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Chronic obstructive pulmonary disease (COPD) is one of the leading causes of mortality worldwide and contributes considerably to morbidity and health care costs. In October 2014, the Centers for Medicare and Medicaid Services introduced financial penalties followed by bundled payments for care improvement initiatives in patients hospitalized with COPD.This study seeks to evaluate whether an evidence-based interprofessional COPD care bundle focused on inpatient, transitional, and outpatient care would reduce hospital readmission rates.A pre- and postintervention analysis comparing readmission rates after a hospitalization for COPD in subjects who received standard of care versus an interprofessional team-led COPD care bundle was conducted. The primary outcome was 30-day all-cause readmissions; secondary outcomes included 60- and 90-day all-cause readmissions, escalation of pharmacotherapy, interprofessional interventions, and hospital length of stay.A total of 189 subjects were included in the control arm and 127 subjects in the COPD care bundle arm. A reduction in 30-day all-cause readmissions between the control arm and COPD care bundle arm (21.7% vs. 11.8%, P = 0.017) was seen. Similar outcomes were seen in 60-day (18% vs. 8.7%, P = 0.013) and 90-day all-cause readmissions (19.6% vs. 4.7%, P0.001). Pharmacists consulted with 68.5% of subjects and assisted with access to outpatient medications in 45.7% of subjects in the COPD care bundle arm. An escalation in maintenance therapy occurred more often in the COPD care bundle arm (22.2% vs. 44.9%, P0.001) than the control arm.An interprofessional team-led COPD care bundle resulted in significant reductions in all-cause hospital readmissions at 30, 60, and 90 days.

To review how private equity entities generate profit for investors and ophthalmologists.There is a preponderance of private equity acquisitions and consolidation in ophthalmology. These private equity entities generate revenue by growth, profit improvement, and efficient use of capital structure. Physician partners sell their revenue and assets to a private equity entity while retaining a percentage of future profit. In general, a greater percentage going forward, will result in a smaller initial buyout. Partners typically receive payment in the form of cash and stock in the private equity entity, aligning incentives of both parties to grow and succeed. Junior associates and future partners typically do not benefit from the cash buyout but might have opportunity to buy shares in the private equity entity.The ophthalmology job market has changed significantly with the rise in private equity. Private equity investors profit from organic growth, economies of scale, and future revenue of ophthalmology practices. Ophthalmology partners benefit from often sizeable buyouts and potentially profitable shares in the private equity entity. Junior and future ophthalmologist may be less likely to succeed financially compared with their contemporaries. Some private equity entities will thrive and other may fail, particularly if they are unable to attract talented new ophthalmologists.

Purpose: This work aimed to assess the incidence of proliferative diabetic retinopathy (PDR) events and improvement to mild non-PDR (NPDR) or better after intravitreal aflibercept injection (IAI) or laser treatment (control) in diabetic macular edema (DME). Methods: PDR events in the VISTA (NCT01363440) and VIVID (NCT01331681) phase 3 clinical trials were evaluated in a combined IAI-treated group (IAI 2 mg every 4 weeks or 2 mg every 8 weeks after 5 initial monthly doses; n = 475) and a macular laser control group (n = 235) through week 100 in eyes without PDR at baseline (Diabetic Retinopathy Severity Scale [DRSS] score ≤ 53). Improvement in the DRSS score to 35 or better was evaluated in those with a baseline DRSS score of 43 or greater. Results: A lower proportion of eyes in the IAI group than in the laser group developed a PDR event through week 100 (4.4% vs 11.1%; adjusted difference, −6.7%; 97.5% CI, −11.7 to −1.6; nominal P = .0008). All PDR events occurred in eyes with a baseline DRSS score of 43, 47, or 53 and not in those with a score of 35 or less. A greater proportion of eyes in the IAI group than in the control group achieved a DRSS score of 35 or less (20.0% vs 3.8%; nominal P Conclusions: Fewer eyes with NPDR and DME treated with IAI than eyes treated with a laser had a PDR event. More eyes treated with IAI improved to mild NPDR or better (DRSS score ≤ 35) through 100 weeks.

Mature follow up from multiple randomized trials have demonstrated the safety and efficacy of external beam partial breast irradiation (PBI) for appropriately selected patients with early stage breast cancer. Despite this evidence, external beam PBI remains underutilized. In this user guide we outline patient selection, workflow, and address possible challenges to aid in implementation of evidence-based external beam PBI.Review of the current guidelines for PBI suitability, surgical considerations, treatment technique, simulation, contouring, and treatment planning, citing the latest published literature to support PBI utilization.Prospective data supports the use of 30 Gy in 5 fractions delivered with intensity modulated radiation therapy on a daily or every other day basis for a significant proportion of early stage breast cancer patients. The surgical cavity must be clearly visualized on treatment planning scan, recommend 3-5 weeks post-operatively, and the recommended clinical target volume expansion on the surgical cavity is 0.5-1.0 cm. A planning target volume expansion, based on motion management and image guidance, of 0.5-1.0 cm should be used. Organ at risk dose constraints of heart V3Gy ≤10% and contralateral breast Dmax ≤1 Gy are often achievable.Five fraction external beam PBI is a highly effective treatment with very limited toxicity for patients with early stage breast cancer following breast conserving surgery. Commonly utilized intensity modulated treatment planning techniques with plan delivery on standard linear accelerators results significant normal tissue sparing and makes implementation feasible at most radiation oncology centers.

Management of chronic myeloid leukemia (CML) has been transformed by the use of tyrosine kinase inhibitors (TKIs). Presently in India, five TKIs are approved for the management of CML with distinct safety profiles. The selection of TKIs for chronic phase (CP)-CML patients is based on treatment goals, underlying comorbidities, and specific TKI toxicity profiles. Bosutinib is one of five TKIs indicated for the first-line treatment of CP-CML and patients with intolerance or resistance to prior TKI therapy. It possesses a distinct safety profile among other TKIs, with less cardiovascular adverse events (AEs), albeit the liver-related and gastrointestinal AEs have higher occurrence. The safety and efficacy of bosutinib have been examined in clinical trials; however, there is a paucity of data from Asia. A virtual expert panel meeting was convened to gather expert opinion from India on the selection of bosutinib as a treatment choice for patients with CP-CML. This is a white paper document drafted with the help of an expert panel of 14 oncologists and hematooncologists from India on bosutinib use in CP-CML. The experts concurred that bosutinib has proven efficacy for CP-CML in global randomized clinical trials and is well suited for CP-CML patients with existing cardiovascular comorbidities. However, it was not recommended for patients with gastrointestinal, pancreatic, or renal abnormalities. This review aims to put forth expert opinion and guidance document on key considerations for CP-CML clinical decision-making in India.

BACKGROUND:Nephrotic syndrome (NS) results in proteinuria of more than 3.5 g protein per day and is characterized by edema,hyperlipidemia,hypoproteinemia and other metabolic disorders.Prevalence of UTI in nephrotic syndrome is high.It precipitates relapse and delays remission. AIMS AND OBJECTIVES:The aim of this retrospective study is to analyze the incidence of UTI,its Predisposing factors along with its bacterial and fungal etiologies in patients with NS and antibiotic sensitivity pattern in nephrotic children with UTI. METHODS: This retrospective study was carried out in a tertiary care, CIVIL HOSPITAL,AHMEDABAD between July 2018 and July 2019 among the admitted cases of nephrotic children under 12 years of age. Examinations for microscopy and cultures of urine, sputum, throat swab, blood and fluid were also carried out in the children,along with routine examination,if found necessary. Urinary specimens were collected by clean catch method following careful preparation of urethral orifices. The specimens were immediately inoculated on culture media. Identification of organisms and antibiotic sensitivity 1 susceptibility testing was performed according to CLSI guidelines 2010 by Kirby –Bauer disc diffusion method. RESULTS: Total 41 nephrotic children were enrolled.Incidence of UTI was fairly high in nephrotic syndrome,especially in frequent relapse (48.48%). Kleibsella pneumonia (45.5%) was the most common organism, followed by E.coli (24.24%),responsible for UTI in both first episode and frequent relapse of nephrotic syndrome in the following study. CONCLUSION: As per the study, common isolates of UTI in nephrotic syndrome have developed resistance to commonly used oral or parenteral drugs.In my study,it is observed that colistin was the most sensitive parenteral drug for all isolates followed by Meropenem and aminoglycoside.

Splenomegaly is common clinical finding in pediatric practice. Splenic enlargement occurs when the spleen is increased by cells or tissue components or by vascular engorgement. Various etiologies can cause splenomegaly. The spleen is rarely the primary site of a disease. Splenomegaly is classified according to the length palpable below the costal margin as mild: 7 cm. Severe/massive splenomegaly doesn't commonly occur in first 5 years of age, occurs after 5 years of age. So, clinical examination of every child is important to diagnose splenomegaly at early stages. Only in the age group of 1 to 5 years females predominated as compared to males. In present study there is obvious male predominance as male: female ratio is 1.8:1. This difference could be due to more priority to male child to seeking medical care with such chronic illness.Present study also suggested that severe/massive splenomegaly doesn't commonly occur in first 5 years of age, occurs after 5 years of age. So, clinical examination of every child is important to diagnose splenomegaly at early stages.

Background The objective of this study was to evaluate factors associated with postoperative opioid use after open treatment of distal radius fractures. Methods The Humana insurance claims database was queried for open treatment of distal radius fractures by Current Procedural Terminology codes. The search was further refined to identify patients who filled an opioid prescription within 6 weeks after their surgery. The study’s outcomes were: (1) limited postoperative opioid use, defined as filling a prescription once in the 6-week to 6-month period after surgery; and (2) persistent postoperative opioid use, defined as filling a prescription more than once in the 6-week to 6-month period after surgery. Logistic regression models were performed to identify factors associated with limited and persistent postoperative opioid use. Subgroup analyses were performed among opioid-naïve patients and those with open fractures. Results This study identified 9141 of 19 220 total patients with limited and persistent opioid use. Significant risk factors included nonhome discharge, inpatient surgical setting, long-term pain, tobacco abuse, and age less than 65 years. Of note, both preoperative opioid use within 1 month before surgery (odds ratio [OR], 2.6; 95% confidence interval [CI], 2.2-2.9) and preoperative opioid use between 1 and 6 months before surgery (OR, 4.0; 95% CI, 3.7-4.4) were significantly associated with persistent postoperative opioid use. Conclusions This study has identified numerous risk factors associated with postoperative opioid use after open treatment of distal radius fractures. Understanding these risk factors is the first step toward reducing postoperative opioid use.

Post-mastectomy radiation therapy (PMRT) in women with pathologic stage T1-2N1M0 breast cancer is controversial.Data from five North American institutions including women undergoing mastectomy without neoadjuvant therapy with pT1-2N1M0 breast cancer treated from 2006 to 2015 were pooled for analysis. Competing-risks regression was performed to identify factors associated with locoregional recurrence (LRR), distant metastasis (DM), overall recurrence (OR), and breast cancer mortality (BCM).A total of 3532 patients were included for analysis with a median follow-up time among survivors of 6.8 years (interquartile range [IQR], 4.5-9.5 years). The 2154 (61%) patients who received PMRT had significantly more adverse risk factors than those patients not receiving PMRT: younger age, larger tumors, more positive lymph nodes, lymphovascular invasion, extracapsular extension, and positive margins (p .05 for all). On competing risk regression analysis, receipt of PMRT was significantly associated with a decreased risk of LRR (hazard ratio [HR], 0.21; 95% confidence interval [CI], 0.14-0.31; p .001) and OR (HR, 0.76; 95% CI, 0.62-0.94; p = .011). Model performance metrics for each end point showed good discrimination and calibration. An online prediction model to estimate predicted risks for each outcome based on individual patient and tumor characteristics was created from the model.In a large multi-institutional cohort of patients, PMRT for T1-2N1 breast cancer was associated with a significant reduction in locoregional and overall recurrence after accounting for known prognostic factors. An online calculator was developed to aid in personalized decision-making regarding PMRT in this population.

The purpose of this study is to report the impact of COVID-19 on hand surgery fellow learning and preparedness for practice. A multi-dimensional questionnaire was distributed to current hand fellows and fellowship directors across the United States. Survey questions included fellowship location, institutional response, impact on practice, education and job search. Thirty-two hand surgery fellows and 14 fellowship directors completed the survey. Of fellows, 59% reported a greater than 75% decrease in case volume. Mean hours worked per week per fellow decreased by 52%. All fellowship directors and 94% of fellows did not expect COVID-19 to impact their ability to graduate, and nearly all fellows felt prepared to start practice after fellowship training. However, many fellows expressed concern about job opportunities. The work hours and exposure of hand surgery fellows to elective surgical cases have been adversely impacted by COVID-19. Nevertheless, current hand fellows feel prepared to enter practice. (Journal of Surgical Orthopaedic Advances 31(1):048-052, 2022).

Purpose To describe 2 cases of multilevel optic disk hemorrhages in adults without a posterior vitreous detachment. Methods The findings on clinical examination, color fundus photography, fluorescein angiography, spectral domain optical coherence tomography at presentation and follow-up are presented. Results Two patients ages 61 and 49 years presented with unilateral floaters secondary to microscopic vitreous hemorrhage. Their best-corrected visual acuities were 20/30 and 20/20, respectively. Fundus examination showed similar nasal crescent of peripapillary subretinal hemorrhage and superior flame hemorrhage. Fluorescein angiography for both patients showed blockage from hemorrhages without leakage. Spectral domain optical coherence tomography showed that the posterior hyaloid was attached at the macula and optic nerve for both patients. Both patients experienced spontaneous resolution of symptoms and signs. Conclusion Previous reports of multilevel optic disk hemorrhages in adults variably suggested the necessity of a posterior vitreous detachment. This report illustrates that a posterior vitreous detachment confirmed on spectral domain optical coherence tomography is not a necessary prerequisite for this entity.

Background The rapid spread of the coronavirus disease 2019 (COVID-19) epidemic has significantly impacted global health. So far, the evidence regarding the risk factors that predict the outcomes of COVID-19 patients is limited. In this study, we identified several risk factors that are associated with increased mortality in COVID-19 patients. Methods We performed a retrospective review of electronic medical records of the patients admitted with an initial diagnosis of COVID-19. We extracted several patient variables (including demographics, lab results, and pre-existing conditions) and examined for their association with increased mortality. Results Of the 487 people included in the study, 340 survived and 147 expired. Significant differences existed in demographics and underlying comorbidities between the two groups. A higher proportion of patients were age 65 and older (87.76% vs 53.24%, p, Highlights • The evidence regarding the risk factors associated with mortality in COVID-19 patients is limited. • Advanced age, an initial presentation with dyspnea, and positive chest imaging findings are associated with increased mortality. • Past history of acute kidney injury and cardiomyopathy are associated with increased mortality. • Early identification of the patients with an increased risk that require early medical intervention may reduce overall morbidity and mortality.

To evaluate risk factors (treatment-related, comorbidities, and lifestyle) for breast cancer-related lymphedema (BCRL) within the context of a Prospective Surveillance and Early Intervention (PSEI) model of care for subclinical BCRL.The parent randomized clinical trial assigned patients newly diagnosed with breast cancer to PSEI with either bioimpedance spectroscopy (BIS) or tape measurement (TM). Surgical, systemic and radiation treatments, comorbidities, and lifestyle factors were recorded. Detection of subclinical BCRL (change from baseline of either BIS L-Dex ≥6.5 or tape volume ≥ 5% and 10%) triggered an intervention with compression therapy. Volume change from baseline ≥10% indicated progression to chronic lymphedema and need for complex decongestive physiotherapy. In this secondary analysis, multinomial logistic regressions including main and interaction effects of the study group and risk factors were used to test for factor associations with outcomes (no lymphedema, subclinical lymphedema, progression to chronic lymphedema after intervention, progression to chronic lymphedema without intervention). Post hoc tests of significant interaction effects were conducted using Bonferroni-corrected alphas of .008; otherwise, an alpha of .05 was used for statistical significance.The sample (n = 918; TM = 457; BIS = 461) was female with a median age of 58.4 years. Factors associated with BCRL risk included axillary lymph node dissection (ALND) (p .001), taxane-based chemotherapy (p .001), regional nodal irradiation (RNI) (p ≤ .001), body mass index30 (p = .002), and rurality (p = .037). Mastectomy, age, hypertension, diabetes, seroma, smoking, and air travel were not associated with BCRL risk.Within the context of 3 years of PSEI for subclinical lymphedema, variables of ALND, taxane-based chemotherapy, RNI, body mass index30, and rurality increased risk.

Purpose Chronic obstructive pulmonary disease (COPD) is a chronic condition that leads to significant morbidity and mortality. Management of COPD hospitalizations utilizing an evidence-based care bundle can provide consistent quality of care and may reduce readmissions. Methods This single center retrospective cohort study evaluated readmission rates in patients hospitalized with a COPD exacerbation. Patients in the pre-intervention cohort received usual care while post-intervention cohort received an innovative inpatient COPD care bundle. The bundle focused on optimizing care in five areas: consults, inpatient interventions, education, transitions of care, and after discharge care. To ensure consistency of interventions, a formal checklist of items was maintained. Results In this study, 149 subjects were included in the pre-intervention cohort and 214 subjects were included in the post-intervention cohort. Thirty-day readmission rates were lower in the post-intervention cohort, 22.4% vs. 38.3% (p=0.001). A reduction in 60-day and 90-day readmission rates was also observed, 13.7% vs. 40.3% (p< 0.001) and 10.1% vs. 32.2% (p

In 2015, the Centers for Medicare and Medicaid Services limited payments to hospitals with high readmission rates for patients admitted with COPD exacerbation. Decreasing readmissions in this patient population improves patient health and decreases health care utilization of resources. We hypothesized a COPD disease management program delivered by a respiratory therapist (RT) in the patient's home may reduce readmission rates for COPD exacerbation.We performed a pre/post interventional study comparing hospital readmissions for subjects with COPD exacerbation that received standard of care in the home versus an RT-led home COPD disease management program. Subjects discharged home from Atlantic Health System with COPD exacerbation were enrolled in the pre-intervention group. Subsequently, an evidence-based home COPD disease management program was implemented by an RT from At Home Medical in the home. The home COPD Disease Management Program was implemented from April 2017-September 2019, and this served as the post-intervention group. The primary end point was readmission rates at 30 d. Secondary end points included 60-d and 90-d readmission rates.A total of 1,093 participants were included in the study, 658 in the pre-intervention cohort and 435 participants in the post-intervention group. Approximately 22.3% (The COPD Disease Management Program is significantly associated with decreased readmission adjusting for demographics and smoking status.

There is increasing interest in shorter courses of radiation therapy (RT) in the management of soft tissue sarcoma (STS). We report our institutional experience for patients undergoing ultra-hypofractionated preoperative RT followed by immediate resection.An IRB approved review of patients treated with preoperative 5 fraction, once daily RT followed by immediate resection (within 7 days) for STS of the extremity or trunk was conducted. The primary endpoints are major wound complications and local control (LC). Secondary endpoints include grade ≥2 toxicity, metastasis free survival (MFS), and overall survival (OS).Twenty-two patients with a median age of 67 years (range 30-87) and median follow-up of 24.5 months (IQR 17.0-35.7) met eligibility criteria; 18/22 patients (81.8%) had ≥ 1 year follow-up. Primary tumor location was lower extremity in 15 patients (68.2%), upper extremity in 5 (22.7%), and trunk in 2 (9.1%). All patients received 30 Gy in 5 fractions. The median time to resection following RT was 1 day (range 0-5). The median time from biopsy to resection was 34 days (range 20-69). Local control was 100%; in patients with localized disease, 2-year MFS and OS were 71.3% and 76.9%, respectively. Major wound complications occurred in 9 patients (40.9%), with wound complications requiring reoperation occurring in 8 patients (36.4%). Other acute and late grade ≥2 toxicities were seen in 0 and 4 patients (18.2%), respectively.Ultra-hypofractionated preoperative RT followed by immediate resection permits expedited completion of oncologic therapy with early results demonstrating excellent local control and acceptable toxicity. Prospective data with long-term follow-up is needed.

111 Background: While incidence rates of cancer are lower among women experiencing homelessness (WEH), cancer mortality remains higher. Barriers to screening include economic, transportation, housing, childcare and other barriers. This study evaluates barriers to mammographic screening as part of a prospective program that provides onsite mammography services to WEH. Methods: Cleveland Clinic partnered with shelters to provide breast health education, patient navigation, and mobile mammograms onsite at shelters. Also, participants received a meal, a bra, and hygiene items. 75 women and persons of other genders completed a mammogram. 55 WEH participated in the study by completing a survey for a response rate of 73.3%. The survey included questions about barriers and demographics. We conducted a preliminary analysis to improve study quality and plan for a follow up study. Results: Participants were 40-75 years old and identified as American Indian/Alaska Native (5.5%), Black/African American (60%), and White (40%). 16% of participants received their first ever mammogram. 34% noted a family history of breast cancer and 22% had previously been advised to return for additional imaging. One participant was a breast cancer survivor. On average, participants’ last mammogram was four years prior with the greatest screening lapse being 18 years prior. A majority (n = 39, 70.9%) disagreed or strongly disagreed with the statement, “I’m afraid the mammogram will be painful.” Likewise, a majority (n = 46, 83.7%) disagreed or strongly disagreed with the statement, “I’m embarrassed about having a mammogram.” A majority (n = 44, 80.0%) also disagreed or strongly disagreed with the statement, “I’m busy and do not have time.” Almost all participants (n = 51, 96.2%) responded “yes” to the statement, “I believe in preventative care screenings.” However, participants’ responses to the statement, “I’m afraid of finding breast cancer” varied widely from strongly disagree (n = 7, 13.0%) and disagree (n = 10, 18.5%), to neutral (n = 15, 27.8%), to agree (n = 12, 22.2%) and strongly agree (n = 10, 18.5%). Conclusions: Our preliminary data shows that most participants believe in preventative screening, showing that novel services such as onsite mammography may address the lack of screening in this population. 40.7% of participants stated they are afraid of finding breast cancer, indicating this is a barrier to screening in the WEH population. Future research should explore reasons for fear (financial burden, mortality, lack of access to care, etc.) and why this may result in a lack of screening.

Injuries to the basilar joint of the thumb can be potentially devastating injuries to baseball players and have significant adverse implications for the athlete’s season and career. These injuries are not infrequent in baseball players. The appropriate management of these injuries is crucial for the safe and timely return to baseball activities. This chapter discusses the fractures and dislocations involving the thumb CMC joint, with specific reference to baseball players. The mechanism of injury, diagnosis, treatment, risks and complications, rehabilitation, and return to play parameters are all addressed in this chapter.

Search systems have unprecedented influence on how and what information people access. These gateways to information on the one hand create an easy and universal access to online information, and on the other hand create biases that have shown to cause knowledge disparity and ill-decisions for information seekers. Most of the algorithms for indexing, retrieval, and ranking are heavily driven by the underlying data that itself is biased. In addition, orderings of the search results create position bias and exposure bias due to their considerable focus on relevance and user satisfaction. These and other forms of biases that are implicitly and sometimes explicitly woven in search systems are becoming increasing threats to information seeking and sense-making processes. In this tutorial, we will introduce the issues of biases in data, in algorithms, and overall in search processes and show how we could think about and create systems that are fairer, with increasing diversity and transparency. Specifically, the tutorial will present several fundamental concepts such as relevance, novelty, diversity, bias, and fairness using socio-technical terminologies taken from various communities, and dive deeper into metrics and frameworks that allow us to understand, extract, and materialize them. The tutorial will cover some of the most recent works in this area and show how this interdisciplinary research has opened up new challenges and opportunities for communities such as SIGIR.

Vitreous floaters are common, related to age, myopia, genetic predisposition, and infiltration of the vitreous body. A subset of patients report symptoms impacting their quality of vision. Treatment with laser vitreolysis, the use of an Nd:YAG laser to vaporize the collagenous vitreous opacities appears to be used more frequently; however, data regarding long-term safety and effectiveness are lacking. We present currently available data regarding efficacy and safety, as well as additional considerations. Laser vitreolysis of symptomatic floaters should not be routinely performed without additional studies documenting its safety and long-term efficacy. Ideally, the procedure would be effective in most patients and be approved by the Food and Drug Administration based on the results of a Food and Drug Administration registration trial before widespread adoption.

Purpose To compare the rates of infectious endophthalmitis following intravitreal injection of ranibizumab using prefilled syringes vs conventional preparation. Design Multicenter retrospective cohort study. Methods All eyes receiving intravitreal injection of 0.5 mg ranibizumab for retinal vascular diseases at 10 retina practices across the United States (2016 to 2017) and Japan (2009 to 2017) were included. The total numbers of eyes and injections were determined from billing codes. Endophthalmitis cases were determined from billing records and evaluated with chart review. Primary outcome was the rate of postinjection acute endophthalmitis. Secondary outcomes were visual acuity and microbial spectrum. Results A total of 243 754 intravitreal 0.5 mg ranibizumab injections (165 347 conventional and 78 407 prefilled) were administered to 43 132 unique patients during the study period. In the conventional ranibizumab group, a total of 43 cases of suspected endophthalmitis occurred (0.026%; 1 in 3845 injections) and 22 cases of culture-positive endophthalmitis occurred (0.013%; 1 in 7516 injections). In the prefilled ranibizumab group, 12 cases of suspected endophthalmitis occurred (0.015%; 1 in 6534 injections) and 2 cases of culture-positive endophthalmitis occurred (0.0026%; 1 in 39 204 injections). Prefilled syringes were associated with a trend toward decreased risk of suspected endophthalmitis (odds ratio 0.59; 95% confidence interval 0.31-1.12; P = .10) and a statistically significant decreased risk of culture-positive endophthalmitis (odds ratio 0.19; 95% confidence interval 0.045-0.82; P = .025). Average logMAR vision loss at final follow-up was significantly worse for eyes that developed endophthalmitis from the conventional ranibizumab preparation compared to the prefilled syringe group (4.45 lines lost from baseline acuity vs 0.38 lines lost; P = .0062). Oral-associated flora was found in 27.3% (6/22) of conventional ranibizumab culture-positive endophthalmitis cases (3 cases of Streptococcus viridans, 3 cases of Enterococcus faecalis) compared to 0 cases in the prefilled ranibizumab group. Conclusion In a large, multicenter, retrospective study the use of prefilled syringes during intravitreal injection of ranibizumab was associated with a reduced rate of culture-positive endophthalmitis, including from oral flora, as well as with improved visual acuity outcomes.

BACKGROUND Lack of access to primary care physicians (PCPs) may be an important contributor to mortality differences attributed to race/ethnicity. This study examined the effects of primary care access on mortality of lung cancer patients in an underserved community. METHODS Medical records of all newly diagnosed patients with primary lung cancer from 2012 to 2016 at a National Cancer Institute (NCI)-designated center in Bronx, New York were reviewed. Demographic data, PCP status, and residence in primary care shortage areas (PCSAs) were collected. Survival data from time of first imaging to death or the end of follow-up on January 1, 2018 were recorded. Survival analysis was performed using Kaplan-Meier and Cox hazards modeling. RESULTS Among 1062 patients, 874 (82%) were PCSA residents, 314 (30%) were Hispanic, and 445 (42%) were African American. PCSA residents were likely Hispanics (P

Tritium concentration in different parts of the rice plants, grown in villages around Tarapur Atomic Power Station, west coast of India, exposed to continuous atmospheric tritium in field condition were studied during two harvesting seasons of the years 2016 and 2017. The TFWT (HTO) and OBT concentrations in different parts of the rice plants were determined along with tritium in soil and air. The HTO to OBT concentration ratio in rice and hay was greater than unity in majority of the samples.

ObjectiveOur goals were to: establish the maximum-tolerated dose of olaparib tablets combined with metronomic carboplatin and paclitaxel in patients with relapsed high-grade serous ovarian cancer; evaluate dose-limiting toxicities; and evaluate efficacy at the maximum tolerated dose.MethodsIn this open-label, single-arm, investigator-initiated trial (ClinicalTrials.gov NCT01650376), patients with high-grade serous ovarian cancer who failed primary platinum and taxane therapy received oral olaparib tablets twice daily days 1–3 each week combined with fixed-dose metronomic carboplatin AUC2 and paclitaxel 60 mg/m2 weekly for 3 out of 4 weeks. A 3 × 3 design was used to determine the olaparib maximum tolerated dose. Combination therapy continued until disease progression, but patients with partial or complete response were transitioned to olaparib maintenance therapy. All patients were included in the analysis.ResultsThe maximum tolerated dose of olaparib tablets was 150 mg twice daily with metronomic carboplatin and paclitaxel. 54 women were enrolled, 14 in phase Ib and 40 in the expansion phase. The median number of prior therapeutic regimens was 3. Response included 13 complete remission (24%) and 16 partial remission (30%) per Response Evaluation Criteria in Solid Tumors version 1.1 (RECIST 1.1) for an overall response rate of 54% (95% CI 40% to 67%). Of 47 patients who underwent BRCA testing, 23 were BRCA mutation (BRCAm) and 24 BRCA wild type (BRCAwt). Progression-free survival for BRCAm was 12.1 months versus 4.8 for BRCAwt (p=0.0001). Median overall survival for BRCAm was 24.1 months versus 10.4 months for BRCAwt (p=0.02). 42 patients (78%) experienced grade 3–4 toxicities with combination therapy; the most common were hematologic. There were no treatment related deaths. Among 14 patients who received maintenance therapy, 7 experienced grade 1–2 non-hematologic toxicities.ConclusionsOlaparib 150 mg tablet twice daily can be safely administered in combination with metronomic carboplatin and paclitaxel in pre-treated relapsed ovarian cancer with 24% complete remission. BRCAm patients had statistically significant longer progression-free survival and overall survival than BRCAwt.Trial registration numberNCT01650376.

Background: An exhaled microRNA-based lung cancer case-control discriminant biomarker strategy is reported.Methods: A microRNA-seq discovery effort compared paired tumor to non-tumor tissue, was reconciled with analogous TCGA and published literature-based tissue-discriminant microRNA data, yielding a candidate panel of 24 microRNAs that are upregulated in either adenocarcinomas and/or squamous cell carcinomas. The technical feasibility of microRNA-PCR assays in exhaled breath condensate (EBC) was tested. The airway origin of exhaled microRNAs was then topographically “fingerprinted”, using paired EBC and bronchoscopic samples. For initial EBC testing, a clinic-based case-control set of 351 individuals (166 NSCLC cases, 185 non-cancer controls) was interrogated with the 24-candidate microRNA panel by qualitative RT-PCR, and curated by melt curve analysis. Data were analyzed by both logistic regression (LR), and by random-forest (RF) models, validated by iterative resampling.Results: Both feasibility of exhaled microRNA detection, and its origins in part from lower airway sources, were confirmed. LR models adjusted for age, sex, smoking status, pack years, quit-years, and underlying lung disease identified exhaled miR-21, 33b, 212 (p.adj,=0.019, 0.018, 0.033, resp.) as case-control discriminant. For the RF analysis, the combined clinical + microRNA models showed modest added discrimination capacity (1.1–2.5%) beyond the clinical models alone: by subgroup, all subjects 1.1% (p = 8.7e-04)); former smokers 2.5% (p = 3.6e-05); early stage 1.2% (p = 9.0e-03). Sensitivity, specificity, positive- and negative-predictive values of the clinical + microRNA models for the entire cohort were 71%-76%.Conclusion: This work suggests that exhaled microRNAs are measurable qualitatively; reflect in part lower airway signatures; and if improved/refined, can potentially help distinguish lung cancer cases from controls.

Together, chronic obstructive pulmonary disease (COPD) and asthma account for the most common non-infectious respiratory pathologies. Conflicting preliminary studies have shown varied effect for COPD and asthma as prognostic factors for mortality in coronavirus disease 2019 (COVID-19). The aim of this study was to explore the association of COPD and asthma with in-hospital mortality in patients with COVID-19 by systematically reviewing and synthesizing with a meta-analysis the available observational studies. MEDLINE, Scopus, and medRxiv databases were reviewed. A random-effects model meta-analysis was used, and I-square was utilized to assess for heterogeneity. In-hospital mortality was defined as the primary endpoint. Sensitivity and meta-regression analyses were performed. Thirty studies with 21,309 patients were included in this meta-analysis (1465 with COPD and 633 with asthma). Hospitalized COVID-19 patients with COPD had higher risk of death compared to those without COPD (OR: 2.29; 95% CI: 1.79–2.93; I2 59.6%). No significant difference in in-hospital mortality was seen in patients with and without asthma (OR: 0.87; 95% CI: 0.68–1.10; I2 0.0%). The likelihood of death was significantly higher in patients with COPD that were hospitalized with COVID-19 compared to patients without COPD. Further studies are needed to assess whether this association is independent or not. No significant difference was demonstrated in COVID-19-related mortality between patients with and without asthma.

Purpose Routine use of face masks for patients and physicians during intravitreal anti–vascular endothelial growth factor (VEGF) injections has increased with the emergence of the coronavirus disease 2019 pandemic. This study evaluates the impact of universal face mask use on rates and outcomes of post-injection endophthalmitis (PIE). Design Retrospective, multicenter, comparative cohort study. Participants Eyes receiving intravitreal anti-VEGF injections from October 1, 2019, to July 31, 2020, at 12 centers. Methods Cases were divided into a “no face mask” group if no face masks were worn by the physician or patient during intravitreal injections or a “universal face mask” group if face masks were worn by the physician, ancillary staff, and patient during intravitreal injections. Main Outcome Measures Rate of endophthalmitis, microbial spectrum, and visual acuity (VA). Results Of 505 968 intravitreal injections administered in 110 547 eyes, 85 of 294 514 (0.0289%; 1 in 3464 injections) cases of presumed endophthalmitis occurred in the “no face mask” group, and 45 of 211 454 (0.0213%; 1 in 4699) cases occurred in the “universal face mask” group (odds ratio [OR], 0.74; 95% confidence interval [CI], 0.51–1.18; P = 0.097). In the “no face mask” group, there were 27 cases (0.0092%; 1 in 10 908 injections) of culture-positive endophthalmitis compared with 9 cases (0.004%; 1 in 23 494) in the “universal face mask” group (OR, 0.46; 95% CI, 0.22–0.99; P = 0.041). Three cases of oral flora–associated endophthalmitis occurred in the “no face mask” group (0.001%; 1 in 98 171 injections) compared with 1 (0.0005%; 1 in 211 454) in the “universal face mask” group (P = 0.645). Patients presented a mean (range) 4.9 (1–30) days after the causative injection, and mean logarithm of the minimum angle of resolution (logMAR) VA at endophthalmitis presentation was 2.04 (~20/2200) for “no face mask” group compared with 1.65 (~20/900) for the “universal face mask” group (P = 0.022), although no difference was observed 3 months after treatment (P = 0.764). Conclusions In a large, multicenter, retrospective study, physician and patient face mask use during intravitreal anti-VEGF injections did not alter the risk of presumed acute-onset bacterial endophthalmitis, but there was a reduced rate of culture-positive endophthalmitis. Three months after presentation, there was no difference in VA between the groups.

Background Aerosolized Azacitidine has been shown to inhibit orthotopic lung cancer growth and induce re-expression of methylated tumor suppressor genes in murine models. We hypothesized that inhaled Azacitidine is safe and effective in reversing epigenetic changes in the bronchial epithelium secondary to chronic smoking. Patients and Methods We report the first in human study of inhaled Azacitidine. Azacitidine in aqueous solution was used to generate an aerosol suspension of 0.25–5 μm particle size. Main inclusion criteria: Stage IV or recurrent NSCLC with predominantly lung involvement, ≥1 prior systemic therapy, ECOG PS 0–1, and adequate pulmonary function. Patients received inhaled Azacitidine daily on days 1–5 and 15–19 of 28-day cycles, at 3 escalating doses (15, 30 and 45 mg/m2 daily). The primary objective was to determine the feasibility and tolerability of this new therapeutic modality. The key secondary objectives included pharmacokinetics, methylation profiles and efficacy. Results From 3/2015 to 2/2018, eight patients received a median number of 2 (IQR = 1) cycles of inhaled Azacitidine. No clinically significant adverse events were observed, except one patient treated at the highest dose developed an asymptomatic grade 2 decreased DLCO which resolved spontaneously. One patient receiving 12 cycles of therapy had an objective and durable partial response, and two patients had stable disease. Plasma Azacitidine was only briefly detectable in patients treated at the higher doses. Moreover, in 2 of 3 participants who agreed and underwent pre- and post-treatment bronchoscopy, the global DNA methylation in the bronchial epithelium decreased by 24 % and 79 % post-therapy, respectively. The interval between last inhaled treatment and bronchoscopy was 3 days. Conclusions Inhaled Azacitidine resulted in negligible plasma levels compared to the previously reported subcutaneous administration and was well-tolerated. The results justify the continued development of inhaled Azacitidine at non-cytotoxic doses for patients with lung-confined malignant and/or premalignant lesions.

Supplemental material, sj-pdf-1-han-10.1177_1558944720988103 for Risk Factors for Prolonged Opioid Use After Open Treatment of Distal Radius Fractures by Mia M. Qin, Charles D. Qin and Chirag M. Shah in HAND

502 Background: Breast conserving surgery (BCS) followed by radiotherapy (RT) has been the mainstay for DCIS treatment. Adjuvant endocrine therapy (ET) has often been recommended based on multiple randomized clinical trials (RCT). However, these studies have failed to identify subsets of patients who did or did not benefit from adjuvant RT/ET therapy after BCS. We evaluated the association of a 7-gene predictive DCIS biosignature (PreludeDx, Laguna Hills, CA) to assess the impact of ET on 10-yr ipsilateral breast recurrence (IBR) risk after BCS alone or with RT. Methods: DCISionRT with integrated Residual Risk subtype (RRt) reported a decision score (DS) and three risk groups, a) Low Risk (DS≤2.8), b) Elevated Risk (DS > 2.8 without RRt) and c) Residual Risk (DS > 2.8 with RRt). DCISionRT/RRt was evaluated in 926 patients from 4 cohorts who were treated with BCS alone or with RT/ET. The three risk groups were assessed for 10-yr total (invasive and in situ) IBR risk by Kaplan Meier and Cox proportional hazards survival analysis. Results: DCISionRT/RRt classified 338 (37%) women as Low Risk, 399 (43%) as Elevated Risk, and 189 (20%) as Residual Risk. Overall, patients treated with ET had a significantly lower 10-yr IBR risk in multivariable analysis independent of RT (HR = 0.55, p = 0.033). In the Low Risk group treated with BCS without RT, the average 10-yr IBR risk was 5.6% (95% CI 2.5-12.1%, n = 124) and was not significantly different with vs without ET (p = 0.33). The 10-yr IBR risk after BCS alone was 22.6% in the Elevated Risk group and 50.3% in the Residual Risk group. Compared to BCS alone, the 10-year IBR risk tended to be lower in patients prescribed ET without RT in the Elevated (11.6%, 95% CI 3.9-32%) and Residual (15.4%, 95% CI 4.1-49%) Risk groups. 10-yr IBR risk was not significantly reduced by RT within the Low Risk group (p = 0.7) but was significantly reduced to 6.3% (95% CI 3.4-12%) by RT within the Elevated Risk (HR = 0.2, p < 0.001) and to 12.5% (95% CI 6.4-23%) within the Residual Risk (HR = 0.2, p < 0.001) groups. 10-yr IBR risk was significantly higher after RT in the Residual (HR = 2.5, p = 0.013) vs. Elevated Risk groups. After BCS and RT, there was no significant reduction in 10-yr IBR risk for those treated with vs without ET in the Elevated (p = 0.22) and Residual (p = 0.87) risk groups. Conclusions: The DCISionRT/RRt biosignature demonstrated prognostic and predictive RT response in Elevated and Residual Risk patients. Consistent with prior RCT data, ET was associated with lower 10-yr IBR risk overall, and within the DCISionRT Elevated and Residual Risk groups without RT. However, neither ET nor RT were asssociated with significant risk reduction in the Low Risk group. There was no added benefit of ET in the Elevated and Residual Risk groups after BCS+RT; the Residual Risk group patients still had a high IBR risk after RT.

6515 Background: Persons experiencing homelessness (PEH) suffer from poor health outcomes, including worse cancer mortality, compared to persons not experiencing homelessness. A portion of the disparity in cancer outcomes is attributable to reduced access to cancer screening, leading to more advanced-stage disease and a higher risk of death compared to the general population. Data regarding cancer screening rates in PEH are scarce. We therefore sought to evaluate baseline rates of breast cancer screening in PEH. Methods: All patients presenting for care from January 1, 2014 onward at a hospital system spanning five counties in a populous Midwestern state were screened for homelessness. Homelessness was identified by two criteria: presence of the Z-code for homelessness (Z59) in the patient’s electronic medical record, and/or patient’s address on record listed as an address matching that of a regional homeless shelter, transitional housing, or “homeless.” Identified PEH were maintained in a prospective registry. For each female PEH in the screening age range, billing data for completed breast cancer screening mammography performed in the previous five years (1/1/17-12/31/21) were extracted (CPT codes 77063, 77067). Data were also extracted for a cohort of non-PEH patients eligible for screening. Demographic and clinical data were extracted for all patients. This study was approved by the hospital system’s IRB. Results: A total of 3,474 female (biological sex) PEH were identified, with 1,320 eligible for screening mammography (alive and between the ages of 40 and 79) in the study timeframe. The median age was 53.5 years old; 44% were Black, 48% White, 8.5% unknown/other race, and 3% Hispanic ethnicity. 28% of PEH were uninsured, and 67% had government insurance; 66% had an assigned primary care physician (PCP). Of PEH eligible for screening mammography, 237 (18%) had at least one screening mammogram during this five-year interval (2017, 2.2%; 2018, 4.3%; 2019, 3.6%; 2020, 3.7%; 2021, 4.3%). In a cohort of 6,240 non-PEH eligible for screening over the same timeframe, the screening mammography rate was 32%, which was significantly higher than the screening rate for PEH (p < 0.00001). Compared to PEH who did not undergo screening mammography, PEH who underwent screening mammography were more likely to have an assigned PCP (90% vs 38%, p < 0.00001), to be a non-current tobacco user (56% vs 35%, p < 0.00001), and to be a non-current illicit drug user (84 % vs 68%, p = 0.0015). PEH who underwent screening mammography were significantly less likely to be uninsured (12% vs 31%, p < 0.00001). Conclusions: In the largest study of its kind to date, we identified low rates of breast cancer screening in female PEH. Interventions to increase breast cancer screening in this vulnerable population are urgently needed and may include increased access to PCPs, tobacco and drug cessation programs, and provision of health insurance.

Background Dexmedetomidine (DEX) withdrawal syndrome has been reported in the pediatric population, but literature describing DEX withdrawal in critically ill adults is limited. The purpose of this study was to determine the incidence of DEX withdrawal in adult patients and to identify factors associated with DEX withdrawal syndrome. Methods A retrospective chart review was performed in the adult intensive care units of two tertiary medical centers. Eligible patients were at least 18 years of age and received DEX for 24 h or more. Patients were excluded if they presented with a primary neurologic diagnosis, had a history of substance abuse, or received any other α2-agonists 24 h before discontinuation of DEX. The primary outcome was the percentage of patients who developed withdrawal as defined by the presence of two or more symptoms (tachycardia, hypertension, vomiting, agitation) within the 24 h following DEX discontinuation. Results Of the 165 patients included, 50 patients experienced withdrawal (30.3%), lasting a median of two days. The incidence of withdrawal was higher in surgical (40%) compared to medical (28%) or cardiac (32%) patients (p = 0.004). Median duration of infusion was 52.5 h (interquartile range [IQR], 37.8 to 102.8) in the withdrawal group and 52 h (IQR, 41 to 87) in the non-withdrawal group (p = 0.887). Median DEX dose was 0.56 μg/kg/h (IQR, 0.39 to 0.83) in the withdrawal group and 0.48 μg/kg/h (0.36 to 0.65) in the non-withdrawal group (p = 0.12). Weaning did not reduce the incidence of withdrawal as compared to abrupt discontinuation (p = 0.68). The withdrawal group was more likely to have concomitantly discontinued opioids (54% vs 12.2%) and benzodiazepines (36% vs 0%) at the time of DEX discontinuation compared to the non-withdrawal group (p = 0.004). Conclusion Development of DEX-associated withdrawal occurred in approximately 30% of adult patients, comparable to rates reported in pediatric literature. There appeared to be no correlation between dose, exposure, and weaning in the occurrence of withdrawal, but concomitant discontinuation of opioids or benzodiazepines as well as ICU admission type could highlight cases requiring closer monitoring.

Introduction Considering the specific set of gastrointestinal endoscopy practitioners, it is witnessed that the number of patients forelective procedures are being deferred by the patients amid various concerns ranging from financial constraint to the fear of infection from the dreaded coronavirus. With Routine endoscopy procedures recommended to be safely postponed, the impact on the practice of Gastrointestinal Endoscopists shall be magnified. Assessment and Strategy The article discusses impact and remedial actions that may be taken by Gastrointestinal Endoscopists, which classified into:- Anindependent practitioner- A consultant- An employeeThe article further touches upon the difficulties that might be envisaged by the Gastrointestinal Endoscopists, and obtain a financial understanding of what could potentially lead to an existential crisis?Those with cash reserves sit in a pleasant position i.e. they can buy assets at an attractive price, experiment with new ideas, research and development, etc. It is imperative in these times to understand the uncertainty cast on operations of Gastrointestinal Endoscopists and prepare a response plan for coming out of this economic crisis. A roadmap also has been devised which provides a possible outline of a plan that can be implemented for handling the economic crisis.It is also important to answer these two questions:1. Who do I want to be during the crisis?2. Who do I want to be when this is over?