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OBJECTIVE To identify racial disparities in cell-free fetal DNA (cffDNA) first-line aneuploidy screening use among advanced maternal age women at a safety net hospital. STUDY DESIGN This retrospective cohort study of women 35 and older who delivered at Boston Medical Center from 2012 to 2015 compared to women who used cffDNA for first-line aneuploidy screening to those who did not. Maternal conventional demographics and social determinants of health were collected. We investigated the relationship between race and odds of cffDNA use, adjusting for covariates by stepwise logistic regression. RESULTS We identified 1223 women. Seventy-two percent were publicly insured. Upon adjusting for parity, prenatal care site, year of delivery, and insurance status, odds of cffNDA use remained lower for Black and Hispanic women (adjusted odds ratio [aOR] 0.47, 95% confidence interval [CI] 0.30, 0.71 and aOR 0.34 [0.21, 0.55]) compared to White women. Language proved to be an effect modifier among Hispanic women that attenuated but did not resolve the disparity in use among Hispanic compared to White women. Racial differences in cffDNA use persisted across the study period. CONCLUSION Disparity in cffDNA screening uptake exists by race in this diverse urban population. The gap in utilization between Hispanic and White women may be related to primary preferred language.

Background Despite recent improvements in treatment technologies, such as surgical resection and chemoradiotherapy, the prognosis of patients with esophagogastric junction adenocarcinoma (EJA) remains poor due to early lymph node metastasis. Since few studies have investigated genes associated with lymph node metastasis in EJA, we aimed to screen lymph node metastasis‐associated genes and clarify their expression status and prognostic significance in EJA. Methods The differential frequency of mutations between carcinoma and para‐carcinoma tissues from 199 cases with EJA was detected using targeted next‐generation sequencing (tNGS). Following a stratified analysis to determine that gender has no effect on the frequency of gene mutations, lymph node metastasis‐related genes, including CDK6, MET, NOTCH1, and LRP1B, were screened, and CDK6 and LRP1B were selected for further study as they displayed significant differences in mutation rates. Differences in their expression status were verified using immunohistochemical (IHC) staining in 18 CDK6‐ and 17 LRP1B‐mutated samples and a randomly matched control group. Results tNGS revealed that CDK6 and LRP1B mutation frequencies were significantly different between EJA cases with (N ≥ 1) or without (N = 0) lymph node metastasis. In particular, CDK6 mutation frequency was expected less, whereas that of LRP1B was remarkably higher in cases with stage N0 than in those with stage N ≥ 1. IHC staining confirmed significant differences in CDK6 and LRP1B expression status between the study and control cohorts. Chi‐square tests revealed that a high CDK6 expression status correlated significantly with smoking history (p = 0.044), T stage (p = 0.035), N stage (p = 0.000), and advanced TNM stage (p = 0.001) in EJA, whereas a high LRP1B expression status only correlated with BMI (p = 0.013) and N stage (p = 0.000). Furthermore, as confirmed by survival status investigation, a high LRP1B expression status predicted good prognosis, and a high CDK6 expression status was an independent predictor of poor prognosis in patients with EJA. Conclusions Taken together, the findings of this study demonstrate that a high CDK6 and LRP1B expression status promotes and inhibits lymph node metastasis in patients with EJA, respectively, suggesting that both CDK6 and LRP1B are significantly potential predictors of lymph node metastasis and prognosis in EJA., Screening of lymph node metastasis‐related genes by targeted next‐generation sequencing in of esophagogastric junction adenocarcinoma. CDK6 and LRP1B were selected for further study to clarify their expression and prognostic significance in AEG.

Background The mechanism of rapidly increased non‐small cell lung cancer (NSCLC) among never‐smoking Chinese women has not been elucidated. Ovarian sex steroid hormones have been suggested to counteract lung cancer development, and sex hormone‐binding globulin (SHBG) is essential in sex hormones regulation. This study aims to exploring single nucleotide polymorphisms (SNPs) in genomic regions associated with SHBG concentrations that contributed to never‐smoking female NSCLC. Methods Candidate genes were selected by a genome‐wide association (GWAS) meta‐analysis and gene expression profiles of never‐smoking NSCLC of Chinese women. The candidate SNPs limited to common minor allele frequency (MAF), missense variant, ethnic heterogeneous distribution, and SNPs were genotyped using the TaqMan method. A two‐stage case‐control design was adopted for exploration and validation of associations between candidate SNPs and risk of NSCLC. All participants were never‐smoking Chinese women. Chi‐square test and multivariate logistic regression were applied. Results Beginning with 12 genomic regions associated with circulating SHBG concentrations and gene expression profiles from never‐smoking NSCLC in Chinese women, candidate SNP rs12233719 and rs7439366 both located in candidate gene UGT2B7, which may be related to circulating SHBG concentrations and cancer risk, were identified. A two‐stage case‐control study was conducted in Shenyang and Tianjin represented as the training stage and validation stage, respectively. Under the dominant model, compared to individuals with the wild G/G genotype, the adjusted OR of those with the T allele was 1.58 (95% CI: 1.15–2.16) in Chinese Shenyang training set, and was 1.49 (95% CI: 1.02–2.18) in Chinese Tianjin validation set, both accompanied with a significant trend relationship consistently. UGT2B7 was upregulated in female NSCLC patients’ tumor tissues and was associated with a poor prognosis in NSCLC. Conclusion Our findings indicated that a sex hormones regulation‐related SNP rs12233719 was associated with never‐smoking female lung cancer risk, which might partially explain NSCLC‐susceptibility in Chinese women., In this study, by conducting a two‐stage case‐control study, we found that a sex hormones regulation related SNP rs12233719 was associated with never‐smoking female lung cancer risk, which might partially explain NSCLC‐susceptibility in Chinese women.

Introduction PREDICT is a prognostication tool that calculates the potential benefit of various postsurgical treatments on the overall survival (OS) of patients with nonmetastatic invasive breast cancer. Once patient, tumor, and treatment details have been entered, the tool will show the estimated 5‐, 10‐, and 15‐year OS outcomes, both with and without adjuvant therapies. This study aimed to conduct an external validation of the prognostication tool PREDICT version 2.2 by evaluating its predictive accuracy of the 5‐ and 10‐year OS outcomes among female patients with nonmetastatic invasive breast cancer in Japan. Methods All female patients diagnosed from 2001 to 2013 with unilateral, nonmetastatic, invasive breast cancer and had undergone surgical treatment at Kyushu University Hospital, Fukuoka, Japan, were selected. Observed and predicted 5‐ and 10‐year OS rates were analyzed for the validation population and the subgroups. Calibration and discriminatory accuracy were assessed using Chi‐squared goodness‐of‐fit test and area under the receiver operating characteristic curve (AUC). Results A total of 636 eligible cases were selected from 1, 213 records. Predicted and observed OS differed by 0.9% (p = 0.322) for 5‐year OS, and 2.4% (p = 0.086) for 10‐year OS. Discriminatory accuracy results for 5‐year (AUC = 0.707) and 10‐year (AUC = 0.707) OS were fairly well. Conclusion PREDICT tool accurately estimated the 5‐ and 10‐year OS in the overall Japanese study population. However, caution should be used for interpretation of the 5‐year OS outcomes in patients that are ≥65 years old, and also for the 10‐year OS outcomes in patients that are ≥65 years old, those with histologic grade 3 and Luminal A tumors, and in those considering ETx or no systemic treatment., This study conducted an external validation of the online PREDICT tool version 2.2 by studying its predictive accuracy of the 5‐ and 10‐year overall survival (OS) in a population of breast cancer patients in Japan. Based on analysis of 636 eligible patients, the differences of the predicted and observed 5‐ and 10‐year OS were not statistically significant and the discriminatory accuracy results were fairly well. Hence, we can say that PREDICT tool accurately estimated the 5‐ and 10‐year overall survival in the Japanese validation population.

OBJECTIVES/HYPOTHESIS To assess the incidence of palatal fistula after primary repair of the cleft palate among two cohorts of Otolaryngologist-Head and Neck Surgeons and to identify patient and surgeon characteristics that may predict fistula development. STUDY DESIGN Retrospective case series with chart review. METHODS Children who underwent primary repair of cleft palate at one of two multidisciplinary cleft centers over a 10 year period were identified. Charts were reviewed for the presence of palatal fistula; chi square test and multivariate logistic regression analysis were performed to determine variables associated with fistula formation. RESULTS From 2007 to 2017, 477 patients underwent primary repair of cleft palate by one of 6 Otolaryngologist-Head and Neck Surgeons. Twenty-four children had incomplete charts, allowing 453 patients to be included in the final analysis. The pooled mean incidence of palatal fistula was 6.6% (P = .525) and varied significantly by cleft type. Logistic regression analysis controlling for multiple variables, showed that Veau IV classification had the highest risk of fistula (OR = 10.582; P = .004). Repair by a specific surgeon was not a significant risk factor for fistula development (P > .07 for each surgeon). CONCLUSIONS Among six Otolaryngologist-Head and Neck Surgeons with fellowship training in cleft palate repair postoperative fistula rates were consistent and compared favorably to standards in the Cleft and Craniofacial surgery literature established by other surgical specialties. Consistent with larger database studies involving multiple surgical specialties, Veau IV classification was the strongest predictor of palatal fistula development, even after adjusting for multiple variables, including differing levels of experience. LEVEL OF EVIDENCE 4 Laryngoscope, 131:1281-1285, 2021.

The health beliefs and practices regarding cervical cancer screening among women in the mountainous and Terai region of Nepal were investigated and examined for the differences. A descriptive cross-sectional study was conducted with a purposive sample of 216 in mountainous and 294 in Terai. The interview tools were a socio-demographic scale, a Nepalese Health Belief Model Scale for Cervical Cancer followed by the Screening Test. Chi-square test, binary logistic regression, Mann-Whitney U, and Kruskal-Wallis were used to analyze the data. The results showed that the screening rate was low for both regions with a significant difference in the benefit of screening and health motivation. Being older and having a positive family history of cervical cancer were shown to be predictors screening practice. Women from both groups preferred female doctors for screening. Culturally appropriate educational interventions focused on the benefits and obstacles of screening is needed to improve the beliefs of cervical cancer and screening and increase the screening rate. Nurses need to be aware of health beliefs regarding cervical cancer during cervical screening and education.

Fibroblast growth factor receptor (FGFR) is associated with proliferation, migration, and angiogenesis of carcinomas, and FGFR signaling inhibitors are considered a key drug for the treatment of solid tumors with FGFR overexpression. Amplification of FGFR2 is reportedly identified in 3%‐10% of gastric cancers (GCs). The aim of this study is to clarify whether the identification of the circulating tumor cells (CTCs) with FGFR2 overexpression is useful to detect patients with FGFR2‐overexpressing GC. One hundred GC patients who underwent gastrectomy were enrolled. A total volume of 8 mL of peripheral blood was collected from each patient just before gastrectomy, and mononuclear cells were enriched by Ficol density gradient centrifugation. These cells were immunostained with PI/CD45/EpCAM/FGFR2. The number of CTCs with FGFR2 expression in each sample was enumerated by FACScan. The FGFR2 expression level of the resected primary tumor was assessed by immunohistochemistry. The number of FGFR2‐positive CTCs in the GC patients' peripheral blood was significantly correlated with the FGFR2 expression level of the primary GC. The relapse‐free survival of the patients with FGFR2‐positive CTCs (≥5 cells/10 mL blood) was significantly poorer (P = .018, log‐rank) than that of the patients without FGFR2‐positive CTCs (, We aim to clarify the clinical significance of FGFR2‐positive CTCs in gastric cancer. FGFR2‐positive CTCs were correlated with the FGFR2 expression level of primary GC. The detection of FGFR2‐positive CTCs might help identify an existing FGFR2‐positive tumor.

To determine the population groups that benefit from a Free Maternal and Child Health (FMCH) programme in Enugu State, South-east Nigeria, so as to understand the equity effects of the programme.A community-based survey was conducted in rural and urban local government areas (LGAs) to aid the benefit incidence analysis (BIA) of the FMCH. Data were elicited from 584 randomly selected women of childbearing age. Data on their level of utilisation of FMCH services and their out-of-pocket expenditures on various FMCH services that they utilised were elicited. Benefits of the FMCH were valued using the unit cost of providing services while the net benefit was calculated by subtracting OOP expenditures made for services from the value of benefits. Costs were calculated in local currency (Naira (₦)) and converted to US Dollars. The net benefits were disaggregated by urban-rural locations and socio-economic status (SES). Concentration indices were computed to provide the level of SES inequity in BIA of FMCH.The total gross benefit incidence was ₦2.681 million ($7660). The gross benefit that was consumed by the urban dwellers was ₦1.581 million ($4517.1), while the rural dwellers consumed gross benefits worth ₦1.1 million ($3608.20). However, OOP expenditure for the supposedly FMCH was ₦6 527 580 (US$18 650.2) in the urban area, while it was ₦3, 194, 706 (US$ 9127.7) among rural dwellers. There was negative benefit incidence for the FMCH because the OOP exceeded the gross benefits at the point of use of services. There was no statistically significant difference in the benefit incidence and OOP expenditure between the urban and rural dwellers and across socio-economic groups.The distribution of the gross benefits of the FMCH programme indicates that it may not have achieved the desired aim of enhanced access particularly to the low-income population. Crucially, the high level of OOP erased whatever societal gain the FMCH was developed to provide. Hence, there is a need to review its implementation and re-strategise to reduce OOP and achieve greater access for improved effectiveness of the programme.Déterminer les groupes de population qui bénéficient d'un programme de santé maternelle et infantile gratuite (F-MCH) dans l'Etat d'Enugu, dans le sud-est du Nigéria, afin de comprendre les effets du programme sur l'équité. MÉTHODE: Une enquête communautaire a été menée dans des zones locales gouvernementales (ZLG) rurales et urbaines pour faciliter l'analyse de l'incidence des bénéfices (AIB) du F-MCH. Des données ont été obtenues auprès de 584 femmes en âge de procréer sélectionnées aléatoirement. Les données sur leur niveau d'utilisation des services F-MCH et leurs dépenses directes de la poche (DDP) pour divers services F-MCH qu'elles ont utilisé ont été obtenues. Les bénéfices du F-MCH ont été évalués en utilisant le coût unitaire de la prestation des services, tandis que le bénéfice net a été calculé en soustrayant les dépenses directes de la poche pour les services de la valeur des bénéfices. Les coûts ont été calculés en monnaie locale (Naira ₦) et convertis en dollars américains USD. Les bénéfices nets ont été ventilés par endroits urbain-rural et par statut socioéconomique (SSE). Les indices de concentration ont été calculés pour fournir le niveau d'iniquité du SSE dans l’AIB du F-MCH. RÉSULTATS: L'incidence des prestations brutes totales était de ₦ 2.681.000 (7.660 USD). Le bénéfice brut qui a été consommé par les habitants des villes était de ₦ 1.581.000 (4.517,1 USD), tandis que les habitants ruraux ont consommé une valeur de bénéfices bruts de ₦ 1,1 million (3,608.20 USD). Cependant, les DDP pour le soi-disant F-MCH étaient de 6.527.580 ₦ (18.650,2 USD) dans la zone urbaine, alors qu'elles étaient de 3 194 706 ₦ (9.127,7 USD) parmi les habitants des zones rurales. Il y avait une incidence négative des bénéfices pour le F-MCH parce que les DDP dépassaient les bénéfices bruts au point d'utilisation des services. Il n'y avait pas de différence statistiquement significative dans l'incidence des bénéfices et les DDP entre les habitants des zones urbaines et rurales et entre les groupes socioéconomiques.La répartition des bénéfices bruts du programme F-MCH indique qu'il n'a peut-être pas atteint l'objectif souhaité d'un accès amélioré, en particulier pour la population à faible revenu. Fondamentalement, le niveau élevé de dépenses directes de la poche a effacé tout gain sociétal que le F-MCH avait été développé pour fournir. Par conséquent, il est nécessaire de revoir sa mise en œuvre et de revoir sa stratégie pour réduire les DDP et obtenir un meilleur accès pour une efficacité accrue du programme.

Objective There has been an unprecedented fall in the rate of stillbirth in twin pregnancy in the UK. It is contested whether implementation of the National Institute for Health and Care Excellence (NICE) guidance on the antenatal management of uncomplicated twin pregnancies has contributed to this change. The aim of this study was to investigate whether the implementation of NICE guidance was associated with a reduction in the rate of stillbirth in twin pregnancies delivered in a large UK hospital. Methods This was a retrospective cohort study including all twin pregnancies delivered at St George's Hospital, London, UK, between 2000 and 2018. Data were analyzed according to two time periods: before implementation of the NICE guidance on twins (before June 2013; pre-NICE) and after its implementation (after June 2013; post-NICE). The exclusion criteria were higher-order multiple gestations, pregnancies of unknown chorionicity, pregnancies complicated by miscarriage, those that underwent termination and those diagnosed with vanishing twin. The main outcome was stillbirth. Other outcomes included neonatal death (NND), admission to the neonatal intensive care unit (NICU) and emergency Cesarean section. We planned a priori a sensitivity analysis according to chorionicity. The chi-square test and Mann–Whitney U-test were used to compare outcomes between the study groups. Results We included in the analysis 1666 twin pregnancies (3332 fetuses), of which 1114 pregnancies (2228 fetuses) were delivered before and 552 pregnancies (1104 fetuses) after June 2013. Of those, 1299 were dichorionic and 354 were monochorionic diamniotic. The incidence of stillbirth was significantly lower in the post-NICE than in the pre-NICE group (3.6 per 1000 births vs 13.5 per 1000 births; P = 0.008). The reduction in stillbirth rate was from 8.5 to 3.6 per 1000 births (P = 0.161) in dichorionic and from 33.6 to 3.8 per 1000 births (P = 0.011) in monochorionic diamniotic twin pregnancies. There was no significant difference in the rates of NND (P = 0.625), NICU admission (P = 0.506) or emergency Cesarean section (P = 0.820) between the two groups. The median gestational age at delivery was significantly lower in the post-NICE than in the pre-NICE group (median 36.3 vs 36.9 weeks; P Conclusions A significant reduction of > 70% in the stillbirth rate in twin pregnancies was noted after implementation of the NICE guidance. This reduction was statistically significant in monochorionic, but not dichorionic, twin pregnancies. The improvement in twin pregnancy outcome was achieved without a concomitant increase in NND, admission to the NICU or emergency Cesarean section. © 2020 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of the International Society of Ultrasound in Obstetrics and Gynecology.

Objectives/hypothesis We sought to characterize rates of progression to posterior glottic stenosis (PGS) from autoimmune or idiopathic subglottic stenosis. Study design This was a retrospective review. Methods Patients from a tertiary-care laryngology practice over a 10-year period with autoimmune or idiopathic subglottic stenosis (SGS) were included. Patients with a history of prolonged intubation or other causes of iatrogenic stenosis were excluded. PGS was confirmed on videostrobolaryngoscopy recordings by a fellowship-trained laryngologist. PGS type (1-4) was also recorded. Demographic information was recorded, and if applicable, autoimmune disease type was specified. Time until PGS was recorded along with the number of interventions. Chi-squared analysis was used to compare PGS in autoimmune and idiopathic SGS. Results A total of 77 patients were identified with autoimmune (32 patients) or idiopathic (45 patients) subglottic stenosis. Autoimmune pathologies included systemic lupus erythematosus, granulomatosis with polyangiitis (GPA), rheumatoid arthritis, relapsing polychondritis, and sarcoidosis, with GPA the most common (14/32). Patients with autoimmune SGS had a higher rate of PGS (10 of 32) compared to idiopathic subglottic stenosis (1 of 45) for an odds ratio of 20 (95% CI: 2.4-166.4, P = .006). Patients with idiopathic SGS were more likely to be female (all 45 compared to 29/32 autoimmune, P = .07) and older (mean 53 (range 29-75) compared to 46 (20-82), P = .02). Conclusions In this large patient cohort, autoimmune SGS patients were found to have a higher likelihood of developing PGS compared to their idiopathic counterparts, suggesting that counseling for this progression may be warranted. Level of evidence 4 Laryngoscope, 131:1816-1820, 2021.

Background This study aimed to compare the efficacy and toxicity of raltitrexed (Saiweijian®) plus cisplatin (SP regimen) and 5‐fluorouracil plus cisplatin (FP regimen) as concurrent chemoradiotherapy (CCRT) in patients with locally advanced nasopharyngeal carcinoma (LA‐NPC). Methods Eligible patients (N = 135) were allocated randomly in a ratio of 1:1 to receive CCRT with either SP or FP. At least 2 cycles of chemotherapy was administrated during radiotherapy. Progression free survival (PFS) was primary endpoint. Secondary endpoints included overall survival (OS), loco‐regional relapse free survival (LRRFS), distant metastasis free survival (DMFS) and toxicity. Results In this study, 68 patients received SP as CCRT, and 67 received FP. Objective responses were noted in 97.1% of the patients in the SP group and in 97.0% of the patients in the FP group (P = 1.00). At the end of a median 36 months follow‐up period, the estimated 3‐year PFS rates were 70.1% for SP and 66.6% for FP, respectively. The 3‐year LRRFS, DMFS and OS rates were 88.9%, 74.7% and 84.0%, respectively, for the SP group, and 92.3%, 71.0% and 73.7%, respectively, for the FP group. Overall, there was no difference between treatment groups with regard to response or survival. The most frequent acute toxicities monitored in both groups were bone marrow suppression, gastrointestinal side effects and oral mucositis (OM). The overall incidence of grade 3‐4 OM in the FP group (47.8%) was higher than in the SP group (11.8%). However, the incidence of other adverse effects observed in both groups was similar (P > .05). Conclusions These data indicate that SP and FP therapies have similar efficacy in treating LA‐NPC. The SP regimen showed a tolerable safety profile along with a lower frequency of severe OM and therefore, an improved life quality. In conclusion, SP was a well tolerated, effective, regimen for LA‐NPC treatment., The incidence of other adverse effects seen in both groups was similar (P > .05).The efficacy of both regimens i.e. SP and FP are found similar. The SP regimen has tolerable safety profile, with a lower incidence of severe OM and consequently, an improved quality of life.

Background Pretreatment clinical staging is essential to select therapy. However, there have been no published pretreatment gastric cancer nomograms constructed using pretreatment clinical prognostic factors, including in nonresection patients. We aimed to develop a new pretreatment gastric cancer nomogram for individualized prediction of overall survival (OS). Methods The nomogram was developed using data of 5231 Japanese gastric cancer patients, and it was created with a Cox regression model. Fifteen clinical variables, which were obtained at pretreatment, were collected and registered. Data of two independent cohorts of patients from Seoul St. Mary's Hospital (1001 patients), and the University of Verona (389 patients) formed the external validation cohorts. The model was validated internally and externally using measures of discrimination (Harrell's C‐index), calibration, and decision curve analysis. Results The developed nomogram showed good discrimination, with a C‐index of 0.855; that of the American Joint Committee on Cancer (AJCC) clinical stage was 0.819. In the external validation procedure, the C‐indexes were 0.856 (AJCC, 0.795) in the Seoul St. Mary's cohort and 0.714 (AJCC, 0.648) in the University of Verona cohort. The nomogram performed well in the calibration and decision curve analyses when applied to both the internal and external validation cohorts. A stage‐specific subset survival analysis of the three risk groups calculated using the nomogram also showed the superiority of nomogram‐prediction when compared to AJCC. Conclusion This new pretreatment model accurately predicts OS in gastric cancer and can be used for patient counseling in clinical practice and stratification in clinical trials., The newly developed gastric cancer pretreatment nomogram can accurately predict overall survival and thereby improve risk stratification and patient selection for routine clinical decision‐making and future clinical trials. This model will improve on the traditional categorical AJCC system in the future.

Objective To describe the clinical characteristics of renal cell carcinoma (RCC) with venous tumor thrombus (VTT) and bland thrombus (BT), and to evaluate the influence of BT on surgical treatment and cancer‐specific survival (CSS) of RCC with VTT. Methods We retrospectively reviewed clinical data of 123 patients with RCC and VTT, who underwent surgical treatment in our center between February 2015 and May 2018. Patients were divided into the BT group (21 patients) and non‐BT group (102 patients). Chi‐square and Mann‐Whitney U test were used for categorical and continuous variables respectively. Univariable log‐rank tests and multivariable Cox regressions were conducted to evaluate the prognostic significance of each variable. Kaplan‐Meier plots were performed to evaluate the influence of BT. Results In the delayed phase of enhanced magnetic resonance imaging (MRI), BT and VTT had difference. Patients were divided according to the relative position of BT: proximal end BT (one patients), contralateral renal vein BT (two patients), distal end BT (12 patients), and multiple BT (six patients). The average length of BT was 8.4 ± 5.8 cm (range: 0.6‐20.0 cm). Patients with BT had longer operative time (P = .001), more surgical blood loss (P = .004), higher proportion of open surgery (P = .006), more postoperative complications (P = .011). BT (hazard ratio [HR] = 3.323, P = .007) were independent risk factors for poor prognosis. Conclusions In the delayed phase of enhanced MRI, BT showed no obvious enhancement, while VTT usually showed enhancement. This was an important basis for preoperative imaging diagnosis of BT. The presence of BT increases the difficulty of surgery, and is correlated with adverse survival outcomes in patients with RCC and VTT., MRI is an important examination for RCC patients with VTT and BT. BT has adverse influence on surgical treatment and survival.

Currently, the features and prognosis of nasopharyngeal carcinoma (NPC) with distant metastases are still rarely reported. Thus, the main purpose of our study was to investigate the metastasis patterns of different histological types of NPC and to clarify the prognostic characteristics of metastases at different sites. Patients were enrolled from the SEER program from 2010 to 2016. Chi‐squared tests were used to compare features between groups. The tendency to develop combined metastases was assessed with the odds ratio. The Kaplan‐Meier method was used for the survival analysis. Univariate and multivariate Cox analyses were used to select the independent prognostic risk factors for inclusion in the nomogram. In the present study, we found the following: (1) tumors are highly likely to metastasize if they have a larger volume, the regional lymph nodes are relatively large, or the regional lymph nodes are biopsied but not removed; (2) the bone and the brain were the most and least common metastatic sites among all histological types and N stages. Metastasis at two sites was the most common pattern, and bone metastasis was generally associated with metastasis to the liver or brain; (3) the prognostic analyses in metastatic patients showed that cancer‐specific survival (CSS) was relatively worse in patients with multiple metastases, and in those with liver metastasis regardless of the number of other metastatic sites; (4) A nomogram was constructed for clinical use based on four independent prognostic risk indicators, including histology, radiation therapy, chemotherapy, and metastatic status. Our findings provide a reference for clinical decision‐making and future diagnostic screening tests for NPC with distant metastases., Our study shows the distribution patterns and prognoses of distant metastases among 4 histological types in NPC. A nomogram was constructed for clinical use based on 4 independent prognostic risk indicators, including histology, radiation therapy, chemotherapy and metastatic status. Our findings provide a reference for clinical decision‐making and future diagnostic screening tests for NPC with distant metastases.

Background The Utrecht Symptom Diary (USD) is a Dutch and adapted version of the Edmonton Symptom Assessment System, a patient‐reported outcome measurement (PROM) tool to asses and monitor symptoms in cancer patients. This study analyses the validity and responsiveness of the USD and the cutoff points to determine the clinical significance of a symptom score. Methods Observational longitudinal cohort study including adult in‐ and outpatients treated in an academic hospital in the Netherlands who completed at least one USD as part of routine care (2012‐2019). The distress thermometer and problem checklist (DT&PC) was used as a reference PROM. Content, construct and criterion validity, responsiveness, and cutoff points are shown with prevalences, area under receiver operating characteristic (ROC) curve, Chi‐squared test, Wilcoxon signed‐rank test, and positive and negative predictive values, respectively. Results A total of 3913 patients completed 22 400 USDs. Content validity was confirmed for all added USD items with prevalences of ≥22%. All USD items also present on the DT&PC demonstrated a good criterion validity (ROC >0.8). Construct validity was confirmed for the USD as a whole and for the items dry mouth, dysphagia and well‐being (P, The USD is a valid 12‐item PROM for the most prevalent symptoms in cancer patients, which has content, criterion, and construct validity and detects clinically important changes over time, in both curative and palliative phase.

Adults with type 2 diabetes (T2DM) and depression are associated with higher hemoglobin A1C (HbA1C ) compared to their nondepressed counterparts. Little is known about related clinical and demographic components contributing to these differences. We examined differences in HbA1C between adults who have T2DM with and without major depression. T tests and chi-square analyses measured differences in HbA1C and clinical/demographic variables. HbA1C was statistically higher in depressed participants compared to nondepressed participants. The difference was no longer statistically significant after controlling for age. Age and HbA1C were negatively correlated across the sample and were still correlated in each group independently. The interaction of age and HbA1C was moderated by depression status. Additionally, mechanisms for diabetes severity differences were assessed using moderation analyses and Blinder-Oaxaca decomposition technique. Seventy-four percent of the mean outcome HbA1C difference between depressed and nondepressed diabetic participants was explained by age. Furthermore, age was negatively correlated with clinical variables, such as diastolic blood pressure and cholesterol. Comparing age to smoking and nonsmoking participants, smokers were statistically younger. Younger adults with T2DM may require more attention regarding self-management, particularly in the context of depression. Depression should be screened and treated among individuals with diabetes since this exacerbates diabetes severity.

BACKGROUND The sister yeast species Cryptococcus neoformans (serotype A) and Cryptococcus deneoformans (serotype D) are causative agents of deadly cryptococcosis and fungal meningoencephalitis. These haploid yeasts can hybridise in nature, giving rise to AD hybrids that are predominantly diploid or aneuploid. Despite their increasing prevalence in clinical settings, much remains unknown about the allelic distribution patterns in AD hybrid strains. OBJECTIVES This study aims to characterise allele distributions in AD hybrids derived from the same basidium as well as from multiple basidia in a laboratory-derived C neoformans × C deneoformans hybrid cross. METHODS We dissected a total of 1625 basidiospores from 31 basidia. The 297 basidiospores that successfully germinated were genotyped by molecular characterisation of 33 markers using PCR-RFLP, with at least two markers on each of the 14 chromosomes in the genome. RESULTS Of the 297 strains, 294 contained at least one heterozygous locus, with a mean heterozygosity of ~30% per strain. Most hybrid genomes and chromosomes displayed significantly distorted allele distributions, with offspring originating from the same basidium tended to have alleles at different loci from the same parent. More basidia were skewed in favour of C deneoformans alleles, the mitochondria-donor parent, than the C neoformans alleles. CONCLUSIONS The divergence between C neoformans and C deneoformans genomes has likely created co-adapted allelic combinations, with their co-segregation in hybrid offspring imparting a significant fitness benefit. However, the diversity of genotypes recovered here in a single hybridisation event indicates the enormous capacity of AD hybrids for adaptation and diversification.

Background Findings from previous studies examining the effectiveness of symptom management on patients with diabetes that were implemented in home settings were inconclusive. Exploring the effects of a diabetes symptom management program on patients with type 2 diabetes mellitus (T2DM) in clinical settings is useful for healthcare providers to improve their diabetes care. Aims To examine the effects of a diabetes symptom management program (DSMP) on HbA1c levels, self-care behaviors, quality of life (QoL), and symptom severity in clinics in patients with T2DM. Methods This study was a single-blind randomized controlled trial. The control group (n = 30) received usual care. The experimental group (n = 30) received DSMP and usual care. The primary outcome variable was HbA1c levels; the secondary outcome variables were self-care behaviors, QoL, and diabetes symptom severity. Outcome variables were measured at baseline (T0), 3 months (T1) and 6 months after the intervention (T2), and HbA1c levels were further collected at 9 months after the intervention (T3). Results The decreasing levels of HbA1c from T0 to T2 and from T0 to T3 and for severity of diabetes symptoms from T0 to T2 in the experimental group were significantly better than those in the control group. The increasing levels of self-care behavior and QoL from T0 to T1 and from T0 to T2 in the experimental group were significantly higher than those in the control group. Linking evidence to action DSMP implemented in the clinic setting has effects on improving HbA1c, self-care behaviors, QoL, and preventing worsening severity of diabetes symptoms for outpatients with T2DM. Healthcare providers could assess diabetes symptoms of patients with high HbA1c levels and provide symptom management care rather than merely providing education on improvement of self-care behaviors.

BACKGROUND High-risk human papillomavirus (HPV)-Papanicolaou (Pap) cotesting is recommended for cervical cancer screening in women aged ≥30 years. The current study analyzed the effectiveness of cotesting on risk management in different age groups. METHODS A retrospective review of a 5-year cytology database identified 9434 women with HPV-Pap cotesting and follow-up cervical biopsy. The 3-year cumulative risk of developing high-grade cervical lesions (≥high-grade squamous intraepithelial lesion [HSIL]) was analyzed using age stratification. RESULTS The 3-year cumulative risk of developing ≥HSIL was found to be significantly different in women with baseline cotesting HPV-positive and Pap-positive results (HPV+/Pap+; defined as ≥atypical squamous cells of undetermined significance), HPV+ and Pap-negative results, and HPV-negative and Pap+ results at 19.2%, 7.9%, and 3.1%, respectively (P

Background Previous studies on bedside handovers have identified nurse-related barriers and facilitators for implementing bedside handovers, but have neglected the existing ward's nursing care system as an important influencing factor. Aims To determine the association between the existing nursing care system (i.e., decentralized, two-tier, or centralized) on a ward and the barriers and facilitators of the bedside handover. Methods Structured individual interviews (N = 106) on 14 nursing wards in eight hospitals were performed before implementation of bedside handovers. The structured interview guide was based on a narrative review. Direct content analysis was used to determine the nursing care system of a ward and the degree to which barriers and facilitators were present. Pearson's Chi-square analysis was used to determine whether there were associations between the nursing care systems concerning the presence of barriers and facilitators for implementing bedside handovers. Results Twelve barriers and facilitators were identified, of which three are new to literature: the possible loss of opportunities for socializing, collegiality, and overview; head nurse's role; and role of colleagues. The extent to which barriers and facilitators were present differed across nursing care systems, with the exception of breach of confidentiality (barrier), and an existing structured handover (facilitator). Overall, nurses working in decentralized nursing care systems report fewer barriers against and more facilitators in favor of using bedside handovers than nurses in two-tier or centralized systems. Linking evidence to action Before implementing bedside handovers, the context of the nursing care system may be considered to determine the most effective process to implement change. Based on these study findings, implementing bedside handovers could be more challenging on wards with a two-tier or centralized care system.

Background The clinical course of motor deficits from lumbosacral radiculopathy appears to improve with or without surgery. Strength measurements have been confined to manual muscle testing (MMT) and have not been extensively followed and quantified in prior studies. Objective To determine if motor weakness and patient-reported outcomes related to lumbosacral radiculopathy improve without surgical intervention over the course of 12 months. Design Prospective observational cohort. Setting Outpatient academic spine practice. Participants Adults with acute radicular weakness due to disk herniation. Methods Forty patients with radiculopathy and strength deficit were followed over a 12-month period. Objective strength and performance tests as well as survey-based measurements were collected at baseline and then every 3 months. Patients underwent comprehensive pain management and rehabilitation and/or surgical approaches as determined in coordination with the treating specialist. This study was approved by the institutional review board of Colorado. Main outcome measurements Testing of strength was through MMT, handheld dynamometer, and performance-based testing. Furthermore, visual analog scale, modified Oswestry Disability Index, and 36-Item Short Form Health Survey (SF-36) were used to measure pain and disability outcomes. Results Of the 40 patients, 33 (82.5%) did not have surgery; 7 (17.5%) had surgery. Twenty-four of the 33 patients (60%) did not undergo surgery and were followed for 12 months (Comprehensive Pain Management and Rehabilitation, Complete [CPM&R-C]), and 9 (22%) did not have surgery and lacked at least one follow-up evaluation (Comprehensive Pain Management and Rehabilitation, Incomplete [CPM&R-I]). No statistically significant differences were found on baseline measures of strength deficits and SF-36 domains between the CPM&R-C, Surgery, and CPM&R-I groups. Pain and disability scores in the Surgery group were significantly higher than in the CPM&R-C at baseline. There were statistically significant improvements in all areas of strength, pain, and function when comparing measurements at the 12-month follow-up to baseline in the CPM&R-C group. Conclusions Individuals with motor deficits due to lumbosacral radiculopathy improve over time regardless of treatment choice. Most did not choose surgery, and almost all of these patients regained full strength at 1 year. Strength recovery typically occurred in the first 3 months, but there was ongoing recovery over the course of a year. Level of evidence II.

PURPOSE: Several studies have identified differences in end-of-life (EOL) care between urban and rural areas, yet little is known about potential differences in care processes or family evaluations of care. The purpose of this study is to examine the relationship between rurality of residence and quality of EOL care within the Veterans Affairs healthcare system. METHODS: This study was a retrospective, cross-sectional analysis of 126,475 veterans who died from October 2009 through September 2016 in inpatient settings across 151 facilities. Using unadjusted and adjusted logistic regression, we compared quality of EOL care between urban and rural veterans using family evaluations of care and four quality of care indicators for receipt of (1) palliative care consult (2) a chaplain visit (3) death in an inpatient hospice unit, and (4) bereavement support. FINDINGS: Veterans from rural areas had lower odds of dying in an inpatient hospice unit compared to veterans from urban areas, before and after adjustment (large rural OR 0.73, 95% CI: 0.70–0.77; P < .001, small rural OR 0.81, 95% CI: 0.77–0.86; P < .001, isolated rural OR 0.87, 95% CI: 0.81–0.93; P < .001). Differences in comparisons of other quality of care indicators were small and of mixed significance. No significant differences were found in family ratings of care in fully adjusted models. CONCLUSION: Receipt of some EOL quality indicators differed with urban-rural residence for some comparisons. However, family ratings of care did not. Our findings call for further investigation into unmeasured individual characteristics and facility processes related to rurality.

BACKGROUND AND AIM Adenoma detection rate (ADR) is an important quality metric in colonoscopy. However, there is conflicting evidence around factors that influence ADR. This study aims to investigate the effect of time of day and endoscopist background on ADR and sessile serrated adenoma/polyp detection rate (SSA/P-DR) for screening colonoscopies. METHODS Consecutive patients undergoing colonoscopy in 2016 were retrospectively evaluated. Primary outcome was the effect of time of day and endoscopist specialty on screening ADR. Secondary outcomes included evaluation of the same factors on SSA/P-DR and other metrics and collinearity of ADR and SSA/P-DR. Linear regression models were used for association between ADR, time of day, and endoscopist background. Bowel preparation, endoscopist, session, patient age, and gender were adjusted for. Linear regression model was also used for comparing ADR and SSA/P-DR. Chi-square was used for difference of proportions. RESULTS Two thousand six hundred fifty-seven colonoscopies, of which 558 were screening colonoscopies, were performed. The adjusted mean ADR (screening) was 36.8% in the morning compared with 30.5% in the afternoon (P

This study aims to determine the rates of complementary and alternative medicine methods used by mothers of children with developmental disabilities, reasons for using methods, and comparison of methods according to diagnosis groups. The cohort in this cross-sectional and correlational study consisted of the mothers of 390 students with developmental disabilities; 77.2% of the mothers reported using at least one complementary and alternative medicine treatment. The highest level of use was found in the groups of mothers of children with cerebral palsy (100%) and autism spectrum disorder (88.5%). The most commonly used treatments were biological therapies consisting of special diets and multivitamins, manipulative and body-based methods including massage and exercise, and mind-body interventions such as prayer, wearing amulets, and seeking help from a Muslim preacher (hodja). However, mothers never used alternative medicine treatments such as homeopathy, acupuncture, or Ayurveda, nor did they use energy-based healing techniques such as reiki, tai chi, yoga, kinesiology, or neurofeedback exercises. Health care professionals, especially nurses as health care team members, should be knowledgeable and careful about the benefits, side effects, administration methods, and contraindications of complementary and alternative medicine treatments. WOS:000542439100022 2-s2.0-85087017614 PubMed: 32362016

Aims and objectives To determine the prevalence and type of occupational injuries in nurses and their associations with workload, working shift, and nurses' individual and organisational factors. Background Nurses are vulnerable to occupational injuries due to the nature of their job. Design A cross-sectional correlational design (based on STROBE Statement) was conducted. Methods This study was conducted among 616 nurses of four public hospitals located in four different provinces in Iran. Data were collected using three questionnaires including an organisational and demographic questionnaire, an occupational injuries checklist and the NASA-TLX questionnaire (about mental workload). Chi-square test, one-way ANOVA and multivariate logistic regression were used in SPSS version 23.0 for statistical analysis. Results Blood and body fluid exposures had the highest prevalence (47.4%) among all injuries. Needlestick injuries showed a significant relation with gender, age, number of shifts in a month and work experience. With increase in mental workload, needlestick injuries increase by 35%. Also, injuries reported by nurses working in rotating shifts were 15%-53% more than nurses working in fixed shifts. Conclusion Working in rotating shifts and work overload was significantly related to all injuries. Decreasing nurses' mental workload, introducing guidelines and efficient training in shift work schedules can help decrease occupational injuries among nurses. Relevance to clinical practice In order to reduce occupational injuries among nurses, in addition to incorporating advanced management and technology, it is necessary to pay attention to psychosocial, individual and organisational risk factors related to occupational injuries and their frequency in nurses. Also, reducing personnel's mental and occupational pressure should be considered.

BACKGROUND/OBJECTIVES: Older adults ≥65 years have the highest outpatient antibiotic prescribing rate of all age groups. We characterized antibiotics prescribed to older adults to guide efforts to improve antibiotic use. DESIGN: Outpatient antibiotic prescriptions dispensed for older adults from 2011–2014 were extracted from the IQVIA Xponent database. A chi-square trend analysis was conducted to assess annual changes in antibiotic prescribing rates. A descriptive analysis of prescribing rates by antibiotic, age group, sex, state, census region, and provider specialty was completed. SETTING: Ambulatory PARTICIPANTS: Adults aged ≥65 years in the United States RESULTS: During 2011–2014, outpatient antibiotic prescribing rates remained stable in U.S. older adults (P = 0.89). In 2014, older adults were dispensed 51.6 million prescriptions (1115 prescriptions/1000 persons). Persons aged ≥75 years had a higher prescribing rate (1157 prescriptions/1000 persons) than persons aged 65–74 (1084 prescriptions/1000 persons). Prescribing rates were highest in the South and lowest in the West (1228 and 854 prescriptions/1000 persons, respectively). The most commonly prescribed class was quinolones, followed by penicillins and macrolides. Azithromycin was the most commonly prescribed drug, followed by amoxicillin and ciprofloxacin. Internists and family physicians prescribed 43% of antibiotic courses. CONCLUSIONS: On average, in 2014, U.S. adults ≥65 years received enough outpatient antibiotic courses for every older adult to receive at least one. Quinolones and azithromycin are potential targets for assessing the appropriateness of antibiotic prescribing among this population. Interventions to improve use targeting internist and family physicians in the South census region might have the potential to be more impactful.

Background Monitoring free muscle flaps with skin grafts is difficult. To intensify the monitoring process for this type of flap, a small skin paddle was included in the flap and analyzed its effects. Methods A retrospective analysis of all patients who underwent scalp reconstruction with a free latissimus dorsi flap and skin graft between 1994 and 2016 was conducted. Flap monitoring was proceeded using a combination of clinical examination and handheld Doppler for both types of flaps. Results A total of 71 patients were included in this study and were divided into a study group (skin paddle included; n = 30) and a control group (conventional method; n = 41). The time between initial surgery to pedicle exploration was significantly shorter in the study group (11.3 ± 2.5 vs 79.8 ± 42.6 hours; P = .024). The flap salvage rate was significantly higher in the study group (100% vs 16.7%; P = .048). Conclusion The efficacy of flap monitoring and flap salvage outcomes were improved by including a small monitoring skin flap.

OBJECTIVE While surgical treatment concentrates in tertiary care centers, an increasing number of patients request postoperative radiation therapy (PORT) at a separate center closer to home. Our goal was to determine whether fragmentation of surgery and PORT were associated with poorer oncologic outcomes. METHODS We conducted a retrospective cohort study of 32,813 head and neck cancer patients treated with surgery and PORT in the National Cancer Data Base. Our main outcome was overall survival (OS). Statistical analysis included χ2 , t tests, Kaplan-Meier, and Cox regression analysis. RESULTS Fragmented care was independently associated with increased risk of mortality (hazard ratio [HR], 1.08; 95% confidence interval [CI], 1.03-1.13), whereas distance to surgical center > 30 miles (HR, 0.92; 95% CI, 0.87-0.97) was associated with improved OS. On subgroup analysis, fragmented care was associated with decreased OS only among patients who had surgery at an academic center (HR, 1.10; 95% CI, 1.04-1.17). Within academic centers, greater distance from the surgical center was associated with improved survival only in patients who received PORT at the same facility (HR, 0.85; 95% CI, 0.78-0.93), but this effect was negated among patients who had fragmented care (HR, 0.97; 95% CI, 0.85-1.11). CONCLUSION When cancer care is fragmented, there is no longer a survival benefit for patients to travel for surgical care at academic medical centers. Fragmented care is independently associated with worse survival, and further research is needed to evaluate the causes of this difference in survival to determine if improving care coordination can mitigate this survival difference. LEVEL OF EVIDENCE NA Laryngoscope, 129:1413-1419, 2019.

Background The treatment failure for oral squamous cell carcinoma (SCC) frequently takes the form of local and regional recurrences. We investigated the role of lingual lymph nodes (LLNs) in the recurrence of SCC of the tongue and the floor of the mouth. Methods A total of 111 patients with SCC of the tongue and the floor of the mouth who received treatment between 2012 and 2017 were included in this study. The patients with lingual lymph nodes that were confirmed to be metastasis on pathological examination were classified into the LNN group. The demographic and clinical data differences between the No-LLN group and the LLN group were compared. Statistical analyses were performed using the Pearson chi-square test RESULTS: The total incidence of LLNs was 17.12% (19/111) and 5 patients (4.5%) demonstrated LLN metastases. All the patients with LLN metastases had a neck lymph node status of N2 classification. The incidence and metastasis of the LLNs were associated with pathological classifications of SCC of the tongue and the floor of the mouth. Conclusions LLNs are rare in patients with SCC of the tongue and the floor of the mouth, and they would be ready to be omitted. The dissection of these LLNs would be of benefit to those patients with advanced pathological grade.

AIM: To compare the efficacy of the main methodologies in attaining sleep and electroencephalography (EEG) abnormalities in children with a view to producing recommendations on best practice. METHOD: Fifty-one UK centres participated. Methods for sleep induction (sleep deprivation, melatonin, and combined sleep deprivation/melatonin) were compared. Data pertaining to demographics, achievement of stage II sleep, and recording characteristics (duration of study, presence of epileptiform activity in awake/sleep states) were prospectively collected for consecutive patients in November and December 2013. RESULTS: Five hundred and sixty-five patients were included. Age range was 1 years to 17 years (mean 7y 10mo), 27.7 per cent had an underlying neurobehavioural condition. Stage II sleep was achieved in 69 per cent of sleep deprived studies, 77 per cent of melatonin studies, and 90 per cent of combined intervention studies (p

BACKGROUND The aetiology of molar-incisor hypomineralisation (MIH) is multifactorial and may involve genetic and environmental factors. AIM To verify the factors associated with MIH in schoolchildren from 8 to 10 years of age. DESIGN This is a case-control study with a sample consisting of children aged 8 to 10 years, paired by gender and school type, in a ratio of 1:3. The case group included 186 children with MIH and the control included 558 children without MIH. Data were collected through a semi-structured questionnaire and clinical examination. Chi-square, linear-by-linear, Mann-Whitney, and logistic regression tests were conducted. A value of P

Recent research has tried to use exosomal RNAs (coding and noncoding) as potential diagnostic markers for hepatocellular carcinoma (HCC). Initially, by using bioinformatics, we selected an HCC-exosomal RNA-based biomarker panel. The choice of this panel depends on the integration of Ras-related in brain (RAB11A) gene expression and its competing endogenous network. This network includes long noncoding RNA RP11-513I15.6 (lncRNA-RP11-513I15.6) and microRNA-1262 (miR-1262). Secondly, we tried to validate the expression of this network in the sera of 60 patients with HCC in comparison with 42 chronic hepatitis C virus-infected patients and 18 healthy controls. Then we assessed the diagnostic efficiency of this panel using a receiver operating characteristic curve analysis. The panel of 3 exosomal RNA-based biomarkers (lncRNA-RP11-513I15.6, miR-1262, and RAB11A) showed excellent sensitivity and specificity in discriminating patients with HCC from patients with chronic hepatitis C virus and healthy controls. Among these 3 RNAs, serum RAB11A mRNA was the most independent prognostic factor. The selected circulatory exosomal RNA-based biomarker panel showed its ability to be used as a diagnostic and prognostic biomarker tool for HCC. Moreover, these biomarkers could be therapeutic targets.

Aim Chondrocalcinosis results from deposition of calcium pyrophosphate dihydrate in articular cartilage. It is a relatively common radiographic finding of the joints, especially the knee. This study investigated the incidence and the risk factors for the development of knee chondrocalcinosis in the general population. Method We used a prospective, ongoing cohort, composed of 5018 people, which was established in 2001 to investigate the epidemiologic characteristics of major chronic diseases in the Republic of Korea. The incidence of knee chondrocalcinosis was assessed per 1000 person-years, and the risk factors were explored by Cox proportional hazard regression analyses. Results A total of 4543 patients who did not have knee chondrocalcinosis at enrollment, year 2001-2002, were evaluated with a mean follow-up duration of 8.4 ± 4.2 years. The crude incidence of knee chondrocalcinosis was 3.19 per 1000 person-years (women, 3.55; men, 2.70), and the whole cumulative incidence of knee chondrocalcinosis was 2.7%. Older age (> 55 years) and higher HbA1C were associated with increased risk of knee chondrocalcinosis. Conclusion This is the first study to report the incidence of knee chondrocalcinosis in the general population of Korea. Older age and high HbA1C were independent risk factors for development of knee chondrocalcinosis.

Objective The purpose of this study was to identify whether determinants of health-related quality of life (HRQoL) in middle-aged female patients with systemic lupus erythematosus (SLE) differed according to the presence or absence of fibromyalgia. Methods One hundred and fifty-two patients with SLE and 139 healthy controls (HCs) completed the Medical Outcomes Study 36-Item Short Form (SF-36) and EuroQol EQ-5D questionnaires about HRQoL. Disease activity and cumulative disease damage were assessed with standard indices. Sleep quality was assessed using the Korean version of the Pittsburgh Sleep Quality Index (K-PSQI). Result The mean EQ-5D and physical and mental components of SF-36 were lower in SLE patients with fibromyalgia (n = 41) than in those without fibromyalgia (n = 111) and HCs. The scores in all eight domains of the SF-36 were lower in SLE patients with fibromyalgia than in patients without fibromyalgia and HCs. Poor sleep (defined as a K-PSQI > 5) was reported by 85% of SLE patients with fibromyalgia, by 51% of patients without fibromyalgia, and by 33% of HCs. Multivariate logistic regression analysis showed that lower educational level, cumulative organ damage severity and poor sleep quality were independent determinants of HRQoL in SLE patients with fibromyalgia, whereas disease activity, sleep quality and depressive mood were independent determinants of HRQoL in those without fibromyalgia. Conclusion Poor sleep quality is the common independent risk factor for poor HRQoL in both middle-aged SLE patients with fibromyalgia and without fibromyalgia. Sleep quality improvement may improve HRQoL in female SLE patients, even in those without fibromyalgia.

Background Advanced practice providers (APPs) can fill care gaps created by physician shortages and improve adherence/compliance with preventive ASCVD interventions. Hypothesis APPs utilizing guideline‐based algorithms will more frequently escalate ASCVD risk factor therapies. Methods We retrospectively reviewed data on 595 patients enrolled in a preventive cardiology clinic (PCC) utilizing APPs compared with a propensity‐matched cohort (PMC) of 595 patients enrolled in primary‐care clinics alone. PCC patients were risk‐stratified using Framingham Risk Score (FRS) and coronary artery calcium scoring (CACS). Results Baseline demographics were balanced between the groups. CACS was more commonly obtained in PCC patients (P

BACKGROUND: Cocaine use has been associated with adverse cardiovascular outcomes in patients with coronary artery disease (CAD). It is unclear whether this is due to direct effects of cocaine or other factors. HYPOTHESIS: Cocaine use is associated with worse outcomes in patients undergoing cardiac catheterization METHODS: We used the Veterans Affairs database to identify veterans undergoing coronary catheterization between 2007 and 2014. We analyzed association between cocaine use and 1‐year all‐cause mortality, myocardial infarction (MI), and cerebrovascular accident (CVA) among veterans with obstructive CAD (N = 122 035). To explore factors contributing to these associations, we sequentially adjusted for cardiac risk factors, risky behaviors, and clinical conditions directly affected by cocaine. RESULTS: 3082 (2.5%) veterans were cocaine users. Cocaine users were younger (median 58.2 vs 65.3 years; P < 0.001), more likely to be African American (58.9% vs 10.6%; P < 0.001), and had fewer traditional cardiac risk factors. After adjustment for cardiac risk factors, cocaine was associated with increased risk of mortality (HR: 1.23, 95% CI: 1.08‐1.39), MI (HR: 1.40, 95% CI: 1.07‐1.83), and CVA (HR: 1.88, 95% CI: 1.38‐2.57). With continued adjustment, increased CVA risk remained significantly associated with cocaine use, whereas MI risk was mediated by risky behaviors and mortality was fully explained by conditions directly affected by cocaine. CONCLUSIONS: Cocaine use is associated with adverse cardiac events in veterans with CAD. Contributors to this association are multifaceted and specific to individual cardiovascular outcomes, including associated risky behaviors and direct effects of cocaine. Effective intervention programs to reduce cardiac events in this population will require multiple components addressing these factors.

BACKGROUND: Pharmacological therapy in patients at high cardiovascular (CV) risk should be tailored to achieve recommended therapeutic targets. HYPOTHESIS: To evaluate individual global CV risk profile and to estimate the control rates of multiple therapeutic targets for in adult outpatients followed in real practice in Italy. METHODS: Data extracted from a cross‐sectional, national medical database of adult outpatients in real practice in Italy were analyzed for global CV risk assessment and rates of control of major CV risk factors, including hypertension, dyslipidemia, diabetes, and obesity. CV risk characterization was based on the European SCORE equation and the study population stratified into 3 groups: low risk ( 40 (males)/>50 (females) mg/dL (OR: 0.926, 95% CI: 0.895–0.958), triglycerides

BACKGROUND: Repeated implantable cardioverter‐defibrillator (ICD) therapies cause myocardial damage and, thus, an increased risk of arrhythmias and mortality. HYPOTHESIS: Cardiac resynchronization therapy–defibrillator (CRT‐D) reduces the number of appropriate therapies in patients with left ventricular dysfunction (left ventricular ejection fraction [LVEF] 35% at the end of follow‐up had a significantly lower risk of receiving a first appropriate therapy relative to those with an ICD (adjusted hazard ratio: 0.24, 95% confidence interval: 0.07–0.83, P = 0.025), independently of ischemic cardiomyopathy, baseline LVEF, and secondary prevention. There were no differences in mortality between the ICD and the CRT‐D groups. CONCLUSIONS: Although patients receiving CRT‐D had a worse clinical profile, they received fewer device therapies in comparison with those receiving an ICD. This reduction is associated with a significant improvement in LVEF.

Objective To model condom usage by jail-incarcerated women incarcerated in US local jails and understand results in terms of fundamental cause theory. Design, sample, measurements We surveyed 102 women in an urban jail in the Midwest United States. Chi-square tests and generalized linear modeling were used to identify factors of significance for women who used condoms during last sex compared with women who did not. Stepwise multiple logistic regression was conducted to estimate the relation between the outcome variable and variables linked to condom use in the literature. Results Logistic regression showed that for women who completed high school odds of reporting condom use during last sex were 2.78 times higher (p = .043) than the odds for women with less than a high school education. Among women who responded no to ever having had a sexually transmitted infection, odds of using a condom during last sex were 2.597 times (p = .03) higher than odds for women who responded that they had had a sexually transmitted infection. Conclusions Education is a fundamental cause of reproductive health risk among incarcerated women. We recommend interventions that creatively target distal over proximal factors.

INTRODUCTION Identification and assessment of Evidence-based dentistry (EBD) outcomes have been elusive. Our objective was to describe EBD skill acquisition during the second (D2) year of pre-doctoral dental education and student competency at the end of the year. METHODS The first and fourth (final) curricular-required EBD Exercises (ie, application of the first 4 steps of the 5-Step evidence-based practice process applied to a real or hypothetical situation) completed by D2 students (n = 151) during 2014-2015 and 2015-2016 were evaluated to measure skill acquisition through use of a novel rubric with measures of performance from novice to expert. Exercises were evaluated on the performance for each step, identification of manuscript details and reflective commentary on manuscript components. Changes in performance were evaluated using the chi-square test for trend and the Wilcoxon signed-rank test. RESULTS Seventy-eight per cent of students scored competent or higher on the Ask step at the beginning of the D2 year; scores improved with 58% scoring proficient or expert on the fourth Exercise (P

BACKGROUND Currently, there is incomplete understanding of the fracture patterns in the implant and their association with clinical factors. PURPOSE The aim of this study was to investigate the incidence and pattern of implant fracture (IF) by using 9-year, long-term multicenter follow-up data. MATERIALS AND METHODS The association of the incidence and differences in fracture patterns with clinical factors (based on patient variables and implant variables) was assessed for statistical significance using the Chi-square and Fisher exact test, as appropriate. RESULTS Among a total of 19 087 implants in 8501 patients (7838 male and 663 female) placed over 9 years, fractures were observed in 70 implants (0.4%) in 57 patients (50 male and 7 female). Cases with less than 50% bone loss had a higher incidence of horizontal and vertical IFs limited to the crest module, which are defined as Type I fractures (n = 13, 18.6%). In contrast, cases with ≥50% severe bone loss exhibited a higher incidence of Type II vertical fractures (n = 22, 31.4%), extending beyond the crestal portion (P = .001). Type III fractures (n = 5, 7.1%), defined as a horizontal fracture beyond the crestal module, were also observed. CONCLUSION Peri-implantitis-induced marginal and vertical bone loss and manufacturing-induced defects were considered to be major factors in IF. Therefore, using clinically verified implant systems and striving to minimize bone loss by preventing and actively treating peri-implantitis is essential to reduce IFs.

BACKGROUND: Sex‐based differences in acute coronary syndrome (ACS) mortality may attenuate with age due to better symptom recognition and prompt care. HYPOTHESIS: Age is a modifier of temporal trends in sex‐based differences in ACS care. METHODS: Among 104 817 eligible patients with ACS enrolled in the AHA Get With the Guidelines–Coronary Artery Disease registry between 2003 and 2008, care and in‐hospital mortality were evaluated stratified by sex and age. Temporal trends within sex and age groups were assessed for 2 care processes: percentage of STEMI patients presenting to PCI‐capable hospitals with a DTB time ≤ 90 minutes (DTB90) and proportion of eligible ACS patients receiving aspirin within 24 hours. RESULTS: After adjustment for clinical risk factors and sociodemographic and hospital characteristics, 2276 (51.7%) women and 6276 (56.9%) men with STEMI were treated with DTB90 (adjusted OR: 0.85, 95% CI: 0.80–0.91, P

BACKGROUND: Pericardial effusion is common in hospitalized patients with chronic kidney disease (CKD). We sought to identify predictors and prognostic impact of pericardial effusion in CKD patients. HYPOTHESIS: Clinical and biochemical parameters can predict pericardial effusion in CKD patients. METHODS: In a retrospective nested case‐control design, we analyzed hospitalized adult patients with CKD stage 4, 5, or end‐stage renal disease diagnosed with pericardial effusion. Controls were same‐stage CKD patients without effusion. RESULTS: Among 84 cases and 61 controls, 44% and 34% were on dialysis, respectively. The mean creatinine was higher among cases versus controls (8.4±6.0 vs. 6.0±3.4 mg/dL, P = 0.002). Effusion was moderate to large in 46% of cases. Independent predictors of any pericardial effusion were serum potassium (OR: 1.95 per 1‐mEq/L increment, 95% CI: 1.21–3.13, P = 0.006), serum corrected calcium (OR: 1.33 per 1‐mg/dL decrement, 95% CI: 1.11–1.67, P = 0.015), and admission heart rate (OR: 1.29 per 10‐bpm increment, 95% CI: 1.03–1.62, P = 0.027). Corrected calcium level was an independent predictor of moderate to large pericardial effusion (OR: 1.38 per 1‐mg/dL decrement, 95% CI: 1.04–1.82, P = 0.023). Corrected calcium

Background Systemic sclerosis (SSc) has increased risk of morbidity and mortality due to pulmonary fibrosis, pulmonary arterial hypertension, renal crisis, infections and malignancies. Chemical exposure, smoking and cytotoxic drugs increase the malignancy risk in rheumatic diseases including SSc. We aim to evaluate characteristics, identify risk factors and mortality in SSc patients with malignancies. Methods One hundred and fifty-three patients with SSc (24 male, 129 female, with mean age of 56.4 ± 12.9 years) according to 2013 American College of Rheumatology/European League Against Rheumatism classification criteria for SSc were enrolled in this study. Clinical, demographic, laboratory and radiological characteristics of the patients were evaluated by using SPSS 17.0. Chi-square test was used to compare qualitative data and descriptive statistics are shown as n (%). Results Seven cases of cancer (three male, four female, with mean age of 51.2 ± 7.0 years) were identified. The tumor types included lung cancer, gastrointestinal tract cancer (gastric adenocarcinoma and gastric neuroendocrine tumor), myelodysplastic syndrome and malignant melanoma (eye and skin). Five (3.4%) died due to infection, cardiopulmonary involvement and renal crisis. Six of them had a diffuse cutaneous SSc clinical subtype, and the ratio for anti-Scl-70 was 71.4%. There was no significant relationship between age, sex, anti-Scl-70, pulmonary and cardiac involvement between cancer and non-cancer patients. Conclusions The malignancies may occur before, together or after the diagnosis of SSc. Both of these disorders have increased morbidity and mortality compared with the general population. Rational treatment, monitoring and reducing the risk factors may prevent the development of malignancy. Also, the clinical features, risk factors and prevalence ratios are similar to that reported by large cohorts.

Aim To determine the association between vitamin D and knee pain among participants of the Malaysian Elders Longitudinal Research (MELoR) study. Method This was a cross-sectional study from the MELoR study consisting of a representative group of 1011 community-dwelling older persons (57% female), mean age 86.5 (54-94) years; 313 were Malays, 367 Chinese and 330 Indians. Participants were asked if they had knee pain. Levels of serum 25-hydroxy cholecalciferol (25-[OH]D), an indicator of vitamin D status, were measured using routine laboratory techniques. Results In unadjusted analysis, presence of knee pain was significantly associated with vitamin D deficiency (odds ratio [OR] 1.42; 95% confidence interval (CI) 1.08-1.85, P 0.011). Vitamin D levels were significantly associated with ethnicity differences where Malays (OR 7.08; 95% CI 4.94-10.15) and Indians (OR 6.10; 95% CI 4.28-9.71) have lower levels of vitamin D compared to Chinese. Subsequent multivariate analysis revealed that the association between vitamin D deficiency and knee pain was confounded by ethnic differences. Conclusion A previous study suggested that vitamin D deficiency was associated with knee pain. This relationship was reproduced in our study, but we further established that the association was explained by ethnic variations. As vitamin D status is dependent on skin tone, diet and sunlight exposure, which are all effected by ethnicity, future studies are now required to determine whether a true relationship exists between vitamin D and knee pain.

BACKGROUND: The clinical significance of atrial premature complexes (APCs) during exercise is unclear. HYPOTHESIS: Frequent APCs during exercise provides prognostic information. METHODS: A total of 998 patients were divided into 2 groups based on the presence of frequent APCs during treadmill testing (>5 beats per stage): the FAPC group (n = 128) vs the non‐FAPC group (n = 870). The primary outcome was new‐onset atrial fibrillation or flutter (AF/AFL) during follow‐up period (356.2 ± 131.1 days). RESULTS: Mean age was 56.0 ± 10.2 years in the FAPC group and 52.6 ± 12.0 years in the non‐FAPC group (P = 0.001). Baseline electrocardiographic and echocardiographic findings were not significantly different between the 2 groups. During exercise, maximal heart rate did not differ between the 2 groups. Chronotropic incompetence was more prevalent in the FAPC group than in the non‐FAPC group (P = 0.04). During follow‐up, the FAPC group had a higher incidence of AF/AFL than did the non‐FAPC group (7 patients [5.5%] vs 5 patients [0.6%]; P