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PURPOSE Calcineurin inhibitors (CNI) are standard components of graft-versus-host disease (GVHD) prophylaxis after hematopoietic cell transplantation (HCT). Prior data suggested that CNI-free approaches using donor T-cell depletion, either by ex vivo CD34 selection or in vivo post-transplant cyclophosphamide (PTCy) as a single agent, are associated with lower rates of chronic GVHD (cGVHD). METHODS This multicenter phase III trial randomly assigned patients with acute leukemia or myelodysplasia and an HLA-matched donor to receive CD34-selected peripheral blood stem cell, PTCy after a bone marrow (BM) graft, or tacrolimus and methotrexate after BM graft (control). The primary end point was cGVHD (moderate or severe) or relapse-free survival (CRFS). RESULTS Among 346 patients enrolled, 327 received HCT, 300 per protocol. Intent-to-treat rates of 2-year CRFS were 50.6% for CD34 selection (hazard ratio [HR] compared with control, 0.80; 95% CI, 0.56 to 1.15; P = .24), 48.1% for PTCy (HR, 0.86; 0.61 to 1.23; P = .41), and 41.0% for control. Corresponding rates of overall survival were 60.1% (HR, 1.74; 1.09 to 2.80; P = .02), 76.2% (HR, 1.02; 0.60 to 1.72; P = .95), and 76.1%. CD34 selection was associated with lower moderate to severe cGVHD (HR, 0.25; 0.12 to 0.52; P = .02) but higher transplant-related mortality (HR, 2.76; 1.26 to 6.06; P = .01). PTCy was associated with comparable cGVHD and survival outcomes to control, and a trend toward lower disease relapse (HR, 0.52; 0.28 to 0.96; P = .037). CONCLUSION CNI-free interventions as performed herein did not result in superior CRFS compared with tacrolimus and methotrexate with BM. Lower rates of moderate and severe cGVHD did not translate into improved survival.

OBJECTIVES To examine the efficacy and safety of radiotherapy for the prevention of heterotopic ossification (HO) about the elbow. DESIGN Retrospective chart review. SETTING Level 1 Trauma Center. PATIENTS/PARTICIPANTS Two hundred and twenty-nine patients who received prophylactic radiotherapy (XRT) over a 15 year period were identified. Patients were included if they received XRT to the elbow joint and had at least 12 weeks of follow up after XRT. Fifty-four patients were ultimately included. INTERVENTION All patients were treated with a single dose of 7 Gy. 98% of patients received XRT within 24 hours after surgery, and all patients received XRT within 72 hours after surgery. MAIN OUTCOMES MEASUREMENTS The primary study measures evaluated were the presence or absence of clinically symptomatic HO and the presence of radiographic HO after XRT to the elbow joint. RESULTS Eighteen patients were treated with XRT after a traumatic injury requiring surgery (primary prophylaxis), and 36 were treated with XRT after excision surgery to remove HO which had already formed (secondary prophylaxis). In the primary cohort, 16.7% developed symptomatic HO after XRT, and 11.1% required surgery to resect heterotopic bone. In the secondary cohort, 11.1% developed symptomatic HO after surgery and XRT, and 5.5% required resection surgery. No secondary malignancies were identified. CONCLUSIONS Our findings suggest that XRT for elbow HO may be safe and effective for both primary and secondary HO. XRT for HO was not shown to be associated with radiation-induced sarcoma in this series, at least in the short term. Further study in a large patient population with extended follow up is required to better characterize populations at high risk for development of HO and secondary malignancy. [ZERO WIDTH SPACE]. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Norovirus (NoV) is the leading cause of acute gastroenteritis (AGE) in many countries that have introduced universal rotavirus mass vaccination. This is the first study to report data on NoV strains in Estonia. We recruited 2249 children aged 0-18 years hospitalized for AGE in Estonian hospitals from 01 February 2015 to 31 August 2016. Norovirus gastroenteritis (NoVGE) was diagnosed in 14.5% (n=325) cases. Stool sample for RNA extraction and genotyping was available in 86% (n=280) of NoVGE cases (2015, n= 91; 2016, n=189). Dominant capsid types detected in 75% (n=210) samples were, GII.4 (63.8%, n=134), GII.3 (15.2%, n=32), GII.17 (6.7% n=14) and GII.6 (5.2% n=11). Prevailing RNA polymerase types found in 77% (n= 215) samples were GII.P31 (51.1%, n=110), GII.P21 (17.7%, n=38), GII.P4 (11.2%, n=24) and GII.P7 (6.5%, n=14). Both regions were typeable for 67% (n=189) of samples. Most prevalent strains were GII.4Sydney_2012[P31] (48.7%, n=92), GII.3[P21] (15.3%, n=29), GII.4Sydney_2012[P4] (5.8%, n=11) and GII.17[P17] (5.8%, n=11). Simpson's diversity index showed a significant difference between the age groups 1-4 and 5-9 years: D 0.64 (95% CI 0.55 to 0.73) versus 0.83 (95% CI 0.81 to 0.86), respectively (p=0.03). An accurate understanding of NoV strain diversity is important for control and preventive measures, especially in the post-rotavirus vaccine era. This article is protected by copyright. All rights reserved.

Although primary cutaneous B-cell lymphomas (PCBCL) comprise 25% of all cutaneous lymphomas, their incidence in the pediatric population is unknown, and the information on pediatric PCBCL has mostly been gathered from individual case reports or series from single centers.This was a population-based, retrospective cohort study of patients in 18 cancer registries in the United States diagnosed between 2000 to 2016 through the Surveillance, Epidemiology, and End Results (SEER) program. Age-adjusted incidence rates were calculated for PCBCL in pediatric (20 years) and adult (≥20 years) populations. Demographic, clinical, and pathological characteristics of PCBCL were compared between the two groups.A total of 48 pediatric and 5128 adult PCBCL cases were included. Median age at diagnosis was 16.5 years and 65 years in the two groups, respectively. The major histologic subtypes of pediatric cases were marginal zone lymphoma (77.1%), followed by diffuse large B-cell lymphoma (12.5%) and follicle center lymphoma (10.4%), which were equally distributed in adults. The age-adjusted pediatric PCBCL incidence rate (per 1,000,000 person-years) was 0.12 (95% CI 0.09-0.16). The incidence in the adult population was approximately 40-fold higher than the one observed in the pediatric group (IRR 41.4, 95% CI 31.2-56.2). All 48 pediatric cases were alive during a median follow-up time of 48 months.Pediatric PCBCL is a very rare disease affecting mostly adolescents of both sexes. The major histologic subtype is marginal zone lymphoma, and the prognosis is favorable.

PURPOSE The Groningen International Study on Sentinel nodes in Vulvar cancer (GROINSS-V)-II investigated whether inguinofemoral radiotherapy is a safe alternative to inguinofemoral lymphadenectomy (IFL) in vulvar cancer patients with a metastatic sentinel node (SN). METHODS GROINSS-V-II was a prospective multicenter phase-II single-arm treatment trial, including patients with early-stage vulvar cancer (diameter < 4 cm) without signs of lymph node involvement at imaging, who had primary surgical treatment (local excision with SN biopsy). Where the SN was involved (metastasis of any size), inguinofemoral radiotherapy was given (50 Gy). The primary end point was isolated groin recurrence rate at 24 months. Stopping rules were defined for the occurrence of groin recurrences. RESULTS From December 2005 until October 2016, 1,535 eligible patients were registered. The SN showed metastasis in 322 (21.0%) patients. In June 2010, with 91 SN-positive patients included, the stopping rule was activated because the isolated groin recurrence rate in this group went above our predefined threshold. Among 10 patients with an isolated groin recurrence, nine had SN metastases > 2 mm and/or extracapsular spread. The protocol was amended so that those with SN macrometastases (> 2 mm) underwent standard of care (IFL), whereas patients with SN micrometastases (≤ 2 mm) continued to receive inguinofemoral radiotherapy. Among 160 patients with SN micrometastases, 126 received inguinofemoral radiotherapy, with an ipsilateral isolated groin recurrence rate at 2 years of 1.6%. Among 162 patients with SN macrometastases, the isolated groin recurrence rate at 2 years was 22% in those who underwent radiotherapy, and 6.9% in those who underwent IFL ( P = .011). Treatment-related morbidity after radiotherapy was less frequent compared with IFL. CONCLUSION Inguinofemoral radiotherapy is a safe alternative for IFL in patients with SN micrometastases, with minimal morbidity. For patients with SN macrometastasis, radiotherapy with a total dose of 50 Gy resulted in more isolated groin recurrences compared with IFL.

Context First-degree relatives of women with polycystic ovary syndrome (PCOS) present hormonal and metabolic alterations compared to girls unrelated to PCOS. It is unknown whether glucose intolerance in the PCOS proband confers a more severe metabolic predisposition on their first-degree relatives. Objective To determine whether glucose tolerance status in women with PCOS is associated with worsened glucose metabolism and sex hormone levels in their peripubertal daughters or sisters. Design Cross-sectional study. Setting Seven academic centers in North America, South America, and Europe. Patients Sixty-four pairs of women with PCOS and their daughters or younger sisters aged between 8 and 14 years were recruited. Twenty-five mothers or older sisters with PCOS were glucose intolerant (GI) and 39 were normal glucose tolerant (NGT). Main Outcome Measures Beta-cell function estimated by the insulin secretion-sensitivity index-2 (ISSI-2) during an oral glucose tolerance test and by the disposition index during a frequently sampled IV glucose tolerance test. Free testosterone and 17-hydroxyprogesterone (17-OHP) levels. Results Being related to a GI PCOS proband was associated with a lower ISSI-2 (P-value = 0.032) after adjusting for ethnicity, body mass index z-score, and pubertal stage. They also had higher free testosterone (P-value = 0.011) and 17-OHP levels compared to girls with an NGT proband, the latter becoming significant after adjusting for confounders (P-value = 0.040). Conclusions Compared to first-degree female relatives of women with PCOS and NGT, first-degree relatives of women with PCOS and GI display lower beta-cell function and hyperandrogenemia, putting them at higher risk of GI and PCOS development.

Background and aims The neutrophil-to-lymphocyte-ratio (NLR) is used as an inflammatory index and has proven to be an accurate prognostic indicator for decompensated cirrhotics; however, its role in patients undergoing transjugular intrahepatic portosystemic shunt (TIPS) has not been evaluated. We examined whether NLR is associated with mortality in decompensated cirrhosis patients undergoing TIPS. Methods We performed a retrospective review of 268 decompensated cirrhotics who underwent TIPS from January 2011 to December 2015 at an academic medical center. NLR, patient demographics, manifestations of cirrhosis, TIPS indications and mortality were recorded. Univariate and multivariate Cox regression analyses for prognostic factors associated with 30-day and 90-day post TIPS mortality were performed. Results A total of 129 (48%) patients received TIPS for refractory ascites with 79 (29%) for variceal bleeding, 14 (5%) for hepatic hydrothorax, and 46 (17%) for other indications. Cirrhosis etiology included hepatitis C (36%), alcohol (28%), nonalcoholic steatohepatitis (20%), or other (15%). Median NLR was 4.42 (IQR 2.75-7.19). Univariate and multivariate analysis showed NLR as an independent predictive factor of 30-day and 90-day mortality. Furthermore, in patients with a Model of End-Stage Liver Disease (MELD) ≤ 15, NLR is superior to MELD/MELD-Na score in predicting 30-day and 90-day mortality. In patients with MELD > 15, MELD/MELD-Na score is superior to NLR. Conclusion Our data indicate that elevated NLR independently predicts 30-day and 90-day mortality. In patients with a MELD ≤ 15, NLR is a better prognostic factor than MELD or MELD-Na in predicting short-term mortality.

The supraclavicular exposure represents an alternative approach for thoracic outlet decompression in neurogenic thoracic outlet syndrome with unique access to neurovascular structures. We aimed to evaluate the learning curve for this approach and associated patient outcomes.Patients undergoing first-time, unilateral, supraclavicular thoracic outlet decompression for neurogenic thoracic outlet syndrome were included. Cumulative-sum and linear-spline-regression analyses were used to determine the operative time learning curve. Patients were consecutively organized into early (learning phase) and late (competency) cohorts. Primary endpoints were the operative time learning curve operation number and association of this learning curve on differences in self-reported postoperative symptomatic improvement between early and late cohorts, adjusting for American Society of Anesthesiology classification, body mass index, previous treatment (opioid/neuropathic medication/botulinum-injection), and length of stay.Among 114 patients, learning curve analyses showed decreasing operative times, plateauing at the 51st operation (ß = -1.63, 95% confidence interval [-2.30, -0.95], P.001). No periprocedural differences existed between early (operations 1-50) and late (operations 51-114) cohorts. Self-reported 90-day outcomes were similar in early and late cohorts (odds ratio [OR]: 1.60 [0.65, 3.95], P = .31). Mediators of poor self-reported outcomes included increasing American Society of Anesthesiology classification (OR 0.21 [0.08, 0.54], P = .001), failed preoperative botulinum injection (OR 0.15 [0.03, 0.65], P = .01), and increased length of stay (OR 0.40 [0.22, 0.73], P = .003).The learning curve for supraclavicular thoracic outlet decompression in neurogenic thoracic outlet syndrome occurred after 51 operations with a trend towards improved 90-day self-reported outcomes from the early to late phases. These findings, along with mediators of poorer outcomes, may aid surgeons in adopting a new approach and counseling patients on expected outcomes.

Background A common complaint of individuals suffering from mental health conditions is feeling invalidated or misunderstood by care providers. This is notable, given that non-collaborative care has been linked to poor engagement, low motivation and treatment non-adherence. This study examined how receiving validation from care providers is experienced by individuals who have an eating disorder (ED) and the impact of receiving validation on the recovery journey. Methods Eighteen individuals who had an eating disorder for an average duration of 19.1 years (two identifying as male, 16 identifying as female), participated in semi-structured interviews on barriers and facilitators to self-compassion. Seven were fully recovered, and 11 were currently participating in recovery-focused residential treatment. Thematic analysis focused on the meaning and impact of receiving validation to participants. Results Five care provider actions were identified: (i) making time and space for me, (ii) offering a compassionate perspective, (iii) understanding and recognizing my treatment needs, (iv) showing me I can do this, and (v) walking the runway. These were associated with four key experiences (feeling trust, cared for, empowered, and inspired), that participants described as supportive of their recovery. Conclusions This research provides insight into patient perspectives of validation and strategies care providers can use, such as compassionate reframing of difficult life experiences, matching interventions to patient readiness, and modeling vulnerability., Plain English Summary Feeling validated (or feeling understood and accepted) is an important aspect of a patient’s experience with health care providers. The purpose of this research was to learn about the role of validation in eating disorders treatment from patients’ perspectives, and to learn how the experience of validation supports recovery from an eating disorder. In this research, interviews were conducted with eighteen individuals who were either currently seeking intensive treatment for an eating disorder or had recently recovered. Five care provider actions were identified as engendering feelings of validation: (i) making time and space for me, (ii) offering a compassionate perspective, (iii) understanding and recognizing my treatment needs, (iv) showing me I can do this, and (v) walking the runway. These actions were associated with four key patient experiences: feeling trust, cared for, empowered, and inspired. Recommendations for care providers to practice validation are made based on study findings.

Objectives This study sought to identify predictors of major clinically important atrial fibrillation endpoints in hypertrophic cardiomyopathy. Background Atrial fibrillation (AF) is a common morbidity associated with hypertrophic cardiomyopathy (HCM). The HCMR (Hypertrophic Cardiomyopathy Registry) trial is a prospective natural history study of 2,755 patients with HCM with comprehensive phenotyping. Methods All patients received yearly telephone follow-up. Major AF endpoints were defined as requiring electrical cardioversion, catheter ablation, hospitalization for >24 h, or clinical decisions to accept permanent AF. Penalized regression via elastic-net methodology identified the most important predictors of major AF endpoints from 46 variables. This was applied to 10 datasets, and the variables were ranked. Predictors that appeared in all 10 sets were then used in a Cox model for competing risks and analyzed as time to first event. Results Data from 2,631 (95.5%) patients were available for analysis after exclusions. A total of 127 major AF endpoints events occurred in 96 patients over 33.3 ± 12.4 months. In the final model, age, body mass index (BMI), left atrial (LA) volume index, LA contractile percent (active contraction), moderate or severe mitral regurgitation (MR), and history of arrhythmia the most important. BMI, LA volume index, and LA contractile percent were age-dependent. Obesity was a stronger risk factor in younger patients. Increased LA volume, reduced LA contractile percent, and moderate or severe MR put middle-aged and older adult patients at increased risk. Conclusions The major predictors of major AF endpoints in HCM include older age, high BMI, moderate or severe MR, history of arrhythmia, increased LA volume, and reduced LA contractile percent. Prospective testing of a risk score based on these parameters may be warranted.

To address the ongoing epidemic of sexually transmitted infections (STIs) in the United States, the National Academies of Sciences, Engineering, and Medicine (National Academies) conducted a consensus study on STI control and prevention in the United States to provide recommendations to the Centers for Disease Control and Prevention and the National Association of County and City Health Officials. The culminating report identified military personnel as one of the priority groups that require special consideration given the high prevalence of STIs and their associated behaviors (e.g., concurrent sexual partners and infrequent condom use) that occur during active duty service. Universal health care access, the relative ease and frequency of STI screening, and the educational opportunities within the military are all assets in STI control and prevention. The report offers a comprehensive framework on multiple and interrelated influences on STI risk, prevention, health care access, delivery, and treatment. It also provides an overview of the multilevel risk and protective factors associated with STIs that could be applied using a sexual health paradigm. The military context must integrate the multilevel domains of influences to guide the effort to fill current gaps and research needs. The Department of Defense, with its large clinical and preventive medicine workforce and its well-established universal health care system, is well positioned to enact changes to shift its current approach to STI prevention, treatment, and control. STI control based on highlighting behavioral, social, cultural, and environmental influences on service members’ sexual health and wellness may well drive better STI care and prevention outcomes.

Nutrition is an important outcome predictor in oncology patients including treatment response, physical disability, quality of life, and overall survival. Sarcopenia (loss of skeletal muscle mass and function) is a demonstrated marker of nutritional status in adults, but data are more limited in children. The purpose of this study was to evaluate whether total psoas muscle area (tPMA) measured at the time of cancer diagnosis predicts overall survival (OS), disease free survival (DFS), or number of days neutropenic. A retrospective study was performed. tPMA was measured at the L3 and L4 mid-lumbar vertebral body level by a single reviewer on cross-sectional imaging studies performed within 2 weeks of primary oncologic diagnosis for all oncology patients who received their primary therapy at Cincinnati Children’s Hospital between 1/1/2000 and 12/31/2013. Spearman’s correlation was used to assess the association between tPMA and OS, DFS, days neutropenic, and adjusted days neutropenic. Subanalysis was performed assessing the relationship of tumor type and age at diagnosis with each parameter. 164 patients (median age 9.9 years; 89 M/75 F) were included in the study. Days neutropenic and normalized days neutropenic were significantly but weakly negatively correlated with tPMA at L3 (r = − 0.24, p

Mast cells and eosinophils are commonly found, expectedly or unexpectedly, in human tissue biopsies. Although the clinical significance of their presence, absence, quantity, and quality continues to be investigated in homeostasis and disease, there are currently gaps in knowledge related to what constitutes quantitatively relevant increases in mast cell and eosinophil number in tissue specimens for several clinical conditions. Diagnostically relevant thresholds of mast cell and eosinophil numbers have been proposed and generally accepted by the medical community for a few conditions, such as systemic mastocytosis and eosinophilic esophagitis. However, for other mast cell- and eosinophil-associated disorders, broad discrepancies remain regarding diagnostic thresholds and how samples are processed, routinely and/or specially stained, and interpreted and/or reported by pathologists. These discrepancies can obfuscate or delay a patient's correct diagnosis. Therefore, a work group was assembled to review the literature and develop a standardized consensus for assessing the presence of mast cells and eosinophils for a spectrum of clinical conditions, including systemic mastocytosis and cutaneous mastocytosis, mast cell activation syndrome, eosinophilic esophagitis, eosinophilic gastritis/enteritis, and hypereosinophilia/hypereosinophilic syndrome. The intent of this work group is to build a consensus among pathology, allergy, dermatology, hematology/oncology, and gastroenterology stakeholders for qualitatively and quantitatively assessing mast cells and eosinophils in skin, gastrointestinal, and bone marrow pathologic specimens for the benefit of clinical practice and patients.

Background We compared the outcomes of laparoscopic hepatectomy (LH) vs. open hepatectomy (OH) for intrahepatic cholangiocarcinoma (iCCA). Methods A systematic review of the MEDLINE, EMBASE, Scopus, and Cochrane Library databases was performed using PRISMA guidelines (end-of-search date: 08-June-2020). Individual patient data on overall survival (OS) and recurrence-free survival (RFS) were extracted. Random-effects meta-analyses, and one- and two-stage survival analyses were conducted. Results Eight retrospective cohort studies comparing LH (n = 544) vs. OH (n = 2256) were identified. LH demonstrated lower overall complication (Risk ratio [RR] = 0.64, 95% confidence interval [CI]: 0.46–0.90; p = 0.01), surgical lymphadenectomy (RR = 0.74, 95% CI: 0.58–0.93; p = 0.01) and margin-positive resection (RR = 0.78, 95% CI: 0.62–0.99; p = 0.04) rates, and higher recurrence-free rate (RR = 1.24, 95% CI: 1.01–1.51; p = 0.04) vs. OH. In Cox regression, no difference was observed regarding OS (Hazard Ratio [HR] = 1.11, 95% CI: 0.65–1.91; p = 0.70) and RFS (HR = 1.19, 95% CI: 0.74–1.90; p = 0.47). Conclusion The use of LH should be considered when feasible in well-selected iCCA patients by hepatobiliary surgeons with experience in minimally-invasive surgery.

Masses and masslike lesions of the pancreas are uncommon in the pediatric population. However, owing to overlapping clinical and imaging features, it can be challenging to differentiate the various causes of pediatric pancreatic masses at initial patient presentation. Clinical data such as patient age, signs and symptoms at presentation, laboratory test results, and potential underlying cancer predisposition syndrome can be helpful when formulating a differential diagnosis. US may be the first imaging study to depict a pancreatic mass in a child, as this examination is frequently performed in children with nonspecific abdominal signs and symptoms because of its wide availability and relatively low cost and the lack of a need for sedation or anesthesia. CT or MRI is typically required for more thorough characterization of the mass and surgical planning. Complete characterization of pancreatic masses includes assessment of vascular involvement, local invasion, and extrapancreatic spread of tumor. The authors provide an up-to-date comprehensive review of the clinical manifestations, histopathologic features, and imaging findings of primary and secondary tumors of the pancreas in children and young adults. Advances in imaging, current prognostic information, and treatment paradigms also are highlighted. Finally, nontumorous masslike lesions of the pediatric pancreas, including vascular malformations, cystic disorders (eg, von Hippel-Lindau syndrome, cystic fibrosis), intrapancreatic accessory spleen, and autoimmune pancreatitis, are discussed.

Background: Artificial intelligence (AI) and machine learning (ML) modeling in hip and knee arthroplasty (total joint arthroplasty [TJA]) is becoming more commonplace. This systematic review aims to quantify the accuracy of current AI- and ML-based application for cognitive support and decision-making in TJA. Methods: A comprehensive search of publications was conducted through the EMBASE, Medline, and PubMed databases using relevant keywords to maximize the sensitivity of the search. No limits were placed on level of evidence or timing of the study. Findings were reported according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Analysis of variance testing with post-hoc Tukey test was applied to compare the area under the curve (AUC) of the models. Results: After application of inclusion and exclusion criteria, 49 studies were included in this review. The application of AI/ML-based models and average AUC is as follows: cost prediction-0.77, LOS and discharges-0.78, readmissions and reoperations-0.66, preoperative patient selection/planning-0.79, adverse events and other postoperative complications-0.84, postoperative pain-0.83, postoperative patient-reported outcomes measures and functional outcome-0.81. Significant variability in model AUC across the different decision support applications was found (P < .001) with the AUC for readmission and reoperation models being significantly lower than that of the other decision support categories. Conclusions: AI/ML-based applications in TJA continue to expand and have the potential to optimize patient selection and accurately predict postoperative outcomes, complications, and associated costs. On average, the AI/ML models performed best in predicting postoperative complications, pain, and patient-reported outcomes and were less accurate in predicting hospital readmissions and reoperations.

PURPOSE To compare home-based unimanual mirror therapy (UMT) and bimanual mirror therapy (BMT) for upper limb recovery in subacute/chronic stroke individuals with moderate-to-severe arm impairment. METHOD Twenty-two participants were randomized into 1 of 3 groups: UMT, BMT or traditional occupational therapy (TOT) home-based programs. The intervention was 6-weeks and consisted of OT 2 days a week, weekly sessions with the research OT, and 30-minutes of the home-based program 5 days a week, according to group allocation. The Action Research Arm Test (ARAT), ABILHAND, Fugl-Meyer Assessment (FMA), grip strength, and Stroke Impact Scale (SIS) were used for outcome measures. RESULTS All groups significantly improved over time on all outcome measures and adhered to the prescribed dosage regardless of group (p

Few cases of natural sudden death presenting as an undiagnosed lymphoma have been reported in the literature, especially in adolescents. Herein we provide a report of sudden death caused by undiagnosed classic Hodgkin lymphoma (cHL). We describe an 18-year-old female who collapsed after several weeks of weight loss, decreased appetite, and dyspnea. At autopsy, a bulky mass arising in the mediastinum and neck compressed the esophagus and trachea, surrounded the great vessels, obliterated the pericardial sac, and infiltrated the myocardium. The lungs were collapsed and large pleural effusions were present. The tumor burden, which weighed at least 2710 g in aggregate, was entirely above the diaphragm. Microscopic examination of the masses showed features typical for nodular sclerosis cHL including large bands of sclerosis, numerous Hodgkin/Reed-Sternberg (HRS) cells, and an eosinophil-rich mixed inflammatory cell infiltrate. Immunohistochemical stains showed the HRS cells to be uniformly positive for CD30 and CD15 and negative for CD3, CD20, CD45, and PAX5. This case exemplifies a rare sudden natural death due to previously undiagnosed cHL in a young patient.

Despite decades of medical, diagnostic, and public health advances related to diagnosis and management of sexually transmitted infections (STI), rates of reportable STIs continue to grow. A 2021 National Academies of Sciences, Engineering, and Medicine report on the current state of STI management and prevention in the United States, entitled Sexually Transmitted Infections: Adopting a Sexual Health Paradigm, offers recommendations on future public health programs, policy, and research. This new report builds upon the 1997 Institute of Medicine report, The Hidden Epidemic: Confronting Sexually Transmitted Diseases, and provides eleven recommendations organized under four action areas: 1) Adopt a sexual health paradigm; 2) Broaden ownership and accountability for responding to STIs; 3) Bolster existing systems and programs for responding to STIs; and 4) Embrace innovation and policy change to improve sexual health. We present our interpretive synopsis of this report, highlighting elements of particular interest to STI and sexual health practitioners, including clinicians, researchers, disease intervention specialists, community outreach workers and public health staff. The report asserts that it is possible to create a healthier and more equitable future where fewer adolescents and adults are infected, fewer babies are born with STIs, and people entering their sexual debut and continuing throughout the life span are taught the language and skills to conceptualize and enact their own vision for what it means to be sexually healthy.

Introduction Maternal mortality and morbidity rates have risen significantly, yet little research has focused on how severe maternal morbidity (SMM) is associated with future reproductive health, such as birth spacing or the likelihood of subsequent SMM. This study focuses on the risk of SMM recurrence and the association of interpregnancy intervals with SMM. Methods This population-based, retrospective cohort study used Iowa hospital discharge data longitudinally linked to birth certificate data between 2009 and 2014. To examine recurrence of SMM, crude and adjusted multivariable logistic regression models were generated. The associations between varying interpregnancy intervals and subsequent SMM were examined. Crude, stratified, and adjusted risk ratios and their associated 95% confidence intervals were estimated. Results A total of 36,190 women were included in this study. Women with SMM in the index delivery had significantly higher odds of SMM in the subsequent delivery (adjusted odds ratio, 8.16; 95% confidence interval, 5.45–12.24) compared with women without SMM. Women with an interpregnancy interval of less than 6 months compared with 18 months or longer were more likely to experience SMM during their subsequent delivery, although the difference was not statistically significant (adjusted odds ratio, 1.41; 95% confidence interval, 0.99, 2.03). Conclusions This study demonstrates that women who experience SMM are at markedly increased risk of subsequent SMM. Further investigation is necessary to inform optimal interpregnancy interval recommendations based on prior maternal health outcomes.

STUDY OBJECTIVE To evaluate sexual function in women undergoing minimally invasive total hysterectomy and sacrocolpopexy (TLH + SCP) with a lightweight polypropylene Y-mesh 1 year after surgery. DESIGN This was a planned secondary analysis of a 5-site randomized trial comparing permanent (2-0 Gore-Tex; W. L. Gore & Associates, Inc., Newark, DE) vs absorbable suture (2-0 polydioxanone suture) for vaginal attachment of a Y-mesh (Upsylon; Boston Scientific Corporation, Natick, MA) graft during TLH + SCP. SETTING Multicenter trial at 5 study sites (4 academic and 1 community). The study sites were: (1) University of North Carolina at Chapel Hill, Chapel Hill, NC; (2) Wake Forest Baptist Hospital, Winston-Salem, NC; (3) Northwestern University, Evanston, IL; (4) Georgia Regents University, Augusta, GA; and (5) Atlantic Health Medical Group, Morristown, NJ. PATIENTS Women previously enrolled in an original study undergoing TLH + SCP. INTERVENTIONS Quality-of-life questionnaires and physical examination. MEASUREMENTS AND MAIN RESULTS The primary objective was to assess changes in sexual function at 1 year after surgery as measured by the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire, International Urogynecological Association-Revised. The secondary objective was to assess the factors associated with postoperative sexual activity and dyspareunia. Of the 200 participants enrolled, 182 (92.8%) completed follow-up: n = 95/99 Gore-Tex and n = 87/101 polydioxanone suture. The mean age was 60 ± 10 years; body mass index was 27 ± 5 kg/m2; 78% were menopausal and 56% sexually active before surgery. At 1 year after surgery, 63% were sexually active: 93% of the sexually active women preoperatively remained so at 1 year, and 24% reported new sexual activity at 1 year (p

OBJECTIVE To develop an in-depth understanding of HPV self-testing cervical screening clinical pathways for never-/under-screened Māori women. METHODS Based on a community-based cluster randomized controlled trial in Aotearoa (New Zealand), a Kaupapa Māori (by Māori, for Māori) qualitative study enrolled Māori women who met the eligibility criteria of the HPV trial intervention (aged 25-69 years, no screen in >4 years). In total, 28 were recruited (22 had a negative test, six had a positive test and colposcopy). They were asked about their clinical pathway. RESULTS The HPV self-test was seen as empowering and promoting bodily autonomy, although some women expressed fears or misconceptions about this new technology. While those with a negative test were relieved, for the six women who had a positive test, there were many fears, compounded by seeking out information on the Internet. When attending colposcopy, the importance of support and responsive care was emphasized. CONCLUSION HPV self-testing has the potential to improve access to cervical screening and reduce inequities for Māori. Care must be taken in the delivery of screening and colposcopy results. Primary care and colposcopy services need to take special care with never-/under-screened Māori women to provide sensitive, responsive care, and mitigate trauma.

Background Collateral findings in pragmatic clinical trials are findings that may have implications for patients’ health but were not generated to address a trial’s primary research questions. It is uncertain how best to communicate these collateral findings to patients. Objectives To determine how reactions to a letter communicating collateral findings relate to who signed the letter, the type of finding, or whether the letter specified that the finding arose from a pragmatic clinical trial. Research Design Web-based survey experiment using a between-subjects design in which respondents were randomly assigned within education strata to view and respond to 1 of 16 hypothetical scenarios. Subjects Adults recruited from an online panel constructed from a probability sample of US-based postal addresses. Measures The primary outcomes were the action the respondent would take next (i.e., contact a doctor immediately or something else) and the respondent’s emotional reactions (i.e., all positive, all negative, mixed, or none). Results A total of 4080 respondents had analyzable data. Although some effects were statistically significant (P < .05), none exceeded a prespecified threshold for policy relevance (15 or more percentage points). Ratings of letter clarity and level of understanding were lower for letters that included a description of the clinical trial. Conclusions Signatory and level of detail about collateral findings did not substantially affect people’s intentions to take the recommended action of contacting their doctor. Deciding whether to include a description of the pragmatic clinical trial requires a trade-off between transparency and more difficulty understanding the contents of the letter. Supplementary Information The online version contains supplementary material available at 10.1007/s11606-021-07087-8.

Introduction. Celiac disease, or gluten-sensitive enteropathy, can be defined as a persistent intolerance of wheat gliadins and other cereal prolamines in the small intestinal mucosa of genetically susceptible individuals. The clinical picture of the disease can often be misleading because it varies greatly from patient to patient, resulting in delayed diagnosis.To analyze the clinical case of a child with celiac disease and acquired ichthyosis.Results.The disease, until a final diagnosis was established, had a severe course due to gastrointestinal and dermatological disorders. From the age of 1.5 years, the child had frequent diarrhea, bloating, which is why she was repeatedly hospitalized in the hospital at the place of residence. However, there was no effect from the ongoing therapeutic measures, and other symptoms such as vomiting, peripheral edema, deficiency of height and weight, and severe peeling of the skin joined in. The diagnosis was finally confirmed at the age of 2.5 years after the test for antibodies to tissue transglutaminase IgA (fifty-fold excess relative to the norm). A genetic study revealed alleles of genes responsible for predisposition to celiac disease. The results of a biopsy of the mucous membrane of the duodenum had signs of atrophy, lymphoid infiltration, corresponding to a lesion of the small intestine according to the classification Marsh III. Microscopic examination of the skin – hyperkeratosis with a decrease in the granular layer. On the basis of the obtained data, the diagnosis was made: Celiac disease, active phase, severe course, complicated by proteinenergy insufficiency severe degree, exudative enteropathy syndrome, 2 degree anemia, concomitant diagnosis: acquired ichthyosis. The girl was prescribed a gluten-free diet, and symptomatic drug therapy was carried out. In dynamics, the condition has improved. After 6 months, at the second visit, gastrointestinal and skin symptoms were absent, physical development was age-appropriate.Conclusions.The classic form of celiac disease usually manifests itself with several major symptoms, such as diarrhea, abdominal pain, weight loss, and nutritional deficiencies. In this article we wanted to talk about a rare combination of celiac disease with ichthyosis, therefore, practitioners should be wary of a combination of skin and gastrointestinal symptoms.

Refinements in surgery, radiation therapy, and chemotherapy since the mid-20th century have resulted in a survival rate exceeding 90% for patients with Wilms tumor (WT). Although this figure is remarkable, a significant proportion of patients continue to have event-free survival (EFS) estimates of

Background Persistent motor or vocal tic disorder (PMVT) has been hypothesized to be a forme fruste of Tourette syndrome (TS). Although the primary diagnostic criterion for PMVT (presence of motor or vocal tics, but not both) is clear, less is known about its clinical presentation. Objective The goals of this study were to compare the prevalence and number of comorbid psychiatric disorders, tic severity, age at tic onset, and family history for TS and PMVT. Methods We analyzed data from two independent cohorts using generalized linear equations and confirmed our findings using meta-analyses, incorporating data from previously published literature. Results Rates of obsessive-compulsive disorder (OCD) and attention deficit hyperactivity disorder (ADHD) were lower in PMVT than in TS in all analyses. Other psychiatric comorbidities occurred with similar frequencies in PMVT and TS in both cohorts, although meta-analyses suggested lower rates of most psychiatric disorders in PMVT compared with TS. ADHD and OCD increased the odds of comorbid mood, anxiety, substance use, and disruptive behaviors, and accounted for observed differences between PMVT and TS. Age of tic onset was approximately 2 years later, and tic severity was lower in PMVT than in TS. First-degree relatives had elevated rates of TS, PMVT, OCD, and ADHD compared with population prevalences, with rates of TS equal to or greater than PMVT rates. Conclusions Our findings support the hypothesis that PMVT and TS occur along a clinical spectrum in which TS is a more severe and PMVT a less severe manifestation of a continuous neurodevelopmental tic spectrum disorder. © 2021 The Authors. Movement Disorders published by Wiley Periodicals LLC on behalf of International Parkinson and Movement Disorder Society.

Objectives This study examined the phenomenology and predictors of early response and remission among youth with obsessive-compulsive disorder (OCD) receiving cognitive-behavioral therapy (CBT). Methods One hundred and thirty-nine youth with a current primary diagnosis of OCD participated in this study. Participants received 10 sessions of CBT augmented by either placebo or d -cycloserine (DCS) as part of a randomized double-blind multi-site clinical trial. Early response and remission status were determined by clinician-rated global symptom improvement (CGI-I) and severity (CGI-S), respectively. Results At the mid-treatment assessment, 45.3% of youth were early responders, and 28.1% were early remitters. At post-treatment assessment, 79.1% of youth were responders and 67.6% were remitters. Early response predicted a higher likelihood of post-treatment response and remission; early remission significantly predicted a higher likelihood of post-treatment remission. Bivariate logistic regressions showed that early response was predicted by lower baseline clinician-rated global severity (CGI-S) and lower depression severity; however, only depression severity remained a significant predictor in the multivariable logistic regression model. Furthermore, bivariate logistic regressions showed that early remission was predicted by lower baseline clinician-rated global severity (CGI-S), lower depression severity, and lower obsessive-compulsive symptom severity (CY-BOCS); however, only global severity remained a significant predictor in the multivariable logistic regression model. Conclusions Lower OCD and depression symptom severity predicted a greater likelihood of early treatment response and remission to CBT. Findings suggest that low OCD and depression symptom severity could serve as baseline characteristics to identify potential candidates for lower-intensity initial interventions in a stepped care approach. The modest predictive value of the variables examined suggests that additional factors could add to prediction of treatment response and remission. Trial registration clinicaltrials.gov Identifier: NCT00864123.

Introduction Recent efforts to standardize reporting of surgeon experience in novel technique publications have recommended reporting of Tang level of expertise (LOE). Question/Purpose The aim of this study was to document trends in LOE reporting for novel technique articles published in the Journal of Wrist Surgery and evaluate whether author experience affects novel research outcomes. Methods A total of 261 articles published from 2018 to 2020 were reviewed. Articles describing novel surgical techniques were included and examined for Tang LOE. Author variables were collected online. Results Eight percent (21/261) of articles discussed novel surgical techniques and one reported LOE. Nearly half (47.6%) of articles did not conduct statistical analysis. Four (19.0%) reported insignificant statistical results and 7 (33.3%) reported significant findings. All significant statistical findings were positive. Number of prior related publications by the senior author did not affect new technique result significance (p = 0.34). Discussion From 2018 to 2020, only one article documented LOE. Authors' variables, including number of prior related publications, were not correlated with significant results in their new publications. This may suggest that an author's established experience in a novel technique, quantified by prior publications on the topic, does not make one more likely to achieve significantly better or worse outcomes in their reviewed Journal of Wrist Surgery study. Conclusions Tang LOE is an important way for readers to classify expertise and should be reported, and potentially modified to better define contributing variables.

Among the histogenic subtypes of melanoma, nodular melanoma (NM) is the major contributor for thicker and fatal melanomas and it has been associated with melanoma-specific death in thin tumours, highlighting an important subgroup of 'aggressive thin' melanomas. This review provides a synthesis of the distinct characteristics of NM, with respect to epidemiology and risk factors, clinical presentation, histopathology, molecular and dermoscopic aspects, and screening practices. The real challenges are to find better biomarkers of aggressiveness and to know whether the control of such aggressive melanomas can be influenced by targeted interventions such as early detection, drug interventions and preventive strategies.

BACKGROUND Severe maternal morbidity (SMM) occurs in 1-2% of pregnancies. Despite the knowledge that a SMM event can contribute to poor fetal/neonatal outcomes, little is known about the preventability of these adverse outcomes. AIMS To examine adverse fetal/neonatal outcomes associated with SMM to determine if these outcomes were potentially preventable. MATERIALS AND METHODS A New Zealand national retrospective cohort study examining cases of SMM with an adverse fetal/neonatal outcome. Maternity and initial neonatal care were explored by multidisciplinary panels utilising a preventability tool to assess whether the fetal/neonatal harm was potentially preventable. Adverse fetal/neonatal outcomes were defined as fetal or early neonatal death, Apgar score

Residents of long-term care facilities (LTCFs) and health care personnel (HCP) working in these facilities are at high risk for COVID-19-associated mortality. As of March 2021, deaths among LTCF residents and HCP have accounted for almost one third (approximately 182,000) of COVID-19-associated deaths in the United States (1). Accordingly, LTCF residents and HCP were prioritized for early receipt of COVID-19 vaccination and were targeted for on-site vaccination through the federal Pharmacy Partnership for Long-Term Care Program (2). In December 2020, CDC's National Healthcare Safety Network (NHSN) launched COVID-19 vaccination modules, which allow U.S. LTCFs to voluntarily submit weekly facility-level COVID-19 vaccination data.* CDC analyzed data submitted during March 1-April 4, 2021, to describe COVID-19 vaccination coverage among a convenience sample of HCP working in LTCFs, by job category, and compare HCP vaccination coverage rates with social vulnerability metrics of the surrounding community using zip code tabulation area (zip code area) estimates. Through April 4, 2021, a total of 300 LTCFs nationwide, representing approximately 1.8% of LTCFs enrolled in NHSN, reported that 22,825 (56.8%) of 40,212 HCP completed COVID-19 vaccination.† Vaccination coverage was highest among physicians and advanced practice providers (75.1%) and lowest among nurses (56.7%) and aides (45.6%). Among aides (including certified nursing assistants, nurse aides, medication aides, and medication assistants), coverage was lower in facilities located in zip code areas with higher social vulnerability (social and structural factors associated with adverse health outcomes), corresponding to vaccination disparities present in the wider community (3). Additional efforts are needed to improve LTCF immunization policies and practices, build confidence in COVID-19 vaccines, and promote COVID-19 vaccination. CDC and partners have prepared education and training resources to help educate HCP and promote COVID-19 vaccination coverage among LTCF staff members.§.

The impact of host genomics on an individual's susceptibility, immune response, and risk of severe outcomes for a given infectious pathogen is increasingly recognized. As we uncover the links between host genomics and infectious disease, a number of ethical, legal, and social issues need to be considered when using that information in clinical practice or workforce decisions. We conducted a survey of the clinical staff at 10 federally funded Regional Ebola and Other Special Pathogen Treatment Centers to understand their views regarding the ethical, legal, and social issues related to host genomics and the administrative and clinical functions of high-level isolation units. Respondents overwhelmingly agreed that genomics could provide valuable information to identify patients and employees at higher risk for poor outcomes from highly infectious diseases. However, there was considerable disagreement about whether such data should inform the allocation of scarce resources or determine treatment decisions. While most respondents supported a confidential employer-based genomic testing system to inform individual employees about risk, respondents disagreed about whether such information should be used in staffing models. Respondents who thought genomic information would be valuable for patient treatment were more willing to undergo genetic testing for staffing purposes. Most respondents felt they would benefit from additional training to better interpret results from genetic testing. Although this study was completed before the COVID-19 pandemic, the responses provide a baseline assessment of provider attitudes that can inform policy during the current pandemic and in future infectious disease outbreaks.

Background Hepatoblastoma is the most common primary pediatric liver malignancy. Indocyanine green (ICG) has been described as an adjunct to resection in small series. Its utility remains undefined in larger cohorts. Methods Records for 29 patients diagnosed with hepatoblastoma who received ICG prior to surgical resection from 2017 to 2020 at a single institution were retrospectively reviewed. The primary outcome was correlation between intraoperative ICG‐avidity and histologic presence of hepatoblastoma. A secondary outcome included the histologic margin designation for resected liver specimens. Results ICG sensitivity was 91% for 120 resected thoracic specimens from 21 patients. Specificity was 57%. In 10% of operations, HB‐positive specimens were resected solely on ICG‐avidity. In an additional 40% of cases, ICG assisted in localizing a preoperatively diagnosed lesion. ICG sensitivity during thoracotomy and thoracoscopic surgery was 95 and 74%, respectively; primary and relapsed disease demonstrated sensitivity of 94 and 73%, respectively. Sensitivity was 92% for 25 resected liver specimens from nine patients with all parenchymal margins grossly negative for disease. Four multifocal lesions were identified with two resected solely by ICG‐avidity. Conclusions ICG is a sensitive adjunct for identifying local and metastatic hepatoblastoma, including lesions not visualized on preoperative imaging, and delineating margins during liver resection. False positives limit specificity; however, there were no adverse outcomes from additional resections. We noted that thoracoscopic surgery can be completed safely in patients with less significant disease burden, and conversion to thoracotomy, if necessary, is straightforward., ICG is a sensitive adjunct for identifying local and metastatic hepatoblastoma, including lesions not visualized on preoperative imaging, and delineating margins during liver resection. With its use, thoracoscopic surgery can be completed safely in patients with less significant disease burden with conversion to thoracotomy, if necessary.

OBJECTIVES Electric scooter (e-scooter) use and resulting injuries have grown exponentially since expansion into ridesharing in 2017. No study has described pediatric e-scooter injuries and focused on their impact in an adolescent cohort. Our primary purpose was to describe the epidemiology of admitted pediatric e-scooter injuries and compare them with existing literature on adults. METHODS We queried the National Electronic Injury Surveillance System for e-scooter injuries between 2015 and 2019 in patients 0-18 years old. Injuries caused by an e-scooter to a nonrider were removed. Patients admitted to the hospital were analyzed and weighted national estimates were calculated. A P value of

Robotic-assisted total knee arthroplasty (RA-TKA) was introduced to improve limb alignment, component positioning, soft-tissue balance and to minimize surgical outliers. This study investigates perioperative outcomes, complications, and early patient-reported outcome measures (PROMs) of one imageless RA-TKA system compared to conventional method TKA (CM-TKA) at 24-month follow-up. This multi-surgeon retrospective cohort analysis compared 111 imageless RA-TKA patients to 110 CM-TKA patients (n = 221). Basic demographic information, intraoperative and postoperative data, and PROMs, including the functional score of the Knee Society Score (KSS-FS), The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and the Short Form 12 Mental and Physical scores (SF-12M and P), were collected and recorded preoperatively, at 3-, 12- and 24-months postoperatively. Range of motion (ROM), estimated blood loss (EBL), surgical duration, and complications were also collected. There were no baseline patient demographic differences between groups. EBL (240 vs. 190 mL, p

Isolated lateral compartment osteoarthritis of the knee is a rare condition affecting approximately 1% of the population, which is ten times less common than osteoarthritis affecting only the medial compartment. Unicompartmental knee arthroplasty (UKA) has many potential advantages over total knee arthroplasty. The benefits of UKA include a smaller incision, preservation of more native tissue (including cruciate ligaments and bone), decreased blood loss, and better overall proprioception. When UKA was first introduced in the 1970s, the outcomes of medial UKA (MUKA) were poor, but the few cases of lateral UKA (LUKA) showed promise. Since that time, there has been a relative paucity of literature focused specifically on LUKA given it is a rare procedure. Refinements in patient selection criteria, implant design, and surgical technique have been made leading to increased popularity. A review of the recent literature reveals that LUKA is associated with excellent long-term clinical outcomes and implant survivorship when performed in properly selected patients. Implant design options include fixed vs mobile bearing as well as metal backed vs all polyethylene tibial component, with improved outcomes noted with fixed bearing designs. Three reasons cited for revision (i.e., fracture of the femoral component, fracture of the tibial component, and valgus malalignment) had been reported in past literature but not recently. Presently, while rare, the most common cause of failure and need for revision are osteoarthritis progression and aseptic loosening. Despite the need for an occasional revision procedure, the survivorship of LUKA is comparable to MUKA, although it should be noted that outcomes of MUKA have been notably varied. Continued pursuit of improved techniques and implant designs will continue to show LUKA to be an excellent procedure for appropriately indicated patients.

Infectious disease outbreaks highlight the importance of trust in public health authorities to avoid fear and improve adherence to recommendations. There is currently no established and validated measure for trust in public health authorities. We aimed to develop and validate an instrument that measures trust in public health authorities and to assess the association between trust in public health authorities and vaccine attitudes. We developed 20 items to measure trust in public health authorities. After implementing a survey in January 2020, we investigated relationships between the items, reduced the number of items, and identified latent constructs of the scale. We assessed variability in trust and how trust was associated with vaccine attitudes, beliefs, and self-reported vaccine acceptance. The pool was reduced to a 14-item trust in public health authorities scale and we found that this trust model was strongly associated with acceptance of vaccines. Our scale can be used to examine the relationship between trust in public health authorities and adherence to public health recommendations. The measure needs to be validated in other settings to determine whether they are associated with other areas where the public question public health authority recommendations.

Objectives The aim of this study was to examine the effect of CYP2C19 genotype on clinical outcomes in patients with coronary artery disease (CAD) who predominantly underwent percutaneous coronary intervention (PCI), comparing those treated with ticagrelor or prasugrel versus clopidogrel. Background The effect of CYP2C19 genotype on treatment outcomes with ticagrelor or prasugrel compared with clopidogrel is unclear. Methods Databases through February 19, 2020, were searched for studies reporting the effect of CYP2C19 genotype on ischemic outcomes during ticagrelor or prasugrel versus clopidogrel treatment. Study eligibility required outcomes reported for CYP2C19 genotype status and clopidogrel and alternative P2Y12 inhibitors in patients with CAD with at least 50% undergoing PCI. The primary analysis consisted of randomized controlled trials (RCTs). A secondary analysis was conducted by adding non-RCTs to the primary analysis. The primary outcome was a composite of cardiovascular death, myocardial infarction, stroke, stent thrombosis, and severe recurrent ischemia. Meta-analysis was conducted to compare the 2 drug regimens and test interaction with CYP2C19 genotype. Results Of 1,335 studies identified, 7 RCTs were included (15,949 patients, mean age 62 years; 77% had PCI, 98% had acute coronary syndromes). Statistical heterogeneity was minimal, and risk for bias was low. Ticagrelor and prasugrel compared with clopidogrel resulted in a significant reduction in ischemic events (relative risk: 0.70; 95% confidence interval: 0.59 to 0.83) in CYP2C19 loss-of-function carriers but not in noncarriers (relative risk: 1.0; 95% confidence interval: 0.80 to 1.25). The test of interaction on the basis of CYP2C19 genotype status was statistically significant (p = 0.013), suggesting that CYP2C19 genotype modified the effect. An additional 4 observational studies were found, and adding them to the analysis provided the same conclusions (p value of the test of interaction Conclusions The effect of ticagrelor or prasugrel compared with clopidogrel in reducing ischemic events in patients with CAD who predominantly undergo PCI is based primarily on the presence of CYP2C19 loss-of-function carrier status. These results support genetic testing prior to prescribing P2Y12 inhibitor therapy.

Background: The objective of the study was to compare family planning and infertility among female and male gynecologic oncologists in the United States Methods: This cross-sectional multiple choice survey was administered to the Society of Gynecologic Oncology gynecologic oncologists. The survey collected information on demographics and practice, family planning, and fertility and infertility experiences. Chi-square and Fisher's exact tests were used to compare experiences by gender. Results: Two hundred eighteen of 1243 (18%) members responded to the survey. The majority were women (71%), Caucasian (78%), and had been practicing fewer than 10 years (56%). One-third (32%) were 35+ years of age at the birth of their first child, and 67% delayed childbearing due to their career. Women were more likely than men to report career choice-influenced family planning. Just under half (44%) expressed current or past concerns about fertility, and this was more prevalent among women; 81% had sought infertility counseling. Among respondents who had fertility struggles, almost half (45%) reported their colleagues were unaware. Forty percent felt their fertility concerns affected work life, and 13% felt stigmatized for their fertility struggles. Conclusions: These findings suggest that a career in gynecologic oncology have an impact on family planning, often resulting in childbearing delays and infertility concerns, especially among women. Support for our colleagues struggling with infertility should be included in wellness initiatives.

Following the publication of reports from landmark international consensuses (Louisville 2008 and Morioka 2014), minimally invasive hepatectomy became widely accepted as a legitimate alternative to open surgery. We aimed to compare the operative, hospitalization, and total economic costs of open (OLR) vs. laparoscopic (LLR) vs. robotic liver resection (RLR). We performed a systematic literature review (end-of-search date: July 3, 2020) according to the PRISMA statement. Random-effects meta-analyses were conducted. Quality assessment was performed with the Cochrane Risk of Bias tool for randomized controlled trials, and the Newcastle–Ottawa Scale for non-randomized studies. Thirty-eight studies reporting on 3847 patients (1783 OLR; 1674 LLR; 390 RLR) were included. The operative costs of LLR were significantly higher than those of OLR, while subgroup analysis also showed higher operative costs in the LLR group for major hepatectomy, but no statistically significant difference for minor hepatectomy. Hospitalization costs were significantly lower in the LLR group, with subgroup analyses indicating lower costs for LLR in both major and minor hepatectomy series. No statistically significant difference was observed regarding total costs between LLR and OLR both overall and on subgroup analyses in either major or minor hepatectomy series. Meta-analyses showed higher operative, hospitalization, and total costs for RLR vs. LLR, but no statistically significant difference regarding total costs for RLR vs. OLR. LLR’s higher operative costs are offset by lower hospitalization costs compared to OLR leading to no statistically significant difference in total costs, while RLR appears to be a more expensive alternative approach.

Background Trends in prescribing for nursing home (NH) residents, which may have been influenced by the coronavirus disease 2019 (COVID-19) pandemic, have not been characterized. Methods Long-term care pharmacy data from 1944 US NHs were used to evaluate trends in prescribing of antibiotics and drugs that were investigated for COVID-19 treatment, including hydroxychloroquine, famotidine, and dexamethasone. To account for seasonal variability in antibiotic prescribing and decreased NH occupancy during the pandemic, monthly prevalence of residents with a prescription dispensed per 1000 residents serviced was calculated from January to October and compared as relative percent change from 2019 to 2020. Results In April 2020, prescribing was significantly higher in NHs for drugs investigated for COVID-19 treatment than 2019; including hydroxychloroquine (+563%, 95% confidence interval [CI]: 5.87, 7.48) and azithromycin (+150%, 95% CI: 2.37, 2.63). Ceftriaxone prescribing also increased (+43%, 95% CI: 1.34, 1.54). Prescribing of dexamethasone was 36% lower in April (95% CI: .55, .73) and 303% higher in July (95% CI: 3.66, 4.45). Although azithromycin and ceftriaxone prescribing increased, total antibiotic prescribing among residents was lower from May (−5%, 95% CI: .94, .97) through October (−4%, 95% CI: .94, .97) in 2020 compared to 2019. Conclusions During the pandemic, large numbers of residents were prescribed drugs investigated for COVID-19 treatment, and an increase in prescribing of antibiotics commonly used for respiratory infections was observed. Prescribing of these drugs may increase the risk of adverse events, without providing clear benefits. Surveillance of NH prescribing practices is critical to evaluate concordance with guideline-recommended therapy and improve resident safety.

The erythema migrans (EM) skin lesion is often the first clinical sign of Lyme disease. Significant variability in EM presenting characteristics such as shape, color, pattern, and homogeneity, has been reported. We studied associations between these presenting characteristics, as well as whether they were associated with age, sex, EM duration, body location, and initiation of antibiotics. Two hundred and seventy one adult participants with early Lyme disease who had a physician-diagnosed EM skin lesion of ≥ 5 cm in diameter and ≤ 72 h of antibiotic treatment were enrolled. Participant demographics, clinical characteristics, and characteristics of their primary EM lesion were recorded. After adjusting for potential confounders, EM size increased along with increasing EM duration to a peak of 14 days. Male EM were found to be on average 2.18 cm larger than female EM. The odds of a red (vs blue/red) EM were 65% lower in males compared to females, and were over 3 times as high for EM found on the pelvis, torso, or arm compared to the leg. Age remained a significant predictor of central clearing in adjusted models; for every 10-year increase in age, the odds of central clearing decreased 25%. Given that EM remains a clinical diagnosis, it is essential that both physicians and the general public are aware of its varied manifestations. Our findings suggest possible patterns within this variability, with implications for prompt diagnosis and treatment initiation, as well as an understanding of the clinical spectrum of EM.

Prolonged operative duration is an independent risk factor for postoperative complications in many orthopedic procedures ranging from shoulder arthroscopy to total hip and knee arthroplasties. It has not been well studied in unicompartmental knee arthroplasty (UKA). The purpose of this study is to assess the effect of operative duration on complications after UKA.Using the American College of Surgeons National Surgical Quality Improvement Program registry, we identified all primary unilateral UKAs from 2005 to 18. Patients were divided into three cohorts based on the operative duration:90 minutes, between 90 and 120 minutes, and120 minutes. Baseline patient and operative demographics (age, gender, etc.) and thirty-day complications were compared using bivariate analysis. Multivariate analysis was used to assess the independent effect of operative duration on postoperative outcomes after adjusting for differences in baseline characteristics.We identified 11,806 patients who underwent primary UKA from 2005 to 18. There was no difference in the "any complication" rate between cohorts. However, operative duration120 minutes was associated with a significantly higher likelihood of reoperation (odds ratio [OR] 2.02, 95% confidence interval [CI]: 1.15-3.57, P = .015), non-home discharge (OR: 2.14, CI: 1.65-2.77, P.001), surgical site infection (OR: 1.76, CI: 1.03-3.01, P = .038), and blood transfusions (OR: 3.23, CI: 1.44-7.22, P = .004) when compared with operative duration90 minutes. There was no difference in mortality rates.Increased operative duration greater than 2 hours in primary UKA is associated with an increased risk of non-home discharge, surgical site infection, reoperation, and blood transfusion.

Purpose In this systematic review, we aimed to clarify the useful anatomic structures and assess available surgical techniques and strategies required to safely perform minimally invasive anatomic liver resection (MIALR), with a particular focus on the hepatic veins (HVs). Methods A systematic review was conducted using MEDLINE/PubMed for English articles and Ichushi databases for Japanese articles through September 2020. The quality assessment of the articles was performed in accordance with the Scottish Intercollegiate Guidelines Network (SIGN). Results A total of 3,372 studies were obtained, and 59 were selected and reviewed. Due to the limited number of published comparative studies and case series, the degree of evidence from our review was low. Thirty-two articles examined the anatomic landmarks and crucial structures for approaching HVs. Regarding the direction of HV exposure, 32 articles focused on the techniques and advantages of exposing HVs from either the root or the periphery. Ten articles focused on the techniques to perform a segmentectomy 8 in particularly difficult cases of MIALR. In seven articles, bleeding control from HVs was also discussed. Conclusions This review may help experts reach a consensus regarding the best approach to the management of hepatic veins during MIALR.

The purpose of this study was to estimate the impact of pneumococcal conjugate vaccine-13 (PCV-13) introduction into the national immunization program in Israel on pneumococcal and non-pneumococcal pediatric community-acquired bacteremia (CAB). This is a retrospective cohort study, including children ≤ 18 years old with CAB, who were hospitalized in Rambam Health Care Campus, a tertiary medical center serving northern Israel, between the years 2004 and 2016. The proportional admission rate of pneumococcal bacteremia among all CAB events and the incidence of CAB and pneumococcal bacteremia per 1000 hospital admissions were compared between the pre- and post-pneumococcal vaccine eras. A total of 275 CAB events were identified. Common isolates were Streptococcus pneumoniae (SPn) (26.9%), Staphylococcus aureus (12.4%), Brucella spp. (11.6%), E. coli (10.9%), and Streptococcus pyogenes (5.8%). The pneumococcal bacteremia rate per 1000 hospital admissions decreased significantly from 1.59 to 0.6 (p < 0.001). The proportional pneumococcal bacteremia rate decreased from 55 (34.4%) to 19 (16.5%) (p 0.001). Penicillin resistance among pneumococcal isolates decreased dramatically from 50.9 to 5.3% (p < 0.001). The rate of bacteremia caused by other pathogens has not been changed significantly at the post-vaccination era (p 0.053). However, an increase in the incidence of S. pyogenes bacteremia from 1.9 to 11.3% (p < 0.001) was noticed. In addition, an outbreak of Brucella bacteremia occurred during the years 2015-2016. This study demonstrates the double positive effect of PVC-13 introduction: a sharp decrease in the proportional rate of pneumococcal bacteremia and in the resistance of SPn to penicillin. Also, there was a moderate decline in the incidence of CAB in exception to bacteremia caused by S. pyogenes. This trend was reversed due to a Brucella outbreak.

Objectives This study aimed to compare a backfill-assisted voiding trial (VT) with and without a postvoid residual (PVR) after pelvic reconstructive surgery. Methods This was a nonblinded randomized controlled trial of women undergoing pelvic organ prolapse and/or stress incontinence surgery. Participants were randomized immediately after surgery to either a PVR VT or a PVR-free VT. Our primary outcome was the rate of VT failure at discharge. Secondary outcomes included days of catheterization, urinary tract infection (UTI), and prolonged voiding dysfunction. With a power of 80% and an α of 0.05, we needed 126 participants to detect a 25% difference in VT failure (60% in PVR VT vs 35% in PVR-free VT). Results Participants were enrolled from March 2017 to October 2017. Of the 150 participants, mean age was 59 years, and 33% underwent vaginal hysterectomy, 48% underwent anterior repair, and 75% underwent midurethral sling. Seventy-five (50%) were randomized to PVR VT and 75 (50%) to PVR-free VT, with no differences in baseline demographic or intraoperative characteristics between the 2 groups. Our primary outcome, VT failure, was not significantly different (53% PVR VT vs 53% PVR-free VT, P = 1.0). There were no significant differences in days of postoperative catheterization (1 [0, 4] in PVR VT vs 1 [0, 4] in PVR-free VT, P = 0.90), UTI (20% PVR VT vs 20% PVR-free VT, P = 1.0), or postoperative voiding dysfunction (4% PVR VT vs 5% PVR-free VT, P = 1.0). Conclusions When performing a backfill-assisted VT, checking a PVR does not affect VT failure, postoperative duration of catheterization, UTI, or voiding dysfunction.