Neural Transformers for Intraductal Papillary Mucosal Neoplasms (IPMN) Classification in MRI images

Early detection of precancerous cysts or neoplasms, i.e., Intraductal Papillary Mucosal Neoplasms (IPMN), in pancreas is a challenging and complex task, and it may lead to a more favourable outcome. Once detected, grading IPMNs accurately is also necessary, since low-risk IPMNs can be under surveillance program, while high-risk IPMNs have to be surgically resected before they turn into cancer. Current standards (Fukuoka and others) for IPMN classification show significant intra- and inter-operator variability, beside being error-prone, making a proper diagnosis unreliable. The established progress in artificial intelligence, through the deep learning paradigm, may provide a key tool for an effective support to medical decision for pancreatic cancer. In this work, we follow this trend, by proposing a novel AI-based IPMN classifier that leverages the recent success of transformer networks in generalizing across a wide variety of tasks, including vision ones. We specifically show that our transformer-based model exploits pre-training better than standard convolutional neural networks, thus supporting the sought architectural universalism of transformers in vision, including the medical image domain and it allows for a better interpretation of the obtained results.

Economics of timed artificial insemination with unsorted or sexed semen in a high-producing, pasture-based dairy production system

This study used a stochastic simulation model to estimate the potential economic benefit of using timed artificial insemination (TAI) in combination with conventional unsorted (TCONV) and sexed (TSEX) semen in heifers only (TCONV-H, TSEX-H) and in both heifers and lactating cows (TCONV-HC, TSEX-HC) in a high-producing, pasture-based production system. The scenarios were compared with a conventional reproductive policy (CONV) in which heifers and cows were inseminated with conventional unsorted semen after estrus detection. Sensitivity analysis was also used to estimate the effect of hormone costs from TAI use on the profitability of each program relative to CONV. The mean annual (± standard deviation) profit advantage (ΔPROF) over CONV for TCONV-H, TCONV-HC, TSEX-H, and TSEX-HC scenarios were €3.90/cow ± 4.65, €34.11/cow ± 25.69, €13.96/cow ± 6.83, and €41.52/cow ± 42.86, respectively. Combined application of both technologies was shown to return a greater annual ΔPROF on average compared with that achievable from TAI alone. However, the risk of not returning a positive annual ΔPROF varied across the scenarios with higher risk in TCONV-H and TSEX-HC. Specifically, TCONV-H and TSEX-HC had a 24 and 18% chance, respectively, of not returning a positive annual ΔPROF. Sensitivity analysis showed that when hormone costs increased by €10/cow TCONV-H and TSEX-HC had a 38 and 23% chance, respectively, of not returning a positive annual ΔPROF. The range in ΔPROF for TCONV policies was most sensitive to the TAI pregnancy rate and TSEX policies were most sensitive to the relative fertility achieved with sexed compared with unsorted semen. This study has shown TAI and sexed semen are complementary technologies that can increase genetic gain and profitability in a pasture-based, dairy production system.

Differences in obstetrical care and outcomes associated with the proportion of the obstetrician's shift completed

BACKGROUND

Understanding and improving obstetrical quality and safety is an important goal of professional societies, and many interventions such as checklists, safety bundles, educational interventions, or other culture changes have been implemented to improve the quality of care provided to obstetrical patients. Although many factors contribute to delivery decisions, a reduced workload has addressed how provider issues such as fatigue or behaviors surrounding impending shift changes may influence the delivery mode and outcomes.

OBJECTIVE

The objective was to assess whether intrapartum obstetrical interventions and adverse outcomes differ based on the temporal proximity of the delivery to the attending's shift change.

STUDY DESIGN

This was a secondary analysis from a multicenter obstetrical cohort in which all patients with cephalic, singleton gestations who attempted vaginal birth were eligible for inclusion. The primary exposure used to quantify the relationship between the proximity of the provider to their shift change and a delivery intervention was the ratio of time from the most recent attending shift change to vaginal delivery or decision for cesarean delivery to the total length of the shift. Ratios were used to represent the proportion of time completed in the shift by normalizing for varying shift lengths. A sensitivity analysis restricted to patients who were delivered by physicians working 12-hour shifts was performed. Outcomes chosen included cesarean delivery, episiotomy, third- or fourth-degree perineal laceration, 5-minute Apgar score of <4, and neonatal intensive care unit admission. Chi-squared tests were used to evaluate outcomes based on the proportion of the attending's shift completed. Adjusted and unadjusted logistic models fitting a cubic spline (when indicated) were used to determine whether the frequency of outcomes throughout the shift occurred in a statistically significant, nonlinear pattern RESULTS: Of the 82,851 patients eligible for inclusion, 47,262 (57%) had ratio data available and constituted the analyzable sample. Deliveries were evenly distributed throughout shifts, with 50.6% taking place in the first half of shifts. There were no statistically significant differences in the frequency of cesarean delivery, episiotomy, third- or fourth-degree perineal lacerations, or 5-minute Apgar scores of <4 based on the proportion of the shift completed. The findings were unchanged when evaluated with a cubic spline in unadjusted and adjusted logistic models. Sensitivity analyses performed on the 22.2% of patients who were delivered by a physician completing a 12-hour shift showed similar findings. There was a small increase in the frequency of neonatal intensive care unit admissions with a greater proportion of the shift completed (adjusted P=.009), but the findings did not persist in the sensitivity analysis.

CONCLUSION

Clinically significant differences in obstetrical interventions and outcomes do not seem to exist based on the temporal proximity to the attending physician's shift change. Future work should attempt to directly study unit culture and provider fatigue to further investigate opportunities to improve obstetrical quality of care, and additional studies are needed to corroborate these findings in community settings.

Effects of herd fertility on the economics of sexed semen in a high-producing, pasture-based dairy production system

This study used a stochastic simulation model to estimate the potential economic benefit of using sexed semen in heifers only and in heifers and lactating cows in a high-producing, pasture-based system under 3 fertility scenarios. Three breeding strategies were modeled: (1) only heifers inseminated with sexed semen and cows inseminated with conventional unsexed semen (SSH); (2) both heifers and cows inseminated with sexed semen (SSHC); and (3) a reference scenario in which all females were inseminated with conventional, unsexed semen (CONV). Each scenario was evaluated under 3 herd fertility states: high (HF), medium (MF), and low (LF), which, under the reference scenario, corresponded to herd replacement rates of 21, 25, and 31%, respectively. The model estimated the economic profit, including the net present value of the genetic gain from selection intensity. The economic return from adoption of sexed semen strategies declined, with reduced levels of baseline herd fertility turning negative in the LF state. The mean (±SD) sexed semen advantage (SSA) per cow for HF-SSH, MF-SSH, and LF-SSH scenarios were €30.61 ± 8.98, €27.45 ± 7.19, and €14.69 ± 11.06, respectively. However, the SSA per cow for HF-SSHC, MF-SSHC, and LF-SSHC scenarios were €49.14 ± 15.43, €18.46 ± 30.08, and -€19.30 ± 57.11. The range in economic profit for SSA for SSH was most sensitive to calf prices in HF-SSH and the pregnancy rate of sexed semen as a percentage of conventional unsorted semen in MF-SSH and LF-SSH. The range in economic profit for SSA for SSHC scenarios was most sensitive to the pregnancy rate of sexed semen as a percentage of conventional unsorted semen in HF-SSHC, MF-SSHC, and LF-SSHC. This study highlights the effect of baseline herd fertility state on the financial advantage of adopting sexed semen in a pasture-based dairy production system.

Acceptability, safety, and patterns of use of oral tenofovir disoproxil fumarate and emtricitabine for HIV pre-exposure prophylaxis in South African adolescents: an open-label single-arm phase 2 trial

BACKGROUND

HIV incidence among adolescents in southern Africa remains unacceptably high. Pre-exposure prophylaxis (PrEP) is an effective HIV prevention intervention but there are few data on its implementation among adolescents. We aimed to investigate the safety, feasibility, and acceptability of PrEP with oral tenofovir disoproxil fumarate and emtricitabine as part of a comprehensive HIV prevention package in an adolescent population in South Africa.

METHODS

This open-label single-arm phase 2 study (PlusPills) was done in two research clinics in Cape Town and Johannesburg, South Africa. Adolescents aged 15-19 years were recruited into the study through recruitment events and outreach in the community. Potential participants were eligible for enrolment if they reported being sexually active. Exclusion criteria were a positive test for HIV or pregnancy at enrolment, breastfeeding, or any relevant co-morbidities. Participants were given oral tenofovir disoproxil fumarate and emtricitabine for PrEP to take daily for the first 12 weeks and were then given the choice to opt in or out of PrEP use at three monthly intervals during scheduled clinic visits. Participants were invited to monthly visits for adherence counselling and HIV testing during the study period. The primary outcomes were acceptability, use, and safety of PrEP. Acceptability was measured by the proportion of participants who reported willingness to take up PrEP and remain on PrEP at each study timepoint. Use was defined as the number of participants who continued to use PrEP after the initial 12-week period until the end of the study (week 48). Safety was measured by grade 2, 3, and 4 laboratory and clinical adverse events using the Division of AIDS table for grading the severity of adult and paediatric adverse events, version 1.0. Dried blood spot samples were collected at each study time-point to measure tenofovir diphosphate concentrations. This trial is registered with ClinicalTrials.gov, NCT02213328.

FINDINGS

Between April 28, 2015, and Nov 11, 2016, 244 participants were screened, and 148 participants were enrolled (median age was 18 years; 99 participants [67%] were female) and initiated PrEP. PrEP was stopped by 26 of the 148 (18%) participants at 12 weeks. Cumulative PrEP opt-out, from the total cohort, was 41% (60 of 148 participants) at week 24 and 43% (63 of 148 participants) at week 36. PrEP was well tolerated with only minor adverse events (grade 2) thought to be related to study drug, which included headache (n=4, 3%), gastrointestinal upset (n=8, 5%), and skin rash (n=2, 1%). Two participants (1%) experienced grade 3 weight loss, which was deemed related to the study drug and resolved fully when PrEP was discontinued. Tenofovir diphosphate concentrations were detectable (>16 fmol/punch) in dried blood spot samples in 108 (92%) of 118 participants who reported PrEP use at week 12, in 74 (74%) of 100 participants at week 24, and in 22 (59%) of 37 participants by the study end at week 48.

INTERPRETATION

In this cohort of self-selected South African adolescents at risk of HIV acquisition, PrEP appears safe and tolerable in those who continued use. PrEP use decreased throughout the course of the study as the number of planned study visits declined. Adolescents in southern Africa needs access to PrEP with tailored adherence support and possibly the option for more frequent and flexible visit schedules.

FUNDING

National Institute of Allergy and Infectious Diseases of the US National Institutes of Health.

Hybrid team based learning-personalised education for teaching epidemiology in public health degrees

Background

University education in Australia and internationally involves teaching diverse students: in terms of age, life experience, previous degrees completed, and level of English competency. In Australia the Bachelors of Public Health (BPH) at The University of Wollongong, epidemiology is a core subject. It aims to equip students with the knowledge and skills needed to design, critique and interpret studies that investigate why different populations experience different health outcomes. A student-centred learning strategy; Hybrid Team Based Learning and Personalised Education teaching strategy (HTBL-PE) was created to maximise academic success. Each phase has a distinct purpose based on learning theories (e.g. TBL, Bloom's taxonomy and Vygotsky). HTBL-PE aims to systematically build students abilities; strengthen self-confidence and belief, by teaching the way students learn and harnessing the capabilities of the team to strengthen the individual.

Objectives

HTBL-PE was evaluated in spring 2019 in the BPH, where their experiences at the beginning and end of semester were measured.

Results

In total 73 out of 84 enrolled students provided data at both time-points (87%). At the end of the semester, the vast majority of students indicated their interest in epidemiology had increased (93%), critical thinking had improved (92%), and confidence as independent learners had increased (86%). Outcomes did not differ significantly by gender or across learning styles. More than two thirds of students had already applied learnings from this subject in other settings (67%). Students' final mark for this subject was significantly higher than their Weighted Average Mark (WAM) prior to the semester (+17.4, p &lt; 0.001). Average scores for the subject were &gt; 84/100 with a &lt; 0.5% failure rate.

Conclusions

HTBL-PE has positive learning outcomes; low failure rates, increased confidence in learning and themselves, increased interest in epidemiology and high overall scores in the subject.

Key messages

An effective new innovative teaching strategy resulted in a subject average score &gt; 84/100 and &lt;0.5% failure rate. The vast majority of students reported increased confidence as independent lifelong learners, critical thinking, confidence in epidemiology (knowledge, skills, and attitudes) and themselves.

1097 Sleep Disturbances, Sleep Burden, And Depressive Symptoms In US Hispanics/Latinos: Results From The HCHS/SOL Sueño Study

Introduction

While sleep disturbances and depression often co-occur, these associations are understudied among Hispanics/Latinos. We examined the associations of sleep disturbances and sleep burden with depressive symptoms among Hispanic/Latino adults in the United States.

Methods

We used cross-sectional data from the Hispanic Community Health Study/Study of Latinos Sueño Ancillary study (2010-2013). The study enrolled 2072 adults (ages 18-64; 51.5% females) who completed one-week wrist-actigraphy and sleep questionnaires. Sleep burden was operationalized as the total count of sleep disturbances across six domains (duration, efficiency, midpoint, variability, insomnia, sleepiness). Depressive symptoms were assessed using the Center for Epidemiological Studies Depression scale (CESD-10). We used weighted survey linear regressions to evaluate the association of sleep disturbances and sleep burden with elevated depressive symptoms (CESD≥10) in individual models adjusted for age, gender, site, heritage, nativity, education, income, and employment. Sensitivity analyses further adjusted for behavioral health risk factors and apnea-hypopnea index.

Results

An estimated 28.3% had elevated depressive symptoms, 8.0% had short sleep duration (&lt;6 hours of sleep), 10.9% had long sleep duration (&gt;9 hours), 45.2% exhibited a later sleep midpoint (≥4:00AM), 38.4% had high sleep timing variability (upper third tertile for between day sleep midpoint), 15.3% had insomnia (ISI≥10), 17.3% had excessive daytime sleepiness (ESS ≥10), 21.5% had poor sleep efficiency (&lt;85%), and 77.4% had a total sleep burden count of ≥0. Insomnia (ß=0.49,95%CI:.43,.56), later sleep timing (ß=0.10,95%CI:.04,.16), excessive daytime sleepiness (ß=0.19,95%CI:.11,.27), poor sleep efficiency (ß=0.09,95%CI:.02,.17), high variability (ß=0.07, 95%CI:.01,.12), and sleep burden (ß=0.11,95%CI:.09,.13), were each positively associated with elevated depressive symptoms in individual adjusted models and sensitivity analyses. Extreme sleep durations were not associated with elevated depressive symptoms.

Conclusion

Multiple inter-related sleep disturbances, particularly those pertaining to sleep quality and timing, are associated with depression and may be targets for future interventions aimed at improving mood among Hispanics/Latinos.

Support

HL127307, HL098927, HL125748

0363 Racial/Ethnic Differences in Actigraphy, Questionnaire, and Polysomnography-Measured Indicators of Sleep Health and Sleep Quality: The Multi-Ethnic Study of Atherosclerosis

Introduction

Paradigm shifts in sleep research suggest the importance of considering multi-dimensional sleep health, compared to single metrics, to promote physical and mental well-being and to understand racial/ethnic disparities in sleep.

Methods

We used data from the Multi-Ethnic Study of Atherosclerosis (MESA; n = 1,740) to create a Sleep Health Score (SHS), including questionnaire (quality, sleepiness); 7-day actigraphy (total sleep time, sleep continuity [sleep maintenance efficiency], timing consistency [midpoint variability], fragmentation, wake after sleep onset, sleep onset latency); and in-home polysomnography (%N3 sleep, %REM sleep, AHI). Sleep parameters were dichotomized based on prior literature or by healthiest quartile(s), with positive values denoting healthier sleep (e.g. Epworth scores &lt; 10). All 11 dichotomized parameters were summed to calculate the SHS (mean=4.9, sd=1.58). We used modified Poisson and linear regression for individual sleep outcomes and the SHS, respectively, adjusting for age and sex.

Results

The sample was older (mean age=68.28, sd=9.08) and 54% female. SHSs were associated with Black race (β=-0.60 [-0.78, -0.42]) and Hispanic ethnicity (β=-0.40 [-0.59, -0.21]), but not Chinese ethnicity (β=-0.16 [-0.41, 0.08]). Compared to Whites (n=644), Blacks (n=485) showed lower adjusted probability of obtaining favorable levels of: sleep continuity, fragmentation, timing consistency, alertness/sleepiness, and sleep depth (%N3 sleep). Chinese respondents (n=202) had lower probability of obtaining favorable levels of: sleep continuity and timing consistency, but higher probability of quality. Hispanics (n=409) had lower probability of obtaining healthy levels of: sleep continuity, timing consistency, and fragmentation. Neither healthy total sleep time (middle quartiles) nor AHI (&lt;30) differed by race/ethnicity.

Conclusion

Among MESA-Sleep participants, summary SHSs were lowest in Blacks, followed by Hispanics. Multiple dimensions of sleep - particularly related to continuity and timing consistency - were less favorable across race/ethnic minority groups. A summary SHS may help monitor sleep health across populations, while measurement of specific sleep components may help identify modifiable targets.

Support

Joon Chung is supported by a T-32 NIH training grant.

Liquid Chromatographic Determination of Tilmicosin in Swine Feed at 200–400 mg/kg Level: Interlaboratory Study

An analytical method for the determination of tilmicosin at 200–400 mg/kg, the intended use concentration range, was evaluated in an interlaboratory study involving 5 laboratories, including the sponsor. The interlaboratory study evaluated the intra- and interlaboratory precision and accuracy of a tilmicosin feed method. The method procedure involved extracting tilmicosin from feed by adding 200 mL extractant to 20 g feed and shaking for 1 h. The extract is filtered and analyzed by gradient liquid chromatography which separates tilmicosin from feed matrix in 30 min. Each laboratory assayed 5 replicates of fortified feed at concentrations of 0,100, 200, 400, and 600 mg/kg. The mean recovery among fortified samples ranged from 81.4 to 98.8%, with a percent coefficient of variation (%CV) ranging from 0.3 to 4.0%. For all blank control feed samples no significant interferences were observed. In addition, each laboratory assayed 5 replicates of medicated feed samples prepared at 2 levels (200 and 400 mg/kg) with either a horizontal or vertical mixer. Along with the medicated feed samples were included 5 replicates of a blank control feed. The identities of the medicated and blank control feed samples were blinded to the analysts. The results for the medicated feed samples ranged from 95.8 to 106% of label claim, with a %CV ranging from 2.1 to 6.7%.

Determination of Ethoxyquin in Feeds by Liquid Chromatography: Collaborative Study

Ethoxyquin is a chemical antioxidant used in feeds, ingredients, fats, and oils. A liquid chromatographic (LC) method for determination of ethoxyquin was developed. The method involves acetonitrile extraction of the sample and isocratic Cis reversed-phase chromatography with ammonium acetate buffer-acetonitrile as mobile phase and fluorescence detection. A collaborative study of the determination of ethoxyquin in various meals and extruded pet foods was conducted by The lams Company Research Laboratory. Eleven laboratories analyzed 16 samples (including 2 blind duplicates) consisting of 7 meat meals and 9 extruded pet foods. Sample means ranged from 0.25 to 289 ppm. Repeatability standard deviations ranged from 0.08 to 3.2 ppm, and repeatability relative standard deviations ranged from 4.5 to 32%. Reproducibility standard deviations ranged from 0.12 to 13 ppm, and reproducibility relative standard deviations ranged from 4.5 to 55%. The LC method for determination of ethoxyquin in feeds has been adopted first action by AOAC INTERNATIONAL.

Imaging of spindle cell lipoma

AIM

To review the evaluation, diagnosis, and treatment of spindle cell lipoma (SCL) with emphasis on the location of these tumours and the spectrum of magnetic resonance imaging (MRI) and computed tomography (CT) appearances.

MATERIALS AND METHODS

The MRI and CT findings of 27 histopathologically proven SCLs were evaluated retrospectively. Imaging features evaluated included margins, percentage visible fat, MRI signal characteristics, oedema, and contrast enhancement patterns.

RESULTS

Patient ages ranged from 18 to 80 years with an average age of 56.5 years. Men were affected twice as frequently as women (M=18, F=9). SCLs ranged in size from 2 to 10 cm, with an average greatest dimension of 5.5 cm. Five lesions (19%) contained no visible fat on CT or MRI, and the leading differential diagnosis of high-grade soft-tissue sarcoma diagnosis was suggested by referring surgeons. Five lesions (19%) had <50% fatty areas, nine lesions (52%) demonstrated >50% but <90% fat at MRI or CT. Only three of 25 lesions (12%) had an appearance of a typical lipoma on unenhanced MRI sequences. All SCLs that were imaged with contrast medium (n = 18) demonstrated some degree of enhancement, with eight (44%) showing marked enhancement, four (22%) showing moderate, and six (33%) minimal enhancement.

CONCLUSION

SCLs have considerably variable imaging appearances and may have minimal or no visible fat at MRI or CT. Imaging features may make it difficult to distinguish this benign tumour from a potentially higher-grade malignant tumour.

Neighborhood Alcohol Environment: Differential Effects on Hazardous Drinking and Mental Health by Sex in Persons Living with HIV (PLWH)

Despite greater mental health co-morbidities and heavier alcohol use among PLWH, few studies have examined the role of the neighborhood alcohol environment on either alcohol consumption or mental health. Utilizing cross-sectional data from a cohort study in a southern U.S. metropolitan area, we examine the association between neighborhood alcohol environments on hazardous drinking and mental health among 358 in-care PLWH (84% African American, 31% female). Multilevel models were utilized to quantify associations between neighborhood alcohol exposure on hazardous drinking and effect modification by sex. Neighborhood alcohol density was associated with hazardous drinking among men but not women. Women living in alcohol dense neighborhoods were nearly two-fold likely to report depression compared to those in less dense neighborhoods, with no association between neighborhood alcohol density and depression among men. Neighborhood alcohol environments may be an important contextual factor to consider in reducing heavy alcohol consumption and improving mental health among PLWH.

Determinants of serum 25-hydroxyvitamin D levels in healthy young adults living in the Western Cape, South Africa

Background: Vitamin D deficiency is fast emerging as a global pandemic. In South Africa few studies have been conducted to determine the vitamin D status of the healthy population.Methods: This prospective study with an analytical component investigated vitamin D status of healthy undergraduate students at two time points (winter and summer) at Stellenbosch University. Serum 25(OH)D was determined, anthropometric measurements taken and dietary vitamin D intake estimated (food-frequency questionnaire). Skin tone was determined (Fitzpatrick skin type classification), and a skin reflectometry device used to measure dermal melanin content.Results: Results of 242 students indicated a mean serum 25(OH)D of 63.80 ± 41.35 ng/ml and a high prevalence of vitamin D sufficiency (88%). Significantly more females experienced suboptimal vitamin D levels than males (18 vs. 5%; p 0.01). Participants with lighter skin tones had higher levels of 25(OH)D than those with darker skin tones (chi-square = 24.02; p = 0.02). The majority (60.74%) had a normal BMI, although there was no significant relationship between BMI and serum 25 (OH)D (Spearman’s r=–0.11; p = 0.09). Total mean dietary vitamin D intake was 7.99 ± 13.81 mcg, with 87.2% having inadequate intake ( 15 mcg). The relationship between total vitamin D intake and serum 25(OH)D was found to be significant in winter (p 0.001) and summer (p = 0.01). Serum vitamin D levels were significantly higher in the winter phase (p 0.001).Conclusions: A low prevalence of vitamin D deficiency was found amongst healthy young adults, despite low dietary vitamin D intakes. Significant relationships were found between serum 25(OH)D and gender, skin tone and vitamin D intake. Further studies need to be conducted, especially in high-risk groups, before results are applied to the greater South African public.

Volumetric laser endomicroscopy and its application to Barrett's esophagus: results from a 1,000 patient registry

Volumetric laser endomicroscopy (VLE) uses optical coherence tomography (OCT) for real-time, microscopic cross-sectional imaging. A US-based multi-center registry was constructed to prospectively collect data on patients undergoing upper endoscopy during which a VLE scan was performed. The objective of this registry was to determine usage patterns of VLE in clinical practice and to estimate quantitative and qualitative performance metrics as they are applied to Barrett's esophagus (BE) management. All procedures utilized the NvisionVLE Imaging System (NinePoint Medical, Bedford, MA) which was used by investigators to identify the tissue types present, along with focal areas of concern. Following the VLE procedure, investigators were asked to answer six key questions regarding how VLE impacted each case. Statistical analyses including neoplasia diagnostic yield improvement using VLE was performed. One thousand patients were enrolled across 18 US trial sites from August 2014 through April 2016. In patients with previously diagnosed or suspected BE (894/1000), investigators used VLE and identified areas of concern not seen on white light endoscopy (WLE) in 59% of the procedures. VLE imaging also guided tissue acquisition and treatment in 71% and 54% of procedures, respectively. VLE as an adjunct modality improved the neoplasia diagnostic yield by 55% beyond the standard of care practice. In patients with no prior history of therapy, and without visual findings from other technologies, VLE-guided tissue acquisition increased neoplasia detection over random biopsies by 700%. Registry investigators reported that VLE improved the BE management process when used as an adjunct tissue acquisition and treatment guidance tool. The ability of VLE to image large segments of the esophagus with microscopic cross-sectional detail may provide additional benefits including higher yield biopsies and more efficient tissue acquisition. Clinicaltrials.gov NCT02215291.

Cancer-Related Stigma in South Africa: Exploring Beliefs and Experiences Among Cancer Patients and the General Public

Background: Stigma refers to a distinctive, discrediting characteristic, rendering its bearer tainted or inferior by others. Definitions of stigma acknowledge the recognition of difference; and devaluation. Evidence, largely from high-income countries suggests that cancer is a stigmatized disease. Cancer-related stigma is not well-documented in South Africa, and little is known about how it impacts health-seeking behavior, treatment adherence, quality of life and psychosocial well-being in cancer patients. Limited research has explored perceptions and cultural representations of cancer but an in-depth focus on this is lacking. This context-specific information is essential for relevant, effective intervention. Aim: This study aims to increase understanding of cancer-related stigma in South Africa and the role of cultural beliefs in contributing to this. Findings will be used to inform a larger study and ultimately, interventions to address cancer-related stigma in communities in which the Cancer Association of South Africa (CANSA) is working. Methods: This qualitative study was conducted in two provinces of South Africa, KwaZulu Natal and the Western Cape and included participants from a range of cultural and racial groups. Cancer patients over 18 years were recruited through CANSA's Service Delivery teams to participate in focus groups or one to one in depth interviews. Six focus groups and 40 in depth interviews were conducted with cancer patients. Data collection focused on understanding patient experiences of cancer stigma; cognitive, emotional and behavioral responses to this; and inputs on interventions to address this. Six focus groups were also conducted with noncancer patients recruited from local communities to explore cultural perceptions of cancer and reasons for stigmatization. Audio recordings were transcribed and translated; coded using NVivo 11; and analyzed by the authors using thematic analysis. Results: Results indicated very poor knowledge of cancer both in patients and nonpatients. Overwhelmingly, findings highlight the perception of cancer as a “death sentence”, influencing patients' experiences and responses of others in numerous ways. The influence of cultural beliefs was relevant, exacerbating stigma in some cases. The location of the cancer also played a role in determining level of stigmatization. Certain body parts (associated with masculine and feminine roles) as well as more visible cancers/side-effects were more stigmatised. Conclusion: Results indicate that stigmatization is a significant factor for cancer patients in South Africa, increasing social isolation and negatively impacting quality of life. The implications of the findings for intervention development will be discussed. Education is needed but requires a different focus for different cultural groups.

Neonatal outcomes of elective early-term births after demonstrated fetal lung maturity

BACKGROUND

Studies of early-term birth after demonstrated fetal lung maturity show that respiratory and other outcomes are worse with early-term birth (37⁰-38⁶ weeks) even after demonstrated fetal lung maturity when compared with full-term birth (39⁰-40⁶ weeks). However, these studies included medically indicated births and are therefore potentially limited by confounding by the indication for delivery. Thus, the increase in adverse outcomes might be due to the indication for early-term birth rather than the early-term birth itself.

OBJECTIVE

We examined the prevalence and risks of adverse neonatal outcomes associated with early-term birth after confirmed fetal lung maturity as compared with full-term birth in the absence of indications for early delivery.

STUDY DESIGN

This is a secondary analysis of an observational study of births to 115,502 women in 25 hospitals in the United States from 2008 through 2011. Singleton nonanomalous births at 37-40 weeks with no identifiable indication for delivery were included; early-term births after positive fetal lung maturity testing were compared with full-term births. The primary outcome was a composite of death, ventilator for ≥2 days, continuous positive airway pressure, proven sepsis, pneumonia or meningitis, treated hypoglycemia, hyperbilirubinemia (phototherapy), and 5-minute Apgar <7. Logistic regression and propensity score matching (both 1:1 and 1:2) were used.

RESULTS

In all, 48,137 births met inclusion criteria; the prevalence of fetal lung maturity testing in the absence of medical or obstetric indications for early delivery was 0.52% (n = 249). There were 180 (0.37%) early-term births after confirmed pulmonary maturity and 47,957 full-term births. Women in the former group were more likely to be non-Hispanic white, smoke, have received antenatal steroids, have induction, and have a cesarean. Risks of the composite (16.1% vs 5.4%; adjusted odds ratio, 3.2; 95% confidence interval, 2.1-4.8 from logistic regression) were more frequent with elective early-term birth. Propensity scores matching confirmed the increased primary composite in elective early-term births: adjusted odds ratios, 4.3 (95% confidence interval, 1.8-10.5) for 1:1 and 3.5 (95% confidence interval, 1.8-6.5) for 1:2 matching. Among components of the primary outcome, CPAP use and hyperbilirubinemia requiring phototherapy were significantly increased. Transient tachypnea of the newborn, neonatal intensive care unit admission, and prolonged neonatal intensive care unit stay (>2 days) were also increased with early-term birth.

CONCLUSION

Even with confirmed pulmonary maturity, early-term birth in the absence of medical or obstetric indications is associated with worse neonatal respiratory and hepatic outcomes compared with full-term birth, suggesting relative immaturity of these organ systems in early-term births.

Bioeconomics of sexed semen utilization in a high-producing Holstein-Friesian dairy herd

A bioeconomic, stochastic spreadsheet model, that included calculation of the net present value of the additional value of all future descendants resulting from increased selection intensity, was developed to study the profitability of using sexed semen in a high input-high output dairy herd. Three management strategies were modeled: (1) only heifers inseminated with sex-sorted semen and cows inseminated with unsorted semen; (2) both heifers and cows inseminated with sex-sorted semen; and (3) a reference scenario, in which all breeding females were inseminated with unsorted semen. A Monte Carlo simulation (@risk software, Palisade Corp., Ithaca, NY) was run to study the sensitivity of net profit and sexed semen advantage to key input parameters. Most input parameters were given truncated normal distributions, whereas the maximum numbers of inseminations in heifers and cows were given discrete distribution functions. The calculated intensity of selection accounted for the different numbers of dairy females born for each of the 100,000 iterations. Using sexed semen (X-sorted, female) was shown to be profitable, with insemination of both heifers and cows being most profitable. The returns on assets were higher when only heifers were inseminated with sexed semen (8.54% ± 2.94; ±SD) or all females were inseminated with sexed semen (8.85% ± 2.93) than when all females were inseminated with unsexed semen (8.38% ± 2.95). The range in net profit was most sensitive to the assumed distributions of milk protein price (€/kg), milk fat price (€/kg), cow pregnancy rate, fertilizer price (€/t), and concentrate price (€/t) when unsorted semen was used. When only heifers or both heifers and cows were inseminated with sex-sorted semen, the range in net profit was most sensitive to the same distributions, with fertilizer price and cow pregnancy rate in reverse order of sensitivity. However, the range in sex-sorted semen advantage (in net profit) when only heifers were inseminated with sex-sorted semen was most sensitive to the assumed distributions of cow pregnancy rate, sex-sorted semen pregnancy rate as a percent of unsorted semen rates, standard deviation of index, additional cost of sex-sorted semen (€/dose), dairy bull calf price (€/head), and dairy heifer calf price (€/head). When both heifers and cows were inseminated, the order of importance of the last 2 inputs was reversed. This study highlights the relatively high effect of pregnancy rate and the genetic value of dairy bulls in determining the level of financial advantage from using sex-sorted semen in a dairy herd.

Muscle, Health and Costs: A Glance at their Relationship

OBJECTIVE

To assess the association between muscle parameters (mass, strength, physical performance) and activities of daily living (ADL), quality of life (QoL), and health care costs.

DESIGN

Cross-sectional Maastricht Sarcopenia Study (MaSS).

SETTING

Community-dwelling, assisted-living, residential living facility.

PARTICIPANTS

227 adults aged 65 and older.

MEASUREMENTS

Muscle mass, hand grip strength and physical performance were assessed by bio-electrical impedance, JAMAR dynamometer and the Short Physical Performance Battery, respectively. Health outcomes were measured by the Groningen Activity Restriction Scale (disability in ADL) and the EQ-5D-5L (QoL). Health care costs were calculated based on health care use in the past three months.

RESULTS

Muscle strength and physical performance showed a strong correlation with ADL, QoL, and health care costs (P<.01); for muscle mass no significant correlations were observed. Regression analyses showed that higher gait speed (OR 0.06, 95%CI 0.01-0.55) was associated with a lower probability of ADL disability. Furthermore, slower chair stand (OR 1.23, 95%CI 1.08-1.42), and more comorbidities (OR 1.58, 95%CI 1.23-2.02) were explanatory factors for higher ADL disability. Explanatory factors for QoL and costs were: more disability in ADL (OR 1.26, 95%CI 1.12-1.41 for QoL; B = 0.09, P<.01 for costs) and more comorbidities (OR 1.44, 95%CI 1.14-1.82 for QoL; B = 0.35, P<.01 for costs).

CONCLUSION

Lower gait speed and chair stand were potential drivers of disability in ADL. Disability in ADL and comorbidities were associated with QoL and health care costs in community-dwelling older adults. Improving physical performance may be a valuable target for future intervention and research to impact health burden and costs.

Preterm neonatal morbidity and mortality by gestational age: a contemporary cohort

BACKGROUND

Although preterm birth <37 weeks' gestation is the leading cause of neonatal morbidity and mortality in the United States, the majority of data regarding preterm neonatal outcomes come from older studies, and many reports have been limited to only very preterm neonates. Delineation of neonatal outcomes by delivery gestational age is needed to further clarify the continuum of mortality and morbidity frequencies among preterm neonates.

OBJECTIVE

We sought to describe the contemporary frequencies of neonatal death, neonatal morbidities, and neonatal length of stay across the spectrum of preterm gestational ages.

STUDY DESIGN

This was a secondary analysis of an obstetric cohort of 115,502 women and their neonates who were born in 25 hospitals nationwide, 2008 through 2011. All liveborn nonanomalous singleton preterm (23.0-36.9 weeks of gestation) neonates were included in this analysis. The frequency of neonatal death, major neonatal morbidity (intraventricular hemorrhage grade III/IV, seizures, hypoxic-ischemic encephalopathy, necrotizing enterocolitis stage II/III, bronchopulmonary dysplasia, persistent pulmonary hypertension), and minor neonatal morbidity (hypotension requiring treatment, intraventricular hemorrhage grade I/II, necrotizing enterocolitis stage I, respiratory distress syndrome, hyperbilirubinemia requiring treatment) were calculated by delivery gestational age; each neonate was classified once by the worst outcome for which criteria was met.

RESULTS

In all, 8334 deliveries met inclusion criteria. There were 119 (1.4%) neonatal deaths. In all, 657 (7.9%) neonates had major morbidity, 3136 (37.6%) had minor morbidity, and 4422 (53.1%) survived without any of the studied morbidities. Deaths declined rapidly with each advancing week of gestation. This decline in death was accompanied by an increase in major neonatal morbidity, which peaked at 54.8% at 25 weeks of gestation. As frequencies of death and major neonatal morbidity fell, minor neonatal morbidity increased, peaking at 81.7% at 31 weeks of gestation. The frequency of all morbidities fell >32 weeks. After 25 weeks, neonatal length of hospital stay decreased significantly with each additional completed week of pregnancy; among babies delivered from 26-32 weeks of gestation, each additional week in utero reduced the subsequent length of neonatal hospitalization by a minimum of 8 days. The median postmenstrual age at discharge nadired around 36 weeks' postmenstrual age for babies born at 31-35 weeks of gestation.

CONCLUSION

Our data show that there is a continuum of outcomes, with each additional week of gestation conferring survival benefit while reducing the length of initial hospitalization. These contemporary data can be useful for patient counseling regarding preterm outcomes.