence intervals): 2.6 (1.9, 3.6); p<0.001]. Patients exhibited significantly higher numbers of EV derived from platelets, endothelial cells, leukocytes, or neutrophils than controls. EV from alveolar-macrophages and alveolar-epithelial-cells were detectable in plasma and were significantly higher in patients. Intercellular Adhesion Molecule 1-positive EV levels were higher in patients, while no difference between tissue factor-positive and angiotensin converting enzyme-positive EV was seen between both groups. Levels of EV did not differ between patients with severe and non-severe COVID-19. Citrullinated histone H 3 levels [ng/ml, median (25th, 75th percentile)] were higher in patients than in controls [1.42 (0.6, 3.4) vs 0.31 (0.1, 0.6), geometric mean ratio: 4.44 (2.6, 7.7); p<0.001], and were significantly lower in patients with non-severe disease compared to those with severe disease. Conclusion EV and citrullinated histone H 3 are associated with COVID-19 and could provide information regarding pathophysiology of the disease.

PMID:34077977 | DOI:10.1055/a-1522-4131

Thromb Haemost. 2021 Jun 2. doi: 10.1055/a-1522-4507. Online ahead of print.

ABSTRACT

BACKGROUND: Thrombosis is a dynamic process, and a thrombus undergoes physical and biochemical changes that may alter its response to reperfusion therapy. This study assessed whether thrombus age influenced reperfusion quality and outcomes after mechanical thrombectomy for cerebral embolism.

METHODS: We retrospectively evaluated 185 stroke patients and thrombi that were collected during mechanical thrombectomy at three stroke centers. Thrombi were pathologically classified as fresh or older based on their granulocytes’ nuclear morphology and organization. Thrombus components were quantified, and the extent of NETosis (the process of neutrophil extracellular trap formation) was assessed using the density of citrullinated histone H3-positive cells. Baseline patient characteristics, thrombus features, endovascular procedures, and functional outcomes were compared according to thrombus age.

RESULTS: Fresh thrombi were acquired from 43 patients, and older thrombi were acquired from 142 patients. Older thrombi had a lower erythrocyte content (P<0.001) and higher extent of NETosis (P=0.006). Restricted mean survival time analysis revealed that older thrombi were associated with longer puncture-to-reperfusion times (difference: 15.6 minutes longer for older thrombi, P=0.002). This association remained significant even after adjustment for erythrocyte content and the extent of NETosis (adjusted difference: 10.8 min, 95% CI: 0.6-21.1 min, P=0.039). Compared with fresh thrombi, older thrombi required more device passes before reperfusion (P<0.001) and were associated with poorer functional outcomes (adjusted common OR: 0.49, 95% CI: 0.24-0.99).

CONCLUSIONS: An older thrombus delays reperfusion after mechanical thrombectomy for ischemic stroke. Adding therapies targeting thrombus maturation may improve the efficacy of mechanical thrombectomy.

PMID:34077976 | DOI:10.1055/a-1522-4507

Laryngorhinootologie. 2021 Jun 2. doi: 10.1055/a-1472-6130. Online ahead of print.

ABSTRACT

OBJECTIVES: As a result of digitalization, the internet embodies the essential information medium. Especially, patients with sudden sensorineural hearing loss (SSNHL) require profound education due to unclear scientific evidence. Thus, our study investigated a German-language internet search about SSNHL.

DESIGN: The first 30 Google-search results with the term “Hörsturz” (SSNHL in German) were categorized, readability-statistic with different readability-scores (FRES: 0=complex, 100=easy; FKL; SMOG; GFI) calculated, and misinformation documented. A structured content-analysis was performed with the DISCERN-questionnaire (1=low, 5=high quality). Certification of the Health-On-The-Net-Foundation (HON) assessed the abidance of recommended standards.

RESULTS: 18 websites (60.0%) accounted for digital media, 7 (23.3%) manufacturers of medical devices, 2 (6.7%) government institutions, and respectively 1 (3.3%) healthcare provider, support-group, and scientific article. Mean word count was 1307.0±840.2, last update 17.1±32.5 months ago, and FRES 36.1±13.9, with the most difficult text by the scientific article (13.7). Mean of DISCERN was 2.2±0.7 with worst rating of manufacturers of medical devices (1.6±0.5). 2 websites (6.7%) were HON-certified, and 14 (46.7%) contained misinformation.

CONCLUSION: Internet-based patient-information should be assessed cautiously due to poor readability, potential conflict of interests, low quality, or wrong information. Hence, healthcare providers and professional associations are urged to provide high-quality patient-information in the internet.

PMID:34077975 | DOI:10.1055/a-1472-6130

Fam Med. 2021 Jun;53(6):423-432. doi: 10.22454/FamMed.2021.541354.

ABSTRACT

BACKGROUND AND OBJECTIVES: Physician burnout has been shown to have roots in training environments. Whether burnout in residency is associated with the attainment of critical educational milestones has not been studied, and is the subject of this investigation.

METHODS: We used data from a cohort of graduating family medicine residents registering for the 2019 American Board of Family Medicine initial certification examination with complete data from registration questionnaire, milestone data, in-training examination (ITE) scores, and residency characteristics. We used bivariate and multilevel multivariate analyses to measure the associations between four professionalism milestones ratings and ITE performance with burnout.

RESULTS: Our sample included 2,509 residents; 36.8% met the criteria for burnout. Multilevel regression modeling showed a correlation between burnout and failure to meet only one of four professionalism milestones, specifically professional conduct and accountability (OR 1.41, 95% CI 1.07-1.87), while no statistically significant relationship was demonstrated between burnout and being in the lowest quartile of ITE scores. Other factors negatively associated with burnout included international medical education (OR 0.60, 95% CI 0.48-0.76) and higher salary compared to cost of housing (OR 0.62, 95% CI 0.46-0.82).

CONCLUSIONS: We found significant association between self-reported burnout and failing to meet expectations for professional conduct and accountability, but no relationship between burnout and medical knowledge as measured by lower ITE performance. Further investigation of how this impacts downstream conduct and accountability behaviors is needed, but educators can use this information to examine program-level interventions that can specifically address burnout and development of physician professionalism.

PMID:34077961 | DOI:10.22454/FamMed.2021.541354

Fam Med. 2021 Jun;53(6):416-422. doi: 10.22454/FamMed.2021.866524.

ABSTRACT

BACKGROUND AND OBJECTIVES: Representation of women in medicine is increasing, including in academic family medicine. Despite this, women continue to hold a minority of senior faculty and leadership roles. This study examines the trends of women first and senior authorship between 2002 and 2017 in five family medicine journals: Family Medicine, Journal of Family Practice, Journal of the American Board of Family Medicine, Annals of Family Medicine, and American Family Physician. The study also examines gender congruence between first and senior authors and women’s membership on editorial boards.

METHODS: We collected and analyzed data on a total of 1,671 original articles published in the five family medicine journals in 2002, 2007, 2012, and 2017. We also examined the gender composition of the journals’ editorial boards.

RESULTS: Overall, women first authorship increased significantly from 32.6% in 2002 to 47.7% in 2017. There was no significant difference in women senior authorship or editorial board representation from 2002 to 2017. Both men and women senior authors partnered with women first authors significantly more over the 15 years.

CONCLUSIONS: While there was a statistically significant increase in women first authors between 2002 and 2017, there is still a gap between women’s authorship and editorial board representation and their representation within academic family medicine. These gaps could help to explain the continued lack of women represented within senior faculty positions.

PMID:34077960 | DOI:10.22454/FamMed.2021.866524