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The purpose of this study was to examine the mortality difference and other outcome measures amongst trauma patients with residents involved in the initial management versus those that were managed by attending physicians only without resident involvement.Retrospective review. Chi-square, Fisher's tests were used to analyze the outcomes, diagnostics, and interventions using the presence of residents in the initial care of patients as an independent variable. Linear and logistic regression were used to estimate adjusted outcomes.Riverside Community Hospital, Riverside California (State-designated level I trauma center) PARTICIPANTS: Data on all trauma patients ≥18 years old that were admitted between July 1, 2018 and June 30, 2020 was collected retrospectively (total 2644 trauma patients). Trauma patients that were transferred from outside facilities were excluded from the study.There was no significant difference in mortality associated with resident involvement in both unadjusted and adjusted analysis. Patients treated by residents, however, had more comorbidities (higher CCI) and were more severely injured (higher ISS). On adjusted analysis, higher ISS was independently associated with resident presence. There was also a statistically significant increase in the use of diagnostic studies and therapeutic interventions in the resident-present group.Involvement of residents in the initial management of our trauma patient population was associated with no difference in overall mortality or morbidity, despite higher injury severity in the resident treated patient group.

To evaluate opioid analgesic utilization and predictors for adverse events during hospitalization and discharge disposition among patients admitted with osteoarthritis (OA) or spine disorders.This is a retrospective study of 12,747 adult patients admitted to 6 private community hospitals from 2017 to 2020. Opioid use during hospitalization and risk factors for hospital-acquired adverse events and non-home discharge were investigated.The total number of patients using opioids decreased, however, the daily morphine milligram equivalent (MME) use for patients on opioids increased from 2017 to 2020. Increased odds of non-home discharge were associated with older age, Medicaid, Medicare insurance, and increased lengths of stay (LOS), increased body mass index, daily MME, and electrolyte replacement in the OA group. In the spine group, older age, black race, Medicaid, Medicare, no insurance, increased Charlson comorbidity index (CCI), LOS, polypharmacy, and heparin use were associated with non-home discharge. Adverse events were associated with increased age, LOS, Medicare, polypharmacy, antiemetic, and benzodiazepine use in the OA group and increased CCI, LOS, and electrolyte replacement in the spine group.Despite the decreasing number of patients using opioids over the years, patients on opioids had an increased daily MME over the same time period.

Only a few studies are available with appropriate data on the effects of non-aspirin, non-steroidal anti-inflammatory drugs (NSAID’s) use in patients with fatty liver disease. We performed a retrospective study of 1347 patients with imaging studies that showed fatty liver disease from 2016 through 2019. Then we determined the change in validated indices using Fibrosis-4 (FIB4) and NAFLD fibrosis score (NFS). Patient’s clinical information, including NSAID’s use, was collected at baseline and then yearly. Using generalized linear model, we estimated the association between the non-aspirin NSAID’s use and change in the baseline indices. Non-aspirin NSAID’s use was found to be associated with significant lowering of FIB-4 score (0.596 units lower, p-value

The primary objective of this study was to determine if the addition of procalcitonin to the existing systemic inflammatory response syndrome (SIRS) and quick Sepsis-related Organ Failure Assessment (qSOFA) scoring systems could improve the predictability of in-hospital sepsis-related mortality. Secondarily, we sought to determine if the addition of procalcitonin could predict the likelihood of ICU admission and discharge home.This is a retrospective, single-center, observational study that looked at data from January 1, 2017 to January 1, 2019. Patients were stratified into four groups: SIRS-positive + procalcitonin2 ng/mL (pSIRS+), SIRS-positive + procalcitonin ≤2 ng/mL (pSIRS-), qSOFA-positive + procalcitonin2 ng/mL (pqSOFA+), and qSOFA-positive + procalcitonin ≤2 ng/mL (pqSOFA-).The study was conducted at a community hospital in Las Vegas, Nevada.Patients were included in the study if they were18 years of age and had hospital admission diagnosis of sepsis with at least one value of procalcitonin level.After patients which met the inclusion criteria, patients were divided into subgroups of SIRS, SIRS + procalcitonin2 ng/mL, qSOFA, qSOFA + procalcitonin2 ng/mL. Primary outcomes were in-hospital mortality and secondary outcomes were ICU admission, length of stay, and discharge to home. 933 patients were included in the study with an overall mortality rate of 21.22%, an overall ICU admission rate of 56.15%, and an overall discharge home rate of 29.58%. In those identified with a sepsis-related diagnosis code, pSIRS+ predicted an in-hospital mortality rate of 31.89% compared to pSIRS- 16.15% (P0.0001). In regards to qSOFA, the addition of procalcitonin added no statistically significant difference in predicting in-hospital mortality. pSIRS+ patients were found to have an ICU admission rate of 76.16% and a discharge home rate of 19.20% compared to pSIRS- who had 47.40% and 34.90%, respectively (P0.0001). Like in our primary outcome, our data for qSOFA was not statistically significant. Procalcitonin added utility to the SIRS scoring system in predicting sepsis-related in-hospital mortality, ICU admission, and discharge home. Procalcitonin did not add statistically significant benefit to the qSOFA scoring system in predicting sepsis-related in-hospital mortality, ICU admission, and discharge home.

The COVID-19 pandemic transformed the final year of undergraduate medical education for thousands of medical students across the globe. Out of concern for spreading SARS-CoV-2 and conserving personal protective equipment, many students experienced declines in bedside clinical exposures. The perceived competency of this class within the context of the pandemic is unclear. We designed and distributed a survey to measure the degree to which recent medical school graduates from the USA felt clinically prepared on 13 core clinical skills. Of the 1283 graduates who matched at HCA Healthcare facilities, 90% (1156) completed the survey. In this national survey, most participants felt they were competent in their clinical skills. However, approximately one out of four soon-to-be residents felt they were clinically below where they should be with regard to calling consultations, performing procedures, and performing pelvic and rectal exams. One in five felt they were below where they should be with regard to safely transitioning care. These perceived deficits in important skill sets suggest the need for evaluation and revised educational approaches in these areas, especially when traditional in-person practical skills teaching and practice are disrupted.

Only a few studies are available with appropriate data on the effects of non-aspirin, non-steroidal anti-inflammatory drugs (NSAIDs) use in patients with fatty liver disease. We performed a retrospective study of 1347 patients with imaging studies that showed fatty liver disease from 2016 through 2019. We then determined the change in validated indices using Fibrosis-4 (FIB4) and NAFLD fibrosis score (NFS). Patient clinical information, including NSAIDs use, was collected at baseline and then yearly. Using generalized linear models, we estimated the association between non-aspirin NSAIDs use and change in baseline indices. Non-aspirin NSAIDs use was found to be associated with significant lowering of FIB-4 score (0.596 units lower, p-value

Introduction Hypercalciuria is one of the reported complications in patients with primary hyperparathyroidism (PHPT). Profound hypercalciuria in the settings of renal stones is considered to be one of the indications for parathyroidectomy. However, limited data is available to describe the rate of hypercalciuria resolution following successful parathyroidectomy in patients with PHPT who had elevated pre-op 24 hour urine calcium levels. Objective To describe efficacy of successful parathyroidectomy (defined as normalization of serum calcium) in patients with primary hyperparathyroidism and hypercalciuria (defined as 24 hour urine calcium > 250 mg/24 hr) on resolution of hypercalciuria (defined as 24 hour urine calcium < 200 mg/24hr). Design: This is a retrospective study in which 51 eligible patients (with parathyroidectomies performed from August 2015 to June 2021) were chart reviewed. Twenty nine patients with complete records pre and post parathyroidectomy were included in the analysis. Setting: Single outpatient endocrinology center in Las Vegas, Nevada. Participants: A population of 29 adults aged 29 to 72 years with confirmed primary hyperparathyroidism and hypercalciuria who had a complete resolution of hypercalcemia status post parathyroidectomy. Main outcome measure: Resolution of hypercalciuria. Results 12 patients (41%) had complete resolution of hypercalciuria after parathyroidectomy. The mean age among patients with resolution was 61.4 years (SD 6.7 years) at the time of surgery vs. 50.5 (SD 11.9 years) among not responders (p= 0.008). There was no significant difference between the resolved and not resolved groups with regard to sex, history of renal stones, history of osteoporosis, location of parathyroid adenoma, pre-op PTH, calcium, and 24 hour urine calcium (p >0.05). Nephrolithiasis occured in 34% of cases. Osteoporosis occurred in 24% of cases. Average pre-op 24 hour urine calcium was 427 mg/24hr (SD 134 mg/24hr, collected on average at 5 months pre-op). Average post-op 24 hour urine calcium was 204 mg/24hr (SD 83 mg/24hr, collected on average at 22 months post-op). In a multivariate analysis, for each year of age (at the time of surgery) increase, the odds of resolution of hypercalciuria increased by 37% (p= 0.036, 95% CI [1.020-1.840]; stepwise logistic regression). For each 1 mg increase in pre-op urine calcium odds of resolution of hypercalciuria decreased by 1.7% after successful parathyroidectomy (p=0.033, 95% CI [0.967, 0.999]). Conclusions These results suggest that hypercalciuria is less likely to resolve in younger patients with PHPT after successful parathyroidectomy compared to older adults. Our data also suggests that resolution of hypercalciuria in primary hypercalciuria is inversely related to the pre-op 24 hour urine calcium levels (the higher the pre-op 24 hour urine calcium level, the less likely the hypercalciuria to resolve after successful parathyroidectomy). Presentation: Sunday, June 12, 2022 1:12 p.m. - 1:17 p.m., Monday, June 13, 2022 12:30 p.m. - 2:30 p.m.

To evaluate the clinical characteristics, hospital courses, outcomes after hospitalization, and factors associated with outcomes in patients with nontraumatic spinal cord injuries (NTSCI).Retrospective analysis.A large for-profit United States health care system.2807 inpatients with NTSCI between 2014 and 2020 were identified using International Classification of Disease codes.Demographic, clinical characteristics, hospital course, and disposition data collected from electronic health record.The mean age was 57.91 ± 16.41 years with 69.83% being male. Incomplete cervical level injury was the most common injury type, spinal stenosis was the most common diagnostic etiology and central cord syndrome was the most common clinical syndrome. The average length of stay was 9.52 ± 15.8 days, with the subgroup of 1308 (46.6%) patients who were discharged home demonstrating a shorter length of stay (6.42 ± 10.24 days). Falls were the most common hospital-acquired complication (NTSCI in this sample were predominantly incomplete cervical central SCIs. Increased CCI, ICU stay, and hospital-acquired pulmonary complications were associated with poorer outcomes after acute care hospitalization among patients with NTSCI.

Background: Approximately 30% of people with multiple sclerosis (MS) require caregiving, with unknown prevalence of abuse and neglect. To explore these issues, we created the Scale to Report Emotional Stress Signs–Multiple Sclerosis (STRESS-MS). The objective was to develop, validate, and field-test a self-report questionnaire for screening people with MS for mistreatment. Methods: We developed the STRESS-MS questionnaire and administered it to 102 adults with advanced MS-related disability and 97 primary informal caregivers, correlating responses with direct observation of mistreatment, conducting an item analysis, and evaluating validity using a Longitudinal, Expert, All Data (LEAD) panel. Results: Most STRESS-MS subscales correlated highly with criterion-standard LEAD panel evaluations of mistreatment, with strong concurrent and discriminant validity. Nearly 53% of participants with MS reported experiencing psychological abuse; 9.8%, financial exploitation; 6.9%, physical abuse; 4.9%, neglect; and 3.9%, sexual abuse. Protective factors for people with MS included social support and older age; risk factors included depression and aggressiveness. The greatest risk factor was an informal caregiver who spent 20 or more hours per week caring for the person with MS. Conclusions: The STRESS-MS questionnaire is reasonably reliable and valid for detecting caregiver mistreatment in adults with MS. Although most informal caregivers are not abusive, this study highlights an underrecognized need to detect and prevent abuse and neglect of people with MS.

BACKGROUND: While medical school graduates compete to get matched into the best residency programs, programs also compete to attract the best applicants. The applicant’s decision to rank their programs of interest is determined by several factors, many of which are not always apparent. METHOD: This study aimed to evaluate significant factors involved in an applicant’s residency program selection. A 12-question survey was sent between June 2020 and September 2020 to all first-year internal medicine residents in the United States (US) through an online national database of residencies using the Survey Monkey platform. We asked them to rank the most significant factors that enticed or deterred them from choosing a specific program. We also compared domestic with international medical graduate (IMG) average ranked responses wherein differences were evaluated using an independent two mean samples t-test. The association between outcomes and predictors was analyzed using Pearson's correlation and chi-square analysis. RESULTS: Out of 9,127 residents, 102 responded to the survey, which equaled a 1.11% response rate. The findings showed that the location, culture, and organization of a program are high-value factors for applicants. Salary, the number of cases seen, and friends near the residency location were not. There are statistically significant differences between graduates of US medical schools and IMG applicants, with the former placing higher importance on the quality of life during residency. Male and female residents also have different priorities with the latter emphasizing program culture and work environment improvement. Residents who chose programs based on academic competitiveness also placed significance on the prestige of the program (r = 0.418, P < .001), program organization/structure (r = 0.3, P = .006), fellowship match rate (r = 0.307, P = .006) and word of mouth (r = 0.520, P < .001). Residents who chose programs based on program culture also put an emphasis on the perceived happiness of the residents (r = 0.450, P = 0.001), and work-life balance (r = 0.359, P = .004). CONCLUSION: Programs can attract stronger applicants if they emphasize modifiable factors that are important to potential residents.

Background: Left Ventricular thrombus are commonly associated with systolic heart failure and acute myocardial infarctions. It is thought to be associated with an increased risk of embolic events. Current guidelines recommend the use of Warfarin for these patients. Off label use of Direct Oral Anticoagulants (DOAC) for these patients are becoming increasingly frequent as Warfarin may be inappropriate for many of these patients. DOACs have already been shown to be advantageous to warfarin in the treatment of pulmonary embolisms, deep vein thrombosis, non-valvular atrial fibrillation and is even now being looked at some instances of valvular atrial fibrillation with updated mechanical valves. Methods: This is a retrospective study on patients diagnosed with a Left Ventricular thrombus discharged on a DOAC versus warfarin looking for ischemic stroke admissions, length of stay and comparing severities of stroke using NIHSS controlling for demographic, comorbid conditions, ED and ICU admissions. Data was collected from 144 HCA hospitals. Results: There were 1704 patients in the warfarin group and 2210 in the DOAC group. There was no statistically significant difference in the odds of being readmitted for ischemic stroke by DOAC compared to warfarin (OR=1.08, [95% CI (0.82, 1.44)], p=0.582). Patients discharged on DOAC had a 81% lower odds of being readmitted within 30 days compared to warfarin (OR=0.19, 95%CI [0.05, 0.76], p = 0.019). The patients with left ventricular thrombus discharged on warfarin showed a higher average length of stay (8.21 ± 9.73) compared to DOAC (6.35 ± 7.61) (p < .001). There was no statistically significant differences in the NIHSS scores by discharge medications (warfarin vs. DOACs, p=0.340). Conclusion: Our study showed no statistically significant difference in using DOAC’s compared to warfarin, the standard of care, in preventing a stroke in patients with a left ventricular thrombus. We were also able to show a decreased readmission rate, a decreased length of stay and no difference in the severity (NIHSS) of stroke. If this data holds true many patients and physicians will chose DOACs over warfarin to improve medication compliance, dosing burden and potential adverse drug interactions.

Objectives The Coronavirus Disease 2019 pandemic has affected the health care system significantly. We compare 2019 to 2020 to evaluate how trauma encounters has changed during the pandemic. Methods Retrospective analysis using a large US health care system to compare trauma demographics, volumes, mechanisms of injury, and outcomes. Statistical analysis was used to evaluate for significant differences comparing 2019 to 2020. Results Data was collected from 88 hospitals across 18 states. 169 892 patients were included in the study. There were 6.3% fewer trauma patient encounters in 2020 compared to 2019. Mechanism of injury was significantly different between 2019 and 2020 with less blunt injuries (89.64% vs. 88.39%, P < .001), more burn injuries (1.84% vs. 2.00%, P = .021), and more penetrating injuries (8.58% vs. 9.75%, P < .001). Compared to 2019, patients in 2020 had higher mortality (2.62% vs. 2.88%, P < .001), and longer hospital LOS (3.92 ± 6.90 vs. 4.06 ± 6.56, P < .001). Conclusion The COVID-19 pandemic has significantly affected trauma patient demographics, LOS, mechanism of injury, and mortality.

BACKGROUND: Introducing graduate medical education to a non-teaching hospital has been a challenging issue due to its perceived possible negative impact on quality and cost of care. OBJECTIVE: To assess the impact of starting a new Internal Medicine (IM) residency program on the quality of care measures in a Graduate Medical Education (GME) naïve community hospital. METHODS: In a retrospective longitudinal study, we compared quality of care parameters (mortality rate, 30-day readmission rate, length of stay, case mix index and severity level) for a hospitalist group ten months before (September 2015–June 2016) and two consecutive years (July 2016–June 2018) after the implementation of an IM residency program at a community hospital. RESULTS: We compared the aggregated data from 1,295 patients before starting the residency program to 2,532 and 3,061 patients, in two consecutive academic years after initiating an IM residency. For the hospitalist group that became the teaching group, the mortality rate decreased significantly from 10 months pre- and the two post-residency periods (2%, 1% and 0.2%, p-value < 0.01), while the mortality rate among non-teaching hospitalist group patients at the same hospital remained unchanged over the same time period (p = 0.70). Length of stay decreased significantly from 10-months pre-residency to 1-year post-residency (6.23 and 5.31, p-value = 0.01). Furthermore, there were no other significant differences between the groups in terms of 30-day readmission rate, complications in care and average cost per case. CONCLUSIONS: Starting a new residency program in a non-teaching hospital improves mortality rate without significantly affecting other quality measures.

e18584 Background: In a national survey 40.9% of 4,975 adults reported delaying or avoiding care due to concerns over COVID-19. Avoidance of medical care with lockdown and a decrease in access to services carries the possibility of increased morbidity and mortality from metastatic disease due to delays in diagnosis. We examine the trends in cancer diagnosis in admitted adult patients, comparing the incidences of diagnoses before lockdowns, after lockdowns, and as restrictions were lifted. Increase in diagnoses linked with metastatic disease in the late pandemic compared to early when lockdowns occurred would show delays in care due to decreased access from the pandemic, and likely increase in morbidity and mortality. Methods: Data was retrospectively analyzed patients admitted to HCA hospitals March 2020 to December 2021, separated to three periods: pre (Mar 2019-Feb 2020), early (Mar 2020-November 2020) and late pandemic (Dec 2020-December 2021). 66,022 patients with ICD-10 codes matching malignancies of lung, small intestine, colorectal, pancreas, breast, or cervix were included and patients that additionally had ICD-10 codes for metastatic disease were identified. Patients with unlinked metastatic disease codes were removed. Population demographics including sex, race, ethnicity, insurance were also included. Results: There was a decrease in lung cancer diagnoses in the pre-pandemic period from 6,546 to early at 3,248, and an increase in the late period to 4,763. Diagnoses of metastatic disease with lung cancer decreased from 4,143 in pre-pandemic to 3,357 in late pandemic. Colorectal cancer (CRC) patients without metastatic disease pre-pandemic numbered at 5,836; 3,717 early pandemic; and 5,672, late pandemic. Diagnoses with metastatic disease decreased from 2,980 to 2,511 in the late period. Pancreatic cancer diagnoses decreased from 1,623 pre-pandemic to 1,508 late pandemic. Associated metastatic disease decreased from 1,181 pre-pandemic to 1,061 late pandemic. Breast cancer diagnoses decreased from 2,241 pre-pandemic to 1,915 late pandemic, and diagnoses with metastatic disease decreased from 2,334 to 1,711. Cervical cancer diagnoses increased from 385 pre-pandemic to 444 late pandemic and diagnoses with metastatic disease decreased from 252 to 187 in the late pandemic. Conclusions: Delays in access to care due to the pandemic are reflected in decreases of diagnoses seen. There was a decrease in lung, colorectal, pancreatic, breast, and cervical cancer diagnoses in the early pandemic period likely due to lockdown and diversion of medical effort. In the late pandemic period, diagnoses of these cancers rose, reflecting loosened restrictions. Our study is not able to determine the impact of delayed diagnosis, but likely results in increased morbidity and mortality. These effects could be mitigated in the future with uninterrupted access to telehealth and cancer screening.

Previous literature demonstrates mortality discrepancies at Level II vs. Level I centers in patients with isolated Traumatic Brain Injury (TBI). Our hypothesis is that the implementation of the 2014 version of the resources manual ("the Orange Book") is associated with an elimination of this outcome disparity.Utilizing the Trauma Quality Program Participant Use File for 2017, we compared TBI outcomes at ACS Level I vs. Level II centers.39,764 records met inclusion criteria where 25,382 (63.8%) were admitted to a Level I center. Level I patients were younger (56.4 vs.59.1 years, p 0.001) and less likely to have been injured in a single level fall (39.5%vs.45.5%, p 0.001). The incidence of severe TBI (11.3%vs.10.3%, p 0.001) was more common. Adjusted mortality at a Level II vs. Level I center were similar [7.8% vs. 8.4%, 0.669].Implementation of 2014 version of the ACS resources manual is associated with improved TBI associated mortality in ACS Level II centers relative to their Level I counterparts.

Prescription drug monitoring programs (PDMPs) have been implemented as tools to help identify misuse of prescription medications. There has been mixed data regarding the efficacy of PDMP, and physician attitudes towards it vary. In an inpatient psychiatric hospital, history of substance use, including prescription medications, and results of urine drug screens (UDS) are obtained during the admission interview.The aim was to determine if the substance use history and UDS are sufficient to identify substance use as compared to information obtained by Arizona's Controlled Substance Prescription Monitoring Program (CSPMP) in an inpatient setting.A prospective chart review was completed on all newly admitted patients to the behavioral units within a 30-day period to identify those that had substance use disorder. CSPMP records were checked for all subjects for patterns of misuse. The test results were not normally distributed, so non-parametric tests were chosen for analyses.Of the 220 patients admitted, 127 patients had a substance use diagnosis. Out of the 127 patients, 67(30.5 %) were diagnosed with either opioid, benzodiazepine or amphetamine and stimulant use disorder. Of the 125 (56.8%) patients who had a substance use disorder, the substance abuse diagnosis had been made by the psychiatrist in the medical chart. CSPMP identified only 2 (0.8%) additional patients that were missed during the intake.The CSPMP provided little benefit to improving substance abuse detection when compared with the clinical interview and UDS results. This is attributed to the comprehensive evaluation done during the intake.

Purpose Point-of-care ultrasound (POCUS) is integral to the practice of emergency medicine (EM). Furthermore, EM-performed POCUS (EM-POCUS) offers consultants the opportunity to avoid delays in care due to wait times for confirmatory imaging studies. This study is the first to describe the perception of POCUS to consulting services at a single institution where EM-POCUS is routinely performed. Methods This study was conducted as a survey distributed to residents from consultant specialties (internal medicine [IM], general surgery [GS], and obstetrics and gynecology [OB-GYN]). Survey questions aimed to describe consultant's confidence and utilization of EM-POCUS. Responses were evaluated using descriptive and comparative analysis. Results Survey responses were obtained from 27 IM (87.1%), 13 GS (100%), and 21 OB-GYN (100%) respondents. Among consultant specialties, 47.5% of respondents reported comfort with EM-POCUS. IM (81.5%) providers were significantly more likely to trust EM-POCUS as compared with OB-GYN (28.6%) and GS (7.7%) providers (p < 0.001). Confidence was further limited when consultants were unable to view POCUS images (23.8% for OB-GYN, 15.4% for GS, 55.6% for IM), but improved with EM provider level of POCUS experience and training (81% for OB-GYN, 76.9% for GS, 77.8% for IM). Overall, consultant utilization of EM-POCUS was 68.9%. Conclusions Study respondents demonstrated limited confidence and utilization of EM-POCUS in this institution. Increased understanding of EM-POCUS training and expanded image availability may improve consultant utilization. Future studies, performed nationally, should further describe the value of EM-POCUS to consultant services. © 2017 Wiley Periodicals, Inc. J Clin Ultrasound 45:408–415, 2017

Introduction: Parathyroidectomy is the standard of care for the treatment of primary hyperparathyroidism (PHP). Patients who are not surgical candidates have limited options of treatment. Percutaneous ethanol injection (PEI) for the treatment of parathyroid adenoma was first introduced in the 1980s. Main safety and efficacy data about PEI of parathyroid adenoma comes from the mayo clinic review publication of the treatment of recurrent primary hyperparathyroidism in patient with MEN1. There is no large review of the treatment of PHP. In our practice, we localize the parathyroid adenoma with ultrasound in preparation for surgery. In addition, non-surgical patients who meet the criteria for treatment of hyperparathyroidism get offered the PEI as an option of treatment. All patients who were treated with PEI had FNA from the parathyroid adenoma and PTH level was measured on the aspirate to confirm the diagnosis. Study design: This is a retrospective longitudinal cohort study of calcium and PTH level in patient with PHP after PEI treatment. All patients with PHP who received PEI treatment between 2013 and 2017 electronic chart was reviewed and data was collected about calcium, PTH level before treatment and after treatment up to one year, also side effect and complication of the procedure was collected. Patient who we do not have the 6 months data we assumed treatment failure Result: Baseline characteristic 60 patients, age 34 to 95, 49 female and 11 male, PTH average 136, calcium average 11.2 Normal calcium was achieved in 39 patients (65%) at 1 week after the PEI and 36 patients (58%) at 6 months, also at 6 months the 26 patients who continued to have elevated calcium 17 of them (65%) had improvement in calcium level after the treatment and it was below 11.2. At one year we did not have lab result for all patients, out of the 36 patients who had normal calcium at 6 months we have the result of 29 patients and they continue to have normal calcium Complications from the procedure: pain in the injection site for a few minutes after injection, 4 patients (6%) had hoarseness that resolved in two weeks in 3 patients and one patient had hoarseness that persisted after one year Conclusion: This is the largest cohort of PHP patients treated with PEI and it showed 58% normalization of calcium after treatment. The main significant complication was recurrent nerve injury which was temporary in most cases

OBJECTIVES To examine the reliability and face validity of ultrasound (US) measurements of distal femoral cartilage thickness (CT) using the infrapatellar view (IPV) with knee extension compared to the traditional suprapatellar view (SPV) with knee hyperflexion in young asymptomatic participants and patients with painful knee osteoarthritis (KOA). METHODS The IPV was obtained in an extended knee position by placing the US transducer on the patellar tendon at a 60° angle tilted toward the distal femoral condyle in 19 young adults (control group) and 70 patients with KOA. The CT was measured at the medial femoral condyle, the intercondylar notch, and the lateral femoral condyle. RESULTS The inter-rater intraclass correlation coefficient was higher for IPV-based CT measurement (range, 0.856-0.858) compared to SPV-based CT measurement (range, 0.315-0.523) among the patients with symptomatic KOA. The IPV-based CT differed significantly between the control group and the KOA group at the intercondylar notch (P

UnlabelledIn this article, we describe an image analysis strategy with improved power for tracking longitudinal amyloid-β (Aβ) PET changes and evaluating Aβ-modifying treatments.MethodsOur aims were to compare the power of template-based cerebellar, pontine, and cerebral white matter reference regions to track 24-mo florbetapir standardized uptake value (SUV) ratio (SUVR) changes; to relate those changes to 24-mo clinical declines; and to evaluate Aβ-modifying treatments in Aβ-positive (Aβ+) and Aβ-negative (Aβ-) patients with probable Alzheimer dementia (pAD), in patients with mild cognitive impairment (MCI), in cognitively normal controls (NCs), and in cognitively normal apolipoprotein E4 (APOE4) carriers and noncarriers. We used baseline and follow-up (∼24 mo) florbetapir PET scans from 332 Aβ+ and Aβ- subjects participating in the multicenter Alzheimer's Disease Neuroimaging Initiative. Each of the proposed analyses included 31 pAD patients, 187 MCI patients, and 114 NCs. Cerebral-to-white matter, cerebellar, and pontine SUVRs were characterized in terms of their longitudinal variability; their power to track longitudinal fibrillar Aβ increases in Aβ+ and Aβ- subgroups and cognitively normal APOE4 carriers and noncarriers; the sample sizes needed to detect attenuated accumulation of or clearance of fibrillar Aβ accumulation in randomized clinical trials; and their ability to relate 24-mo fibrillar Aβ increases to clinical declines.ResultsAs predicted, cerebral-to-white matter SUVR changes were significantly less variable and had significantly greater power to detect 24-mo fibrillar Aβ increases and evaluate Aβ-modifying treatment effects in Aβ+ pAD, MCI, and NC subjects and cognitively normal APOE4 carriers. They were also distinguished by the ability to detect significant associations between 24-mo Aβ increases and clinical declines.ConclusionA cerebral white matter reference region may improve the power to track longitudinal fibrillar Aβ increases, to characterize their relationship to longitudinal clinical declines, and to evaluate Aβ-modifying treatments in randomized clinical trials.

Background and aims To assess whether aspartate aminotransferase (AST), alanine aminotransferase (ALT) and alkaline phosphatase (AP) levels can predict the diagnosis of primary biliary cholangitis (PBC) or any other diagnoses and whether PBC occurs either simultaneously or independently of other liver diseases among antimitochondrial antibody (AMA)-positive patients. Methods Demographic and clinical variables were assessed in 90 AMA-positive patients with and without liver biopsies. These patients were further categorised as having a diagnosis of PBC, overlap syndrome or ‘not established with a diagnosis of PBC’. Receiver operating characteristic curves were constructed to determine the thresholds of liver enzymes that predict these three diagnoses. Results The 48 patients with liver biopsies were more frequently female and had significantly higher AP levels compared with the non-liver biopsy group. Based on liver biopsy findings, 12, 12 and 22 patients were assigned a diagnosis of PBC, overlap syndrome with autoimmune hepatitis and PBC and ‘not established diagnosis of PBC’, respectively. Seven of 12 patients classified as PBC had AP level of ˂200 IU. AST, ALT and AP levels were significant predictors of a diagnosis of overlap syndrome compared with the rest of the patients; however, these tests were not discriminatory between diagnoses of PBC and ‘not established with PBC’. Findings of fatty liver and bile duct injury on liver biopsies were not significantly associated with any liver test pattern. Conclusions As the liver test pattern did not correlate with the liver biopsy findings of PBC or other non-PBC diagnoses in AMA-positive patients at risk for other disease, a liver biopsy and/or non-invasive liver assessment along with serum liver tests should be interpreted to complete liver evaluation.

Purpose Management of the critically ill patient requires rapid assessment and differentiation. Point-of-care ultrasound (POCUS) improves diagnostic accuracy and guides resuscitation. This study sought to describe the use of critical care related POCUS amongst different specialties. Methods This study was conducted as an online 18-question survey. Survey questions queried respondent demographics, preferences for POCUS use, and barriers to implementation. Results 2735 recipients received and viewed the survey with 416 (15.2%) responses. The majority of respondents were pulmonary and critical care medicine (62.5%) and emergency medicine (19.9%) providers. Respondents obtained training through educational courses (26.5%), fellowship (23.9%), residency (21.6%), or self-guided learning (17.2%). POCUS use was common for diagnostic and procedural guidance. Emergency medicine providers were more likely to utilize POCUS to evaluate undifferentiated hypotension (98.5%, P

Background There is growing interest in the evaluation of preclinical Alzheimer's disease (AD) treatments. As a result, there is a need to identify a cognitive composite that is sensitive to track preclinical AD decline to be used as a primary endpoint in treatment trials. Methods Longitudinal data from initially cognitively normal, 70- to 85-year-old participants in three cohort studies of aging and dementia from the Rush Alzheimer's Disease Center were examined to empirically define a composite cognitive endpoint that is sensitive to detect and track cognitive decline before the onset of cognitive impairment. The mean-to-standard deviation ratios (MSDRs) of change over time were calculated in a search for the optimal combination of cognitive tests/subtests drawn from the neuropsychological battery in cognitively normal participants who subsequently progressed to clinical stages of AD during 2- and 5-year periods, using data from those who remained unimpaired during the same period to correct for aging and practice effects. Combinations that performed well were then evaluated for representation of relevant cognitive domains, robustness across individual years before diagnosis, and occurrence of selected items within top performing combinations. Results The optimal composite cognitive test score comprised seven cognitive tests/subtests with an MSDR = 0.964. By comparison, the most sensitive individual test score was Logical Memory Delayed Recall with an MSDR = 0.64. Conclusions We have identified a composite cognitive test score representing multiple cognitive domains that has improved power compared with the most sensitive single test item to track preclinical AD decline and evaluate preclinical AD treatments. We are confirming the power of the composite in independent cohorts and with other analytical approaches, which may result in refinements, have designated it as the primary endpoint in the Alzheimer's Prevention Initiative's preclinical treatment trials for individuals at high imminent risk for developing symptoms due to late-onset AD.

To identify a cognitive composite that is sensitive to tracking preclinical Alzheimer's disease decline to be used as a primary end point in treatment trials.We capitalized on longitudinal data collected from 1995 to 2010 from cognitively unimpaired presenilin 1 (PSEN1) E280A mutation carriers from the world's largest known early-onset autosomal dominant Alzheimer's disease kindred to identify a composite cognitive test with the greatest statistical power to track preclinical Alzheimer's disease decline and estimate the number of carriers age 30 years and older needed to detect a treatment effect in the Alzheimer's Prevention Initiative's (API) preclinical Alzheimer's disease treatment trial. The mean-to-standard-deviation ratios (MSDRs) of change over time were calculated in a search for the optimal combination of 1 to 7 cognitive tests/subtests drawn from the neuropsychological test battery in cognitively unimpaired mutation carriers during a 2- and 5-year follow-up period (n = 78 and 57), using data from noncarriers (n = 31 and 56) during the same time period to correct for aging and practice effects. Combinations that performed well were then evaluated for robustness across follow-up years, occurrence of selected items within top-performing combinations, and representation of relevant cognitive domains.The optimal test combination included Consortium to Establish a Registry for Alzheimer's Disease (CERAD) Word List Recall, CERAD Boston Naming Test (high frequency items), Mini-Mental State Examination (MMSE) Orientation to Time, CERAD Constructional Praxis, and Raven's Progressive Matrices (Set A), with an MSDR of 1.62. This composite is more sensitive than using either the CERAD Word List Recall (MSDR = 0.38) or the entire CERAD-Col battery (MSDR = 0.76). A sample size of 75 cognitively normal PSEN1 E280A mutation carriers aged 30 years and older per treatment arm allows for a detectable treatment effect of 29% in a 60-month trial (80% power, P = .05).We have identified a composite cognitive test score representing multiple cognitive domains that, compared to the most sensitive single test item, has improved power to track preclinical Alzheimer's disease decline in autosomal dominant Alzheimer's disease mutation carriers and to evaluate preclinical Alzheimer's disease treatments. This API composite cognitive test score will be used as the primary end point in the first API trial in cognitively unimpaired autosomal dominant Alzheimer's disease carriers within 15 years of their estimated age at clinical onset. We have independently confirmed our findings in a separate cohort of cognitively healthy older adults who progressed to the clinical stages of late-onset Alzheimer's disease, described in a separate report, and continue to refine the composite in independent cohorts and compared with other analytic approaches.

Methamphetamine abuse is rapidly becoming a significant public health problem. Methamphetamines are increasingly common cause of Heart Failure. However, the prevalence and the precipitating risk factors still remain unclear. This is a retrospective case control study based on chart review of