Associations of pre-diagnosis physical activity with treatment tolerance and treatment efficacy in breast cancer patients with neoadjuvant chemotherapy

PURPOSE

Higher pre-diagnosis physical activity (PA) is associated with lower all-cause mortality in breast cancer (BCa) patients. However, the association with pathological complete response (pCR) is unclear. We investigated the association between pre-diagnosis PA level and chemotherapy completion, dose delay, and pCR in BCa patients receiving neoadjuvant chemotherapy (NACT).

METHODS

180 stage I-III BCa patients receiving NACT (mean [SD] age of diagnosis: 60.8 [8.8] years) in the Sister Study were included. Self-reported recreational and total PA levels were converted to metabolic equivalent of task-hours per week (MET-hrs/wk). The pCR was defined as no invasive or in situ residual in breast or lymph node (ypT0 ypN0). Multivariable logistic regression analyses estimated odds ratios (ORs) and 95% confidence intervals (CIs) for treatment outcomes.

RESULTS

In this sample, 45 (25.0%) BCa patients achieved pCR. Higher pre-diagnosis recreational PA was not associated with lower likelihood of chemotherapy completion (highest vs. lowest tertile: OR = 0.87, 95% CI = 0.30-2.56; Ptrend = 0.84), greater dose delay (OR = 1.45, 95% CI = 0.54-3.92; Ptrend = 0.46), or greater odds of pCR (OR = 1.28, 95% CI = 0.49-3.34; Ptrend = 0.44). Associations were similar for pre-diagnosis total PA. Meeting the recommended level of recreational PA was not associated with pCR overall (≥ 7.5 vs. < 7.5 MET-hrs/wk: OR = 1.33, 95% CI = 0.59-3.01).

CONCLUSIONS

Although small sample size and limited information on exercise closer to time of diagnosis limit interpretation, pre-diagnosis PA was not convincingly associated with treatment tolerance or treatment efficacy in BCa patients receiving NACT. Future investigations are needed to better understand the impact of pre-diagnosis PA on BCa treatment.

Isolated non-immune mediated second-degree atrioventricular block in fetus: natural history and predictive factors for spontaneous recovery

OBJECTIVES

To uncover the clinical course of fetal isolated non-immune mediated second-degree AVB and determine the factors associated with the spontaneous recovery for fetal non-immune second-degree atrioventricular block (AVB).

METHODS

A total of 20 fetuses with isolated, non-immune mediated second-degree AVB were prospectively recruited between 2014 and 2022. These fetuses were divided into the spontaneous recovery group (n=12) and the non-spontaneous recovery group (n=8). Maternal and fetal basic characteristics, intrauterine and postnatal outcomes were compared between groups.

RESULTS

Twelve fetuses restored 1:1 atrioventricular conduction in utero and did not recur during the postnatal follow-up period. The residual eight fetuses maintained as second-degree AVB and six of them were aborted due to parental request in utero. Of the two live children with second-degree AVB, one of them progressed to complete AVB at the latest follow up at the age of 34 months, but without any symptoms, heart enlargement or dysfunction. The residual one progressed to complete AVB and was finally diagnosed with type 2 long-QT syndrome. Fetuses in the spontaneous recovery group presented with earlier gestational age at diagnosis (20.0[17.0-26.0] vs. 24.5[18.0-35.0] weeks, p=0.004) and higher atrial rate (147[130-160] vs 138.00[125.00-149.00] bpm, p=0.006) in comparison with the non-spontaneous recovery group. A cut-off value of 22.5 weeks of gestational age and 144 bpm of atrial rate at diagnosis could predict the failure of spontaneous recovery, with sensitivities of 87.5%, 75%, and specificities of 92.0%, 87.5%, respectively.

CONCLUSIONS

The outcome of fetal non-immune second-degree AVB was favorable. Earlier gestational age at diagnosis and higher atrial rate were related to spontaneous reversion for isolated non-immune-mediated second-degree AVB. However, prenatal gene test should be performed for those with persistent AVB to exclude the heritable disorders including LQTS. These findings may provide important references for clinical management and prenatal counseling. This article is protected by copyright. All rights reserved.

The safety signal detection and analysis of monoclonal antibodies against SARS-CoV-2 based on real-world evidence - the suitable selectivity for different populations

OBJECTIVE

Bebtelovimab (BEB), Tixagevimab/Cilgavimab (TIX/CIL), and Sotrovimab (SOT) are important agents against the severe acute respiratory syndrome coronavirus 2-Omicron strain. However, due to their short duration of application, little is known about their safety profiles. This research aimed to explore the safety profile of these monoclonal antibodies (mAbs) via real-world evidence databases and data mining tools.

MATERIALS AND METHODS

Safety reports were retrieved from the database of the U.S. Food and Drug Administration (FDA) Adverse Event Reporting System from April 2022 to March 2023. To detect the safety signal, the disproportionality analysis was performed using the reporting odds ratio method.

RESULTS

SOT had the greatest proportion of "skin and subcutaneous tissue disorders" and "disorders of investigations"; BEB showed significant associations with "gastrointestinal disorders" and "nervous system disorders"; TIX/CIL had the weakest correlation with "skin and subcutaneous tissue disorders" and "general disorders and administration site conditions". Furthermore, there were still other signals related to nervous system disorders, gastrointestinal disorders only caused by BEB. TIX/CIL has been reported solely to be associated with multiple types of cardiovascular disorders. As for SOT alone, signals were strongly related to infusion reactions and hypersensitivity.

CONCLUSIONS

In summary, SOT may be unsuitable for allergic patients and may lead to abnormal test results. BEB showed the highest correlations with gastrointestinal and neuropsychiatric events. In addition, its infusion reactions should also be noted. TIX/CIL can lead to a variety of cardiovascular events.

Cost Effectiveness of Zanubrutinib Versus Ibrutinib in Relapsed or Refractory Chronic Lymphocytic Leukemia

BACKGROUND

While the efficacy and safety of zanubrutinib have been established in relapsed or refractory chronic lymphocytic leukemia, the evidence on cost effectiveness is still lacking.

OBJECTIVE

We aimed to evaluate the cost effectiveness of zanubrutinib versus ibrutinib in relapsed or refractory chronic lymphocytic leukemia from the commercial payer perspective in the USA.

METHODS

A partitioned survival model was developed based on survival curves from the phase III ALPINE trial. We reconstructed patient-level data for each curve and conducted a parametric estimation to incorporate long-term clinical outcomes and treatment costs into the model. Medical costs and utilities were obtained from public data and previous cost-effectiveness studies. A discount rate of 3.0% per annum was applied and costs were adjusted to 2023 US dollars. The incremental cost-effectiveness ratio was calculated by dividing the incremental costs of zanubrutinib over ibrutinib by the incremental life-years or quality-adjusted life-years. Deterministic and probabilistic sensitivity analyses were performed to examine the robustness of the results.

RESULTS

Over a 10-year analysis period, the incremental cost-effectiveness ratio of zanubrutinib versus ibrutinib was $91,260 per life-year gained and $120,634 per quality-adjusted life-year gained, making it cost effective within a threshold of $150,000 per quality-adjusted life-year gained. The incremental cost-effectiveness ratio was most sensitive to drug acquisition costs and progression-free survival distributions, and the probability of zanubrutinib being cost effective was approximately 52.8%, with a 30.0% likelihood of dominance.

CONCLUSIONS

Zanubrutinib is likely to be cost effective versus ibrutinib in relapsed or refractory chronic lymphocytic leukemia in the USA, but the high threshold should be noted. Our findings may provide a basis for pricing strategy and reimbursement decisions for zanubrutinib.

[Propensity score matching analysis of the short-term efficacy of Kamikawa versus double- tract reconstruction in laparoscopic proximal gastric cancer surgery]

Objective: To compare the short-term efficacy of Kamikawa anastomosis and double-tract reconstruction (DTR) after proximal gastrectomy. Methods: This was a propensity score matched, retrospective, cohort study. Inclusion criteria comprised age 20-70 years, diagnosis of gastric cancer by pathological examination of preoperative endoscopic biopsies, tumor diameter ≤4 cm, and location in the upper 1/3 of the stomach (including the gastroesophageal junction), and TNM stage IA, IB, or IIA. The study cohort comprised 73 patients who had undergone laparoscopic proximal gastric cancer radical surgery in the Department of Gastroenterology, Tangdu Hospital, Air Force Medical University between June 2020 and February 2023, 19 of whom were in the Kamikawa group and 54 in the DTR group. After using R language to match the baseline characteristics of patients in a ratio of 1:2, there were 17 patients in the Kamikawa group and 34 in the DTR group. Surgery-related conditions, postoperative quality of life, and postoperative complications were compared between the two groups. Results: After propensity score matching, there were no statistically significant differences in baseline data between the two groups (P>0.05). Compared with the DTR group, the Kamikawa group had longer operative times (321.5±15.7 minutes vs. 296.8±26.1 minutes, t=32.056, P<0.001), longer anastomosis times (93.0±6.8 minutes vs. 45.3±7.7 minutes, t=56.303, P<0.001), and less bleeding (76 [54~103] mL vs.112 [82~148) mL, Z=71.536, P<0.001); these differences are statistically significant. There were no statistically significant differences between the two groups in tumor size, time to first postoperative passage of gas, postoperative hospital stay, number of lymph nodes removed, duration of lymph node dissection, or total hospitalization cost (all P>0.05). The median follow-up time was 6.1 ± 1.8 months. As to postoperative quality of life, the Kamikawa group had a lower rate of upper gastrointestinal contrast reflux than did the DTR group (0 vs. 29.4% [10/34], χ2=6.220, P=0.013); this difference is statistically significant. However, differences between the two groups in quality of life score on follow-up of 3 months and 6 months on the Gastroesophageal Reflux Disease (GERD) scale were not statistically significant (all P>0.05). The incidence of postoperative complications was 2/17 in the Kamikawa group, which is significantly lower than the 41.2% (14/34) in the DTR group (χ2=4.554, P=0.033). Conclusion: Kamikawa anastomosis and DTR are equally safe and effective procedures for reconstructing the digestive tract after proximal gastric surgery. Although Kamikawa anastomosis takes slightly longer and places higher demands on the surgical team, it is more effective at preventing postoperative reflux.

[Research progress on the role of resveratrol in wound healing]

The difficulty of wound healing in patients is a difficult problem that doctors in all clinical departments may encounter, and there is still no good solution. Resveratrol is a kind of natural active substance, which has anti-inflammatory, antioxidant, antibacterial, and angiogenesis promoting effects, and is a potential drug to promote wound healing. However, the clinical application of resveratrol is limited due to its low bioavailability. In this review, the molecular mechanism of resveratrol in promoting wound healing and its administration methods in wound treatment were reviewed to provide ideas for the redevelopment of resveratrol.

Opioid and Non-Opioid Pharmacotherapy Use for Pain Management Among Privately Insured Pediatric Patients With Cancer in the United States

BACKGROUND

This study examined the trends and patterns of opioid and non-opioid pharmacotherapy use among a large national sample of privately insured pediatric patients with cancer in the United States.

MATERIALS AND METHODS

We identified pediatric (aged < 21) patients diagnosed with central nervous system (CNS), lymphoma, gonadal, leukemia, or bone cancer from MarketScan data 2005-2019. We examined the proportion of patients who filled a prescription for the following 5 types of pharmacotherapy: opioid, anticonvulsant, non-steroidal anti-inflammatory drug (NSAID), antidepressant, and muscle relaxant during active cancer treatment. We assessed the trends and patterns in pharmacotherapy using multivariable logistic regressions.

RESULTS

Among 4174 patients included, 2979 (71%) had an opioid prescription; 746 (18%), 384 (9%), 202 (5%), and 169 (4%) had anticonvulsant, NSAID, antidepressant and muscle relaxant prescriptions, respectively. Multivariable logistic regression showed a nonlinear trend in the use of opioids among pediatric patients with cancer over time such that use slightly increased until 2012 (OR of 1.40 [95% CI, 1.12-1.73] for 2012 vs. 2006) but then decreased thereafter (OR of 0.51 [0.37-0.68] for 2018 vs. 2012). The use of anticonvulsants, NSAIDs, and muscle relaxants increased significantly linearly over time (all P < .005).

CONCLUSION

There has been a downward trend in the use of opioids in recent years among pediatric patients with cancer and an upward trend in the use of non-opioid pharmacotherapy for pain management potentially as an alternative to opioids.

Predicting operative time for metabolic and bariatric surgery using machine learning models: A retrospective observational study

BACKGROUND

Predicting operative time is essential for scheduling surgery and managing the operating room (OR). This study aimed to develop machine learning (ML) models to predict the operative time for metabolic and bariatric surgery (MBS) and to compare each model.

METHODS

We used the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database between 2016 and 2020 to develop ML models, including linear regression, random forest (RF), support vector machine, gradient-boosted tree, and XGBoost model. Patient characteristics and surgical features were included as variables in the model. We used the mean absolute error (MAE), root mean square error (RMSE), and R2 score to evaluate model performance. We identified the ten most important variables in the best-performing model using the Shapley Additive exPlanations algorithm.

RESULTS

In total, 668,723 patients were included in the study. The XGBoost model outperformed the other ML models, with the lowest RMSE and highest R2 score. RF performed better than linear regression. The relative performance of the ML algorithms remained consistent across the models, regardless of the surgery type. The surgery type and surgical approach were the most important features to predict the operative time; specifically, sleeve gastrectomy (vs. Roux-en-Y gastric bypass) and the laparoscopic approach (vs. robotic-assisted approach) were associated with a shorter operative time.

CONCLUSIONS

The XGBoost model best predicted the operative time for MBS among the ML models examined. Our findings can be useful in managing OR scheduling and in developing software tools to predict the operative times of MBS in clinical settings.

Effects of empagliflozin on progression of chronic kidney disease: a prespecified secondary analysis from the empa-kidney trial

BACKGROUND

Sodium-glucose co-transporter-2 (SGLT2) inhibitors reduce progression of chronic kidney disease and the risk of cardiovascular morbidity and mortality in a wide range of patients. However, their effects on kidney disease progression in some patients with chronic kidney disease are unclear because few clinical kidney outcomes occurred among such patients in the completed trials. In particular, some guidelines stratify their level of recommendation about who should be treated with SGLT2 inhibitors based on diabetes status and albuminuria. We aimed to assess the effects of empagliflozin on progression of chronic kidney disease both overall and among specific types of participants in the EMPA-KIDNEY trial.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA), and included individuals aged 18 years or older with an estimated glomerular filtration rate (eGFR) of 20 to less than 45 mL/min per 1·73 m2, or with an eGFR of 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher. We explored the effects of 10 mg oral empagliflozin once daily versus placebo on the annualised rate of change in estimated glomerular filtration rate (eGFR slope), a tertiary outcome. We studied the acute slope (from randomisation to 2 months) and chronic slope (from 2 months onwards) separately, using shared parameter models to estimate the latter. Analyses were done in all randomly assigned participants by intention to treat. EMPA-KIDNEY is registered at ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and then followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroups of eGFR included 2282 (34·5%) participants with an eGFR of less than 30 mL/min per 1·73 m2, 2928 (44·3%) with an eGFR of 30 to less than 45 mL/min per 1·73 m2, and 1399 (21·2%) with an eGFR 45 mL/min per 1·73 m2 or higher. Prespecified subgroups of uACR included 1328 (20·1%) with a uACR of less than 30 mg/g, 1864 (28·2%) with a uACR of 30 to 300 mg/g, and 3417 (51·7%) with a uACR of more than 300 mg/g. Overall, allocation to empagliflozin caused an acute 2·12 mL/min per 1·73 m2 (95% CI 1·83-2·41) reduction in eGFR, equivalent to a 6% (5-6) dip in the first 2 months. After this, it halved the chronic slope from -2·75 to -1·37 mL/min per 1·73 m2 per year (relative difference 50%, 95% CI 42-58). The absolute and relative benefits of empagliflozin on the magnitude of the chronic slope varied significantly depending on diabetes status and baseline levels of eGFR and uACR. In particular, the absolute difference in chronic slopes was lower in patients with lower baseline uACR, but because this group progressed more slowly than those with higher uACR, this translated to a larger relative difference in chronic slopes in this group (86% [36-136] reduction in the chronic slope among those with baseline uACR <30 mg/g compared with a 29% [19-38] reduction for those with baseline uACR ≥2000 mg/g; ptrend<0·0001).

INTERPRETATION

Empagliflozin slowed the rate of progression of chronic kidney disease among all types of participant in the EMPA-KIDNEY trial, including those with little albuminuria. Albuminuria alone should not be used to determine whether to treat with an SGLT2 inhibitor.

FUNDING

Boehringer Ingelheim and Eli Lilly.

A comparative study of in vitro dose-response estimation under extreme observations

Quantifying drug potency, which requires an accurate estimation of dose-response relationship, is essential for drug development in biomedical research and life sciences. However, the standard estimation procedure of the median-effect equation to describe the dose-response curve is vulnerable to extreme observations in common experimental data. To facilitate appropriate statistical inference, many powerful estimation tools have been developed in R, including various dose-response packages based on the nonlinear least squares method with different optimization strategies. Recently, beta regression-based methods have also been introduced in estimation of the median-effect equation. In theory, they can overcome nonnormality, heteroscedasticity, and asymmetry and accommodate flexible robust frameworks and coefficients penalization. To identify a reliable estimation method(s) to estimate dose-response curves even with extreme observations, we conducted a comparative study to review 14 different tools in R and examine their robustness and efficiency via Monte Carlo simulation under a list of comprehensive scenarios. The simulation results demonstrate that penalized beta regression using the mgcv package outperforms other methods in terms of stable, accurate estimation, and reliable uncertainty quantification.

Impact of primary kidney disease on the effects of empagliflozin in patients with chronic kidney disease: secondary analyses of the EMPA-KIDNEY trial

BACKGROUND

The EMPA-KIDNEY trial showed that empagliflozin reduced the risk of the primary composite outcome of kidney disease progression or cardiovascular death in patients with chronic kidney disease mainly through slowing progression. We aimed to assess how effects of empagliflozin might differ by primary kidney disease across its broad population.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA). Patients were eligible if their estimated glomerular filtration rate (eGFR) was 20 to less than 45 mL/min per 1·73 m2, or 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher at screening. They were randomly assigned (1:1) to 10 mg oral empagliflozin once daily or matching placebo. Effects on kidney disease progression (defined as a sustained ≥40% eGFR decline from randomisation, end-stage kidney disease, a sustained eGFR below 10 mL/min per 1·73 m2, or death from kidney failure) were assessed using prespecified Cox models, and eGFR slope analyses used shared parameter models. Subgroup comparisons were performed by including relevant interaction terms in models. EMPA-KIDNEY is registered with ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroupings by primary kidney disease included 2057 (31·1%) participants with diabetic kidney disease, 1669 (25·3%) with glomerular disease, 1445 (21·9%) with hypertensive or renovascular disease, and 1438 (21·8%) with other or unknown causes. Kidney disease progression occurred in 384 (11·6%) of 3304 patients in the empagliflozin group and 504 (15·2%) of 3305 patients in the placebo group (hazard ratio 0·71 [95% CI 0·62-0·81]), with no evidence that the relative effect size varied significantly by primary kidney disease (pheterogeneity=0·62). The between-group difference in chronic eGFR slopes (ie, from 2 months to final follow-up) was 1·37 mL/min per 1·73 m2 per year (95% CI 1·16-1·59), representing a 50% (42-58) reduction in the rate of chronic eGFR decline. This relative effect of empagliflozin on chronic eGFR slope was similar in analyses by different primary kidney diseases, including in explorations by type of glomerular disease and diabetes (p values for heterogeneity all >0·1).

INTERPRETATION

In a broad range of patients with chronic kidney disease at risk of progression, including a wide range of non-diabetic causes of chronic kidney disease, empagliflozin reduced risk of kidney disease progression. Relative effect sizes were broadly similar irrespective of the cause of primary kidney disease, suggesting that SGLT2 inhibitors should be part of a standard of care to minimise risk of kidney failure in chronic kidney disease.

FUNDING

Boehringer Ingelheim, Eli Lilly, and UK Medical Research Council.

Opioid Overdose Hospitalizations During COVID-19: The Experience of Pennsylvania

Objective

The COVID-19 pandemic placed extreme burden on hospitals, while opioid overdose is another challenging public health issue. This study aimed to examine the trends and outcomes of opioid overdose hospitalizations in Pennsylvania during 2018 to 2021.

Design

We identified opioid overdose hospitalizations in the state of Pennsylvania using the state-wide hospital discharge database (PHC4) 2018 to 2021. We examined the number of opioid overdose hospitalizations, the corresponding mortality and discharges against medical advice comparing the pre-COVID period (2018-2019) and the COVID period (2020-2021). We also assessed what patient and hospital characteristics were associated with in-hospital death or leaving against medical advice.

Results

A total of 13 446 opioid-related hospitalizations were identified in 2018 to 2021. Compared to pre-pandemic, a higher percentage of cases involving synthetics (17.0%vs 10.3%, P < .0001) were observed during COVID. After controlling for covariates, there was no significant difference in opioid overdose in-hospital deaths in the years 2020 to 2021 compared to 2018 to 2019 (OR = 0.846, 95% CI: 0.71-1.01, P = .065). The COVID period was significantly associated with more leaving against medical advice compared to years 2018 to 2019 (OR = 1.265, 95% CI: 1.11-1.44, P = .0003). Compared to commercial insurance, Medicaid insurance was associated with higher odds of both in-hospital death (OR = 1.383, 95% CI: 1.06-1.81, P = .0176) and leaving against medical advice (OR = 1.903, 95% CI: 1.56-2.33, P < .0001).

Conclusion

There were no substantial changes in the number of overall opioid overdose cases and deaths at hospitals following the outbreak of COVID-19 in Pennsylvania. This observation suggests that an increased number of patients may have succumbed to overdoses outside of hospital settings, possibly due to a higher severity of overdoses. Further, we found that patients were more likely to leave against medical advice during the COVID-19 pandemic.

Safety and efficacy of endovascular versus microsurgical treatment of unruptured wide-necked middle cerebral artery aneurysms: a propensity score-matched analysis of the NeuroVascular Quality Initiative Quality Outcomes Database Cerebral Aneurysm Registry

OBJECTIVE

Unruptured, wide-necked middle cerebral artery (WN-MCA) aneurysms have traditionally been considered ideal candidates for microsurgery (MS), although endovascular treatment (EVT) has dramatically increased in popularity with the advent of novel devices such as intrasaccular flow disruptors. The purpose of this study was to evaluate the safety and efficacy of MS versus EVT for unruptured WN-MCA aneurysms.

METHODS

The NeuroVascular Quality Initiative Quality Outcomes Database (NVQI-QOD) Cerebral Aneurysm Registry, a multiinstitutional, prospectively collected procedural database, was queried for cases of unruptured WN-MCA aneurysms treated with MS or EVT between 2015 and 2022. A wide neck was defined as an aneurysm neck ≥ 4 mm or a dome/neck ratio ≤ 2. Demographics and aneurysm characteristics were queried. Propensity score matching (PSM) was utilized to match aneurysm size, number of aneurysms treated, patient age, and aneurysm status. Safety outcomes were evaluated including intraoperative and postoperative complication rates. Aneurysm occlusion status and clinical outcomes using the modified Rankin Scale (mRS) score at discharge and the last follow-up were also assessed.

RESULTS

Of 671 unruptured MCA aneurysms, 319 were wide necked. Thirty cases were excluded, as the aneurysm had been previously treated. Two hundred eighty-nine operations (203 EVT, 86 MS) in 282 patients satisfied inclusion criteria. After PSM, there were 86 operations in each group for analysis. The mean aneurysm width was 5.0 (EVT) versus 4.9 mm (MS; p = 0.285). Safety data showed similar intraoperative (7.0% EVT vs 3.5% MS, p = 0.496) and postoperative (4.7% vs 7%, p = 0.746) complication rates. The MS patients were more likely to have complete aneurysm occlusion at discharge (90.4% vs 58.8%, p < 0.001). In a limited subset of patients (52.9%) for whom outcome data were available, the EVT patients were more likely to have an mRS score 0 at discharge (50/59 [84.7%] vs 29/54 [53.7%], p < 0.0003] and at the last follow-up (36/55 [65.5%] vs 13/36 [36.1%], p = 0.006).

CONCLUSIONS

This study describes a large, modern cohort of propensity score-matched patients who underwent treatment of unruptured WN-MCA aneurysms. Safety data on intraoperative and postoperative complication rates were similar in both treatment groups. MS was more likely to result in complete aneurysm occlusion at discharge. In a subset of patients with available outcome data, EVT was associated with better functional outcomes at discharge and the last follow-up. Given the lack of complete follow-up data and rates of retreatment, these results should be interpreted cautiously.

A Multicenter Retrospective Database Evaluation of Pediatric Patients Diagnosed With Tinea Capitis

PURPOSE

Tinea capitis is a common pediatric superficial dermatophyte infection associated with lower socioeconomic status, overcrowded environments, and poor hygiene internationally. Nevertheless, to the authors' knowledge, no studies in the United States have reported an association between tinea capitis diagnoses and diagnostic codes for social determinants of health (SDOH). The objectives of the present study were to analyze the diagnostic and treatment approach and frequency of SDOH diagnostic codes in order to assess the presence of racial disparities in the treatment of pediatric patients aged 0 to 18 years diagnosed with tinea capitis.

METHODS

This study comprised a retrospective analysis using the TriNetX electronic health record database of de-identified pediatric tinea capitis data in ambulatory and emergency settings. The data evaluated demographics, SDOH diagnostic codes, medication codes, and procedure codes.

RESULTS

Analysis of 19,677 patients (17,471 [88.8%] ambulatory and 2206 [11.2%] emergency encounters) demonstrated that a low frequency of patients had a confirmatory test for tinea capitis (ie, potassium hydroxide prep or fungal culture; 5.5%), prescription for dual therapy (25.2%), or SDOH diagnostic codes (5.5%). Patients with races classified as Black (odds ratio = 0.48, 95% confidence interval = 0.41-0.57, p < 0.001) and "other" (odds ratio = 0.52, 95% confidence interval = 0.33-0.81, p = 0.004) had a lower likelihood of having an ambulatory encounter, but a higher likelihood of receiving dual therapy.

CONCLUSIONS

This study found that diagnostic testing, dual therapy, and SDOH diagnostic codes were underutilized for pediatric patients diagnosed with tinea capitis. In addition, patients of races classified as Black and "other" were more likely to be diagnosed in emergency encounters, but had a higher likelihood of receiving dual therapy regardless of encounter type. Further research is needed to determine how to improve the management of tinea capitis and better understand its relationship with SDOH.

The Effects of Human Papillomavirus Status and Treatment on the Positive Predictive Value of Post-radiotherapy 18F-Fluorodeoxyglucose Positron Emission Tomography-Computed Tomography in Advanced Head and Neck Squamous Cell Carcinoma

AIMS

The high negative predictive value of post-chemoradiation (CRT) positron emission tomography-computed tomography (PET-CT) is well established in head and neck squamous cell cancers (HNSCC). The positive predictive value (PPV) remains under scrutiny, with increasing evidence that it is affected by several factors. The aim of this study was to assess the PPV of post-treatment PET-CT for residual nodal disease when stratified by treatment modality and tumour human papillomavirus (HPV) status.

MATERIALS AND METHODS

This was a retrospective cohort study in a tertiary oncology centre carried out between January 2013 and December 2019. Patients were radically treated with radiotherapy only/CRT for node-positive HNSCC. PET-CT nodal responses were categorised as complete, equivocal (EQR) or incomplete (ICR), and outcomes extracted from electronic records.

RESULTS

In total, 480 patients were evaluated, all had a minimum potential follow-up of 2 years, with a median of 39.2 months. The PPV of 12-week PET-CT was significantly different between HPV-positive (22.5%) and HPV-unrelated (52.7%) disease, P < 0.001. It was also significantly different between the CRT (24.8%) and radiotherapy-only (51.1%) groups, P = 0.001. The PPV of an EQR was significantly less than an ICR, irrespective of HPV status and primary treatment modality. In HPV-positive disease, the PPV of an EQR was 9.0% for the CRT group compared with 21.4% for radiotherapy only, P = 0.278. The PPV in those who achieved an ICR was 34.2% in the CRT group, significantly lower than 70.0% in the radiotherapy-only group, P = 0.03.

CONCLUSION

The PPV of 12-week PET-CT is significantly lower for HPV-positive compared with HPV-unrelated HNSCC. It is poorer in patients with HPV-positive disease treated with CRT compared with radiotherapy alone.

Prevalence of Moral Injury, Burnout, Anxiety, and Depression in Healthcare Workers 2 Years in to the COVID-19 Pandemic

ABSTRACT

COVID-19 has led to marked increases in healthcare worker distress. Studies of these phenomena are often limited to a particular element of distress or a specific subset of healthcare workers. We administered the Moral Injury Symptom Scale for Healthcare Professionals, Copenhagen Burnout Inventory, Patient Health Questionnaire-9, and Generalized Anxiety Disorder-7 via online survey to 17,000 employees of a large academic medical center between December 2021 and February 2022. A total of 1945 participants completed the survey. Across all roles, the prevalence of moral injury, burnout, depression, and anxiety were 40.9%, 35.3%-60.6%, 25.4%, and 24.8%, respectively. Furthermore, 8.1% had been bothered by thoughts that they would be better off dead or of hurting themselves for "several days" or more frequently. Healthcare workers across all roles and practice settings are experiencing unsustainable levels of distress, with 1 in 12 regularly experiencing thoughts of self-harm.

Hyperon Polarization along the Beam Direction Relative to the Second and Third Harmonic Event Planes in Isobar Collisions at sqrt[s_{NN}]=200 GeV

The polarization of Λ and Λ[over ¯] hyperons along the beam direction has been measured relative to the second and third harmonic event planes in isobar Ru+Ru and Zr+Zr collisions at sqrt[s_{NN}]=200  GeV. This is the first experimental evidence of the hyperon polarization by the triangular flow originating from the initial density fluctuations. The amplitudes of the sine modulation for the second and third harmonic results are comparable in magnitude, increase from central to peripheral collisions, and show a mild p_{T} dependence. The azimuthal angle dependence of the polarization follows the vorticity pattern expected due to elliptic and triangular anisotropic flow, and qualitatively disagrees with most hydrodynamic model calculations based on thermal vorticity and shear induced contributions. The model results based on one of existing implementations of the shear contribution lead to a correct azimuthal angle dependence, but predict centrality and p_{T} dependence that still disagree with experimental measurements. Thus, our results provide stringent constraints on the thermal vorticity and shear-induced contributions to hyperon polarization. Comparison to previous measurements at RHIC and the LHC for the second-order harmonic results shows little dependence on the collision system size and collision energy.

Evolution of point defects in pulsed-laser-melted Ge1-xSnxprobed by positron annihilation lifetime spectroscopy

Direct-band-gap Germanium-Tin alloys (Ge1-xSnx) with high carrier mobilities are promising materials for nano- and optoelectronics. The concentration of open volume defects in the alloy, such as Sn and Ge vacancies, influences the final device performance. In this article, we present an evaluation of the point defects in molecular-beam-epitaxy grown Ge1-xSnxfilms treated by post-growth nanosecond-range pulsed laser melting (PLM). Doppler broadening - variable energy positron annihilation spectroscopy and variable energy positron annihilation lifetime spectroscopy are used to investigate the defect nanostructure in the Ge1-xSnxfilms exposed to increasing laser energy density. The experimental results, supported with ATomic SUPerposition calculations, evidence that after PLM, the average size of the open volume defects increases, which represents a raise in concentration of vacancy agglomerations, but the overall defect density is reduced as a function of the PLM fluence. At the same time, the positron annihilation spectroscopy analysis provides information about dislocations and Ge vacancies decorated by Sn atoms. Moreover, it is shown that the PLM reduces the strain in the layer, while dislocations are responsible for trapping of Sn and formation of small Sn-rich-clusters.

Career satisfaction in women surgeons: A systematic review and meta-analysis

BACKGROUND

Career satisfaction among women surgeons have been well-reported in literature. This study provides a comprehensive review to understand career satisfaction and its contributory factors among female surgeons.

METHODS

PRISMA guidelines were utilized to extract studies for systematic review and meta-analysis. Outcomes assessed included surgical career satisfaction, career reconsideration, work-life balance, and gender bias and discrimination (GBD). Odds ratios were calculated comparing women to men for each outcome.

RESULTS

This study demonstrated that female surgeons were less likely to endorse overall career satisfaction (OR, 0.68; 95% CI, 0.55-0.85) and work-life balance satisfaction (OR, 0.61; 95% CI, 0.40-0.92) compared to male surgeons. It also revealed that women surgeons were more likely to report workplace GBD (OR, 13.82; 95% CI, 4.37-43.65).

CONCLUSIONS

Future interventions may be necessary to increase career and work-life balance satisfaction among women surgeons while reconciling the need to ensure they are adequately informed of the obligations of a surgical career.

Associations Between Leisure-Time Physical Activity Level and Peripheral Immune Cell Populations in the US General Population, Analysis of the National Health and Nutrition Examination Survey Data, 1999-2018

BACKGROUND

Chronic levels of inflammation are associated with higher risk of many chronic diseases. Physical activity (PA) lowers the risk of cancer, cardiovascular disease (CVD), diabetes and others. One mechanism for PA-induced protection may be through the immune system. We investigated the association between leisure-time PA and peripheral immune cell populations in a large nationally representative sample of the US general population.

METHODS

A total of 17,093 participants [mean (SE) age of 41.6 (0.3) years] of the National Health and Nutrition Examination Survey 1999-2018 were included. Self-reported leisure-time PA was converted to metabolic equivalent of task hours per week (MET-hrs/wk). White blood cell (WBC) count, WBC ratios, and platelet count were derived. Multivariable linear regression analyses were used to estimate associations between leisure-time PA level and peripheral immune cell populations. Multivariable logistic regression analyses were used to estimate associations between leisure-time PA and metrics of WBC count and neutrophil-to-lymphocyte ratio (NLR) which may predict mortality.

RESULTS

A higher leisure-time PA level was associated with a lower WBC count (> 14.0 vs. < 1.2 MET-hrs/wk adjusted mean (95% confidence interval [CI]): 7.12 (6.86, 7.38) vs. 7.38 (7.12, 7.64) 1000 cells/μL, Ptrend < 0.001) and a lower NLR (> 14.0 vs. < 1.2 MET-hrs/wk adjusted mean (95% CI) 2.04 (1.90, 2.18) vs. 2.13 (1.99, 2.28), Ptrend = 0.007). Leisure-time PA level was not associated with lymphocyte-to-monocyte ratio (LMR; Ptrend = 0.25) or platelet-to-lymphocyte ratio (PLR; Ptrend = 0.69). Compared to the lowest leisure-time PA level (< 1.2 MET-hrs/wk), the highest leisure-time PA level (≥ 14.0 MET-hrs/wk) was associated with a lower probability of a high WBC count (> 8.1 × 109 cells/L; odds ratio [OR] = 0.76, 95% CI = 0.66-0.88) and high NLR (> 2.68; OR = 0.84, 95% CI = 0.72-0.99), which may predict CVD and all-cause mortality. The highest leisure-time PA level also linked to a lower probability of a high WBC count (≥ 8.3 × 109 cells/L; OR = 0.76, 95% CI = 0.66-0.88), which may predict cancer mortality.

CONCLUSIONS

We observed an inverse association between leisure-time PA level, WBC count, and NLR, particularly for neutrophil levels. These results suggest that participants at higher levels of leisure-time PA may have lower levels of inflammation, which may be important for future chronic disease outcomes.

REAP-2: An interactive quantitative tool for robust and efficient dose-response curve estimation

REAP-2 is an interactive dose-response curve estimation tool for Robust and Efficient Assessment of drug Potency. It provides user-friendly dose-response curve estimation for in vitro studies and conducts statistical testing for model comparisons with a redesigned user interface. We also make a major update of the underlying estimation method with penalized beta regression, which demonstrates great reliability and accuracy in dose estimation and uncertainty quantification. In this note, we describe the method and implementation of REAP-2 with a highlight on potency estimation and drug comparison.

Chronic Cannabigerol as an Effective Therapeutic for Cisplatin-Induced Neuropathic Pain

Cannabigerol (CBG), derived from the cannabis plant, acts as an acute analgesic in a model of cisplatin-induced peripheral neuropathy (CIPN) in mice. There are no curative, long-lasting treatments for CIPN available to humans. We investigated the ability of chronic CBG to alleviate mechanical hypersensitivity due to CIPN in mice by measuring responses to 7 and 14 days of daily CBG. We found that CBG treatment (i.p.) for 7 and 14 consecutive days significantly reduced mechanical hypersensitivity in male and female mice with CIPN and reduced pain sensitivity up to 60-70% of baseline levels (p < 0.001 for all), 24 h after the last injection. Additionally, we found that daily treatment with CBG did not evoke tolerance and did not incur significant weight change or adverse events. The efficacy of CBG was independent of the estrous cycle phase. Therefore, chronic CBG administration can provide at least 24 h of antinociceptive effect in mice. These findings support the study of CBG as a long-lasting neuropathic pain therapy, which acts without tolerance in both males and females.

[Predictive value of plasma exosomal miR-124-3p for the risk of chronic cerebral hypoperfusion]

Objective: To investigate the predictive value of plasma exosomal microRNA (miR)-124-3p in the risk of chronic cerebral hypoperfusion (CCH). Methods: A case-control study. Thirty patients who were diagnosed with CCH (CCH group) based on cranial artery spin labeling (ASL) in the neurology outpatient clinic of Sichuan Provincial People's Hospital from March 2022 to June 2022 and 30 healthy volunteers (control group) were included. Age, gender, smoking history, alcohol consumption history, diabetes history, hypertension, hyperlipidemia history, uric acid, fasting blood glucose, homocysteine and plasma exosomal miR-124-3p expression level were compared between the two groups. Comparisons of categorical variables were analyzed by either χ2 test or Fisher's exact test. If the data of continuous variables followed a normal distribution, they were expressed as mean±standard deviation (SD) and compared by t-test for two independent samples; otherwise, the data were expressed as M(Q1, Q3), and analyzed by Mann-Whitney U test for comparison between two groups. The correlation between cerebral blood flow and exosomal miR-124-3p levels was analyzed by Pearson's correlation. Binary multifactorial logistic regression analysis was used to determine the risk factors associated with CCH, and corresponding odds ratios (OR) and 95% confidence intervals (CI) were calculated. P<0.05 was considered significant. Results: There was no significant difference in age (64±8 vs. 60±8 years old), gender (33.3% vs. 30.0%), history of smoking (20.0% vs. 3.3%), alcohol consumption (20.0% vs. 6.7%), diabetes mellitus (13.3% vs. 13.3%), hypertension (53.3% vs. 30.0%), history of hyperlipidemia (46.7% vs. 36.7%), uric acid (288±60 vs.319±67 μmol/L), and fasting glucose [4.99(4.63, 5.91) vs. 5.28(5.09, 6.05) mmol/L] and homocysteine [11.35(10.18, 13.08) vs.11.00(9.78, 13.03) μmol/L] between the CCH and control groups (P>0.05). Plasma exosomal miR-124-3p expression was significantly higher in the CCH group than in the control group [13.08 (8.59, 21.55) vs. 2.85 (1.44, 5.10), respectively; U=169.50, P<0.001]. Pearson's correlation test showed that the level of exosomal miR-124-3p was negatively correlated with cerebral blood flow in the hypoperfused region in patients with CCH (r=-0.932, P<0.001). Multi-factor logistic regression analysis showed that plasma exosomal miR-124-3p was independently associated with the risk of CCH (OR=1.169,95%CI 1.063-1.286,P=0.001). Conclusions: The expression of plasma exosomal miR-124-3p is negatively correlated with cerebral blood flow in areas of low perfusion and is an independent risk factor for CCH. Plasma exosomal miR-124-3p may thus serve as a valid biomarker for CCH risk prediction.

Retrospective Analysis of Sugammadex Use in Adolescent Females on Progestin-Containing Contraceptives

STUDY OBJECTIVE

Sugammadex, a novel neuromuscular blockade reversal agent, functions as a steroid binder postulated to decrease hormone exposure used within progestin-containing contraceptive medications. Thus, alternative non-medication contraceptive methods are recommended to prevent unplanned pregnancies. The study aims were to evaluate sugammadex use in adolescent females prescribed a progestin-containing contraceptive and positive pregnancy screening frequency. We hypothesized that sugammadex use is infrequent in this population and no pregnancy screens would be positive.

METHODS

This is a retrospective observational cohort study utilizing the TriNetX electronic health record database of female subjects aged 12-21 years reported to be prescribed sugammadex. The data collected were analyzed for demographic characteristics, International Classification of Diseases 9th and 10th edition diagnostics, medication, procedural codes, progestin-containing medication timing, and timing of pregnancy screening.

RESULTS

We included 18,686 subjects (contraceptive group, 2017 [10.8%], and no contraceptive group, 16,669 [89.2%]). Both groups had similar frequencies of pregnancy screening (contraceptive group, 54 [2.7%], vs no contraceptive group, 366 [2.2%]). Of the contraceptive group, 1 (0.05%) subject, 17 years of age, was confirmed to have a positive pregnancy screen 35 days after surgery.

CONCLUSION

We found that sugammadex may be administered to adolescent females prescribed progestin-containing contraceptives, but positive pregnancy screens are rare. Effective counseling, use of nonhormonal contraceptives 7 days after sugammadex administration, and the theoretical reproductive risks of this agent may have contributed to these findings. Continued counseling after sugammadex use in the adolescent population is recommended to avoid the occurrence of unplanned pregnancies.

[Construction of a schistosomiasis transmission risk assessment system in Wuhan City based on analytic hierarchy process]

OBJECTIVE

To construct a schistosomiasis transmission risk assessment system in Wuhan City and preliminary evaluate its application effect, so as to promote the rational allocation of schistosomiasis control resources and accelerate the progress towards schistosomiasis elimination.

METHODS

The schistosomiasis risk assessment indicators were collected through referring schistosomiasis surveillance data of Wuhan City from 2014 to 2020, literature review and expert interviews. Indicators within each criterion and sub-criterion were screened using the Delphi method, and a hierarchical structure model was created based on analytic hierarchy process. Quantitative assignment of each indicator was conducted according to relative importance, and the weight and combination weight of each criterion were calculated in each analytic hierarchy framework to create a schistosomiasis transmission risk assessment system, which was used for the schistosomiasis transmission risk assessment in 12 national schistosomiasis surveillance sites in Wuhan City.

RESULTS

A three-level schistosomiasis transmission risk assessment system was preliminarily constructed, which included a target layer, 5 criterion layers and 21 sub-criterion layers. Of all indicators in the criterion layer, transmission route had the highest weight (0.433), followed by source of Schistosoma japonicum infection (0.294); and among all indicators in the sub-criterion layer, S. japonicum infection in Oncomelania hupensis and sentinel mice had the highest combination weight (0.125), followed by prevalence of S. japonicum infection in humans (0.091) and bovines (0.053), snail control by chemical treatment (0.049), positive rate of inquiry examinations (0.048), allocation of schistosomiasis control professionals (0.045), and areas of submerged snail-infested settings (0.041). Of the 12 national schistosomiasis surveillance sites in Wuhan City, there were 5 sites with weights of > 0.8, 4 sites with weights of 0.6 to 0.8, and 3 sites with weights of < 0.6 in 2020.

CONCLUSIONS

A schistosomiasis transmission risk assessment system has been constructed based on analytic hierarchy process in Wuhan City, which may provide a evidence-based basis for health resource allocation and decision-making for schistosomiasis control.

Information-based continuous nursing on pregnant women with gestational diabetes mellitus

OBJECTIVE

Gestational diabetes mellitus (GDM) is a serious pregnancy complication, and women with undiagnosed diabetes mellitus can develop chronic hyperglycemia during pregnancy. The purpose of this study is to investigate the impact of information-based continuity of care on glucose levels, health awareness, and maternal and infant outcomes in pregnant women with GDM, thereby providing a basis for the clinical implementation of effective interventions for GDM to reduce or avoid adverse outcomes due to GDM.

PATIENTS AND METHODS

One hundred and sixty cases of pregnant women with GDM who underwent treatment in the obstetrics and gynecology department of our hospital from June 2019 to September 2021 were randomly selected as the study population and divided into the control group (n=80) and the study group (n=80). Women in the control group were received with conventional nursing intervention, and those in the study group were obtained with information-based continuity of care on the basis of the control group. Basic clinical data were collected. The levels of fasting blood glucose (FBG), 2h postprandial glucose (2hPG), knowledge of health education, treatment compliance scores, and changes in delivery outcomes were compared between the two groups. According to the maternal blood glucose control level, 160 pregnant women with GDM were divided into the better control group (143 cases) and the poor control group (17 cases). The risk factors affecting the level of maternal glycemic control in gestational diabetes were analyzed.

RESULTS

After the intervention, the levels of FBG and 2hPG were significantly lower in both groups than those before the intervention, while the levels of FBG and 2hPG in the study group were notably lower than those in the control group. The health education knowledge score and treatment compliance score after the intervention were significantly higher than those before the intervention, and the health education knowledge score and treatment compliance score in the study group were observably higher than those in the control group (p<0.01). The adverse pregnancy outcomes of pregnant women in the study group were significantly reduced compared with those in the control group (p<0.05). Logistic regression analysis showed that body mass index (BMI), dietary control, literacy, and information-based continuity of care were all influential factors for maternal glycemic control level (p<0.05). Among the influencing factors, dietary control and continuity of care had clinical value in predicting maternal glycemic control levels in gestational diabetes.

CONCLUSIONS

Continuous nursing based on informatization can effectively control the blood glucose level of pregnant women with GDM, improve the treatment compliance of pregnant women and the awareness rate of gestational diabetes knowledge so as to reduce the occurrence of adverse pregnancy outcomes and improve the health level. In addition, BMI and dietary control are independent risk factors that affect the blood glucose control level of pregnant women. Relevant intervention measures should be formulated according to the relevant influencing factors to effectively control the blood glucose level of pregnant women with GDM and improve maternal and infant outcomes.

[Comparison of the effects and safety of dydrogesterone and medroxyprogesterone acetate on endometrial hyperplasia without atypia: a randomized controlled non-inferior phase Ⅲ clinical study]

Objective: To compare the effects and safety of dydrogesterone (DG) and medroxyprogesterone acetate (MPA) on the treatment in patients with endometrial hyperplasia without atypia (EH). Methods: This was a single-center, open-label, prospective non-inferior randomized controlled phase Ⅲ trial. From February 2019 to November 2021, patients with EH admitted to the Obstetrics and Gynecology Hospital of Fudan University were recruited. Enrolled patients were stratified according to the pathological types of simple hyperplasia (SH) or complex hyperplasia (CH), and were randomised to receive MPA or DG. Untill May 14, 2022, the median follow-up time after complete response (CR) was 9.3 months (1.1-17.2 months). The primary endpoint was the 6-month CR rate (6m-CR rate). The secondary endpoints included the 3-month CR rate (3m-CR rate), adverse events rate, recurrence rate, and pregnancy rate in one year after CR. Results: (1) A total of 292 patients with EH were enrolled in the study with the median age of 39 years (31-45 years). A total of 135 SH patients were randomly assigned to MPA group (n=67) and DG group (n=68), and 157 CH patients were randomly assigned to MPA group (n=79) and DG group (n=78). (2) Among 292 patients, 205 patients enrolled into the primary endpoint analysis, including 92 SH patients and 113 CH patients, with 100 patients in MPA group and 105 in DG group, respectively. The 6m-CR rate of MPA group and DG group were 90.0% (90/100) and 88.6% (93/105) respectively, and there were no statistical significance (χ²=0.11, P=0.741), with the rate difference (RD) was -1.4% (95%CI:-9.9%-7.0%). Stratified by the pathology types, the 6m-CR rate of SH patients was 93.5% (86/92), and MPA group and DG group were respectively 91.1% (41/45) and 95.7% (45/47); and the 6m-CR rate of CH patients was 85.8% (97/113), and MPA group and DG group were 89.1% (49/55) and 82.8% (48/58) respectively. The 6m-CR rates of the two treatments had no statistical significance either (all P>0.05). A total of 194 EH patients enrolled into the secondary endpoint analysis, including 88 SH patients and 106 CH patients, and 96 patients in MPA group and 98 in DG group, respectively. The 3m-CR rate of SH patients were 87.5% (77/88), while the 3m-CR rates of MPA group and DG group were 90.7% (39/43) and 84.4% (38/45), respectively; the 3m-CR rate of CH patients was 66.0% (70/106), and MPA group and DG group had the same 3m-CR rate of 66.0% (35/53). No statistical significance was found between the two treatments both in SH and CH patients (all P>0.05). (3) The incidence of adverse events between MPA group and DG group had no statistical significance (P>0.05). (4) A total of 93 SH patients achieved CR, and the cumulative recurrence rate in one year after CR were 5.9% and 0 in MPA group and DG group, respectively. While 112 CH patients achieved CR, and the cumulative recurrence rate in one year after CR were 8.8% and 6.5% in MPA group and DG group, respectively. There were no statistical significance between two treatment groups (all P>0.05). Among the 93 SH patients, 10 patients had family planning but no pregnancy happened during the follow-up period. Among the 112 CH patients, 21 were actively preparing for pregnancy, and the pregnancy rate and live-birth rate in one year after CR in MPA group were 7/9 and 2/7, while in DG group were respectively 4/12 and 2/4, and there were no statistical significance in pregnancy rate and live-birth rate between the two treatment groups (all P>0.05). Conclusions: Compared with MPA, DG is of good efficacy and safety in treating EH. DG is a favorable alternative treatment for EH patients.

Covariate handling approaches in combination with dynamic borrowing for hybrid control studies

Borrowing data from external control has been an appealing strategy for evidence synthesis when conducting randomized controlled trials (RCTs). Often named hybrid control trials, they leverage existing control data from clinical trials or potentially real-world data (RWD), enable trial designs to allocate more patients to the novel intervention arm, and improve the efficiency or lower the cost of the primary RCT. Several methods have been established and developed to borrow external control data, among which the propensity score methods and Bayesian dynamic borrowing framework play essential roles. Noticing the unique strengths of propensity score methods and Bayesian hierarchical models, we utilize both methods in a complementary manner to analyze hybrid control studies. In this article, we review methods including covariate adjustments, propensity score matching and weighting in combination with dynamic borrowing and compare the performance of these methods through comprehensive simulations. Different degrees of covariate imbalance and confounding are examined. Our findings suggested that the conventional covariate adjustment in combination with the Bayesian commensurate prior model provides the highest power with good type I error control under the investigated settings. It has desired performance especially under scenarios of different degrees of confounding. To estimate efficacy signals in the exploratory setting, the covariate adjustment method in combination with the Bayesian commensurate prior is recommended.

Racial and Ethnic Disparities Among US Academic Dermatology Leadership and Its Influence on Resident Diversity

BACKGROUND

Diversity in medicine improves mentorship and patient care. However, dermatology is one of the least diverse specialties. We analyzed the racial distributions across leadership positions at academic dermatology programs and explored potential influences on resident racial/ethnic composition.&nbsp; Methods: A list of ACGME-accredited dermatology programs was obtained. Residency program websites, hospital websites, and publicly available data were used to ascertain race and ethnicity of academic dermatology leadership and residents. SAS version 9.4 was used to calculate descriptive statistics and associations between racial/ethnic composition of dermatologists in leadership positions and residents.&nbsp; Results: URM individuals were significantly underrepresented across both leadership (6.9%) and resident (12.0%) positions. No statistically significant correlation was found between the percent of URM leadership and URM residents.&nbsp; Conclusion: Diversity among the US population, medical students, dermatology trainees, and faculty are not reflected in departmental leadership in academic dermatology. This may influence URM recruitment into the field, retention of URM faculty and residents, and mentorship opportunities for URM dermatologists interested in leadership positions. Efforts are needed to improve disparities in representation across leadership roles in academic dermatology.&nbsp; Fritsche M, Singh P, Zhou S, et al. Racial and ethnic disparities among US Academic Dermatology Leadership and its influence on resident diversity. J Drugs Dermatol. 2023;22(7):653-656. doi:10.36849/JDD.7114.

Pyoderma Gangrenosum Is Associated With Increased Risk of Inflammatory Pouch-Related Complications: A Retrospective Cohort Study

Background

Pyoderma gangrenosum (PG) is a rare, neutrophilic dermatosis that is a well-established extraintestinal manifestation (EIM) of inflammatory bowel disease. The clinical implications of developing PG in patients with ulcerative colitis (UC) who undergo total proctocolectomy colectomy and ileal pouch anal anastomosis (TPC-IPAA) surgery remain unknown.

Methods

Study participants were selected from patients enrolled in the Carlino Family Inflammatory Bowel and Colorectal Disease Biobank between 1998 and 2021 with a pre-colectomy diagnosis of UC and who underwent TPC-IPAA surgery. A retrospective study comparing patients with PG and those without PG was performed. The outcomes measured included the development of pouchitis, pouchitis classification, presence of pouch fistula, anal fistula, anal stenosis, and pouch failure.

Results

In this study, 357 IPAA patients were included, 10 of whom suffered PG. Patients with PG and without PG had similar demographics and clinical characteristics. Both groups had similar rates of pouchitis (80% in PG patients and 64% in patients without PG, P = .504). However, IPAA patients with PG had a higher risk of developing pouch fistula (50% vs 10%, P = .002), anal fistula (40% vs 12%, P = .031), and Crohn's-like disease of the pouch (70% vs 15%, P = .003) compared to patients without PG. Patients who developed PG prior to their first episode of pouchitis were more likely to eventually experience pouch failure (odds ratio: 20.7, 95% confidence interval: 3.9, 110.7, q = 0.003 after false discovery rate adjustment).

Conclusions

Among UC patients who undergo TPC-IPAA surgery, the development of PG portends poor pouch outcomes and is predictive of pouch failure.

Southern ocean carbon and heat impact on climate

The Southern Ocean greatly contributes to the regulation of the global climate by controlling important heat and carbon exchanges between the atmosphere and the ocean. Rates of climate change on decadal timescales are therefore impacted by oceanic processes taking place in the Southern Ocean, yet too little is known about these processes. Limitations come both from the lack of observations in this extreme environment and its inherent sensitivity to intermittent processes at scales that are not well captured in current Earth system models. The Southern Ocean Carbon and Heat Impact on Climate programme was launched to address this knowledge gap, with the overall objective to understand and quantify variability of heat and carbon budgets in the Southern Ocean through an investigation of the key physical processes controlling exchanges between the atmosphere, ocean and sea ice using a combination of observational and modelling approaches. Here, we provide a brief overview of the programme, as well as a summary of some of the scientific progress achieved during its first half. Advances range from new evidence of the importance of specific processes in Southern Ocean ventilation rate (e.g. storm-induced turbulence, sea-ice meltwater fronts, wind-induced gyre circulation, dense shelf water formation and abyssal mixing) to refined descriptions of the physical changes currently ongoing in the Southern Ocean and of their link with global climate. This article is part of a discussion meeting issue 'Heat and carbon uptake in the Southern Ocean: the state of the art and future priorities'.

Measurements of the Elliptic and Triangular Azimuthal Anisotropies in Central ^{3}He+Au, d+Au and p+Au Collisions at sqrt[s_{NN}]=200 GeV

The elliptic (v_{2}) and triangular (v_{3}) azimuthal anisotropy coefficients in central ^{3}He+Au, d+Au, and p+Au collisions at sqrt[s_{NN}]=200  GeV are measured as a function of transverse momentum (p_{T}) at midrapidity (|η|<0.9), via the azimuthal angular correlation between two particles both at |η|<0.9. While the v_{2}(p_{T}) values depend on the colliding systems, the v_{3}(p_{T}) values are system independent within the uncertainties, suggesting an influence on eccentricity from subnucleonic fluctuations in these small-sized systems. These results also provide stringent constraints for the hydrodynamic modeling of these systems.

Multicenter retrospective database evaluation of Takotsubo syndrome in subjects undergoing catheter ablation for atrial fibrillation

Background

Intracardiac catheter ablation for atrial fibrillation with pulmonary vein isolation may result in Takotsubo syndrome (TS), but the frequency, predisposing factors (age, sex, mental health disorders), and outcomes are currently unknown. This study sought to assess the frequency, predisposing factors, and outcomes of subjects who underwent intracardiac catheter ablation for atrial fibrillation with pulmonary vein isolation and were diagnosed with TS.

Methods

This was a retrospective observational cohort study utilizing TriNetX® electronic health record (EHR) data. We included subjects aged older than 18 years who underwent intracardiac catheter ablation for atrial fibrillation with pulmonary vein isolation. The study population was divided into two groups (no TS diagnostic code presence and TS diagnostic code presence). We analyzed the distributions of age, sex, race, diagnostic codes, common terminology procedures (CPT), and vasoactive medication codes and examined mortality rate within 30 days.

Results

We included 69,116 subjects. Of these, 27 (0.04%) had a TS diagnostic code, the cohort was comprised mostly of females [17 (63.0%)], and 1 (3.7%) death within 30 days was reported. There were no significant differences in age and frequency of mental health disorders between those patients in TS and non-TS cohorts. Adjusting for age, sex, race, ethnicity, patient regionality, and mental health disorder diagnostic code, those patients who developed TS had a significantly higher odds of dying in 30 days after catheter ablation compared to those without TS (OR = 15.97, 95% CI: 2.10-121.55, p = .007).

Conclusions

Approximately 0.04% of subjects who underwent intracardiac catheter ablation of atrial fibrillation by pulmonary vein isolation had a subsequent diagnostic code of TS. Further study is needed to determine whether there are predisposing factors associated with the development of TS in subjects who undergo catheter ablation of atrial fibrillation by pulmonary vein isolation.

Observation of Directed Flow of Hypernuclei _{Λ}^{3}H and _{Λ}^{4}H in sqrt[s_{NN}]=3 GeV Au+Au Collisions at RHIC

We report here the first observation of directed flow (v_{1}) of the hypernuclei _{Λ}^{3}H and _{Λ}^{4}H in mid-central Au+Au collisions at sqrt[s_{NN}]=3  GeV at RHIC. These data are taken as part of the beam energy scan program carried out by the STAR experiment. From 165×10^{6} events in 5%-40% centrality, about 8400 _{Λ}^{3}H and 5200 _{Λ}^{4}H candidates are reconstructed through two- and three-body decay channels. We observe that these hypernuclei exhibit significant directed flow. Comparing to that of light nuclei, it is found that the midrapidity v_{1} slopes of _{Λ}^{3}H and _{Λ}^{4}H follow baryon number scaling, implying that the coalescence is the dominant mechanism for these hypernuclei production in the 3 GeV Au+Au collisions.

Beam Energy Dependence of Triton Production and Yield Ratio (N_{t}×N_{p}/N_{d}^{2}) in Au+Au Collisions at RHIC

We report the triton (t) production in midrapidity (|y|<0.5) Au+Au collisions at sqrt[s_{NN}]=7.7-200  GeV measured by the STAR experiment from the first phase of the beam energy scan at the Relativistic Heavy Ion Collider. The nuclear compound yield ratio (N_{t}×N_{p}/N_{d}^{2}), which is predicted to be sensitive to the fluctuation of local neutron density, is observed to decrease monotonically with increasing charged-particle multiplicity (dN_{ch}/dη) and follows a scaling behavior. The dN_{ch}/dη dependence of the yield ratio is compared to calculations from coalescence and thermal models. Enhancements in the yield ratios relative to the coalescence baseline are observed in the 0%-10% most central collisions at 19.6 and 27 GeV, with a significance of 2.3σ and 3.4σ, respectively, giving a combined significance of 4.1σ. The enhancements are not observed in peripheral collisions or model calculations without critical fluctuation, and decreases with a smaller p_{T} acceptance. The physics implications of these results on the QCD phase structure and the production mechanism of light nuclei in heavy-ion collisions are discussed.

[Application of endoscopic suturing instrument in laparoscopic gastrojejunostomy]

Objective: To investigate the safety and feasibility of using an endoscopic suturing instrument in laparoscopic gastrojejunostomy. Methods: A descriptive case series study was conducted to retrospectively analyze the clinical data of 5 patients with gastric cancer who underwent laparoscopic distal gastrectomy (Billroth II + Braun anastomosis) at Tangdu Hospital, Air Force Medical University from October 2022 to January 2023. The common opening was closed using an endoscopic suturing instrument. The indications were as follows: (1) patients aged between 18 and 80 years; (2) patients with gastric adenocarcinoma; (3) cTNM between I-III; (4) lower-third gastric cancer and radical gastrectomy is recommended; (5) no history of upper abdominal surgery (except for laparoscopic cholecystectomy). The surgery was performed as follows: A side-to-side gastrojejunostomy was performed with endoscopic linear cutter stapler. Then the common opening was closed with endoscopic suturing instrument. During suturing and closing the common opening, a vertical mattress suture was used to completely invert and close the mucosa-to-mucosa and serosa-to-serosa of the gastric and jejunum walls. After the first layer of suture was completed, the seromuscular layer was sutured from top to bottom to embed the common opening of stomach and jejunum. Results: Laparoscopic closure of the common gastrojejunal opening with endoscopic suturing instrument was successfully completed in all 5 patients. The operative time was (308.6±22.6) minutes, while the time of gastrojejunostomy was (15.4±3.1) minutes. The operative blood loss was (34.0±10.8) ml. No intraoperative or postoperative complications occurred in any of the patients. The first passage of gas occurred at (2.6±0.9) days, and the postoperative hospital stay was (7.0±1.9) days. Conclusion: The application of endoscopic suturing instrument in laparoscopic gastrojejunostomy is safe and feasible.

Gamification educational intervention improves pediatric nurses' comfort and speed drawing up code-dose epinephrine

PURPOSE

Drawing up weight-based doses of epinephrine is a vital skill for pediatric nurses; however, non-intensive care unit (ICU) nurses may not routinely perform this skill and may not be as efficient or comfortable doing so during pediatric resuscitations. This study aimed to evaluate the impact of a gamification program on non-ICU pediatric nurses' knowledge and skills regarding epinephrine for pediatric cardiac arrest.

DESIGN AND METHODS

Comfort and time to draw up three doses of epinephrine during out-of-ICU in-hospital pediatric cardiac arrest were measured pre- and post- a gamification-centered educational intervention.

RESULTS

Nursing comfort improved from 2.93 ± 1.90 to 6.68 ± 1.46 out of 10 (mean difference 3.6 +/- 2.1, p < 0.001). Overall time to draw up three doses of epinephrine decreased after the intervention by an average of 27.1 s (p = 0.019). The number of nurses who could complete the task in under 2 min improved from 23% to 59% (p = 0.031).

CONCLUSIONS

At baseline few non-ICU nurses could draw up multiple weight-based doses of epinephrine in under two minutes. A gamification simulation-based educational intervention improved pediatric non-ICU nurses' comfort and speed drawing up epinephrine.

PRACTICE IMPLICATIONS

Wide-spread implementation of gamification-centered educational initiatives could result in faster epinephrine administration and improved mortality rates from in-hospital pediatric cardiac arrest.

Measurement of Sequential ϒ Suppression in Au+Au Collisions at sqrt[s_{NN}]=200 GeV with the STAR Experiment

We report on measurements of sequential ϒ suppression in Au+Au collisions at sqrt[s_{NN}]=200  GeV with the STAR detector at the Relativistic Heavy Ion Collider (RHIC) through both the dielectron and dimuon decay channels. In the 0%-60% centrality class, the nuclear modification factors (R_{AA}), which quantify the level of yield suppression in heavy-ion collisions compared to p+p collisions, for ϒ(1S) and ϒ(2S) are 0.40±0.03(stat)±0.03(sys)±0.09(norm) and 0.26±0.08(stat)±0.02(sys)±0.06(norm), respectively, while the upper limit of the ϒ(3S) R_{AA} is 0.17 at a 95% confidence level. This provides experimental evidence that the ϒ(3S) is significantly more suppressed than the ϒ(1S) at RHIC. The level of suppression for ϒ(1S) is comparable to that observed at the much higher collision energy at the Large Hadron Collider. These results point to the creation of a medium at RHIC whose temperature is sufficiently high to strongly suppress excited ϒ states.

Posterior Averaging Information Criterion

We propose a new model selection method, named the posterior averaging information criterion, for Bayesian model assessment to minimize the risk of predicting independent future observations. The theoretical foundation is built on the Kullback-Leibler divergence to quantify the similarity between the proposed candidate model and the underlying true model. From a Bayesian perspective, our method evaluates the candidate models over the entire posterior distribution in terms of predicting a future independent observation. Without assuming that the true distribution is contained in the candidate models, the new criterion is developed by correcting the asymptotic bias of the posterior mean of the in-sample log-likelihood against out-of-sample log-likelihood, and can be generally applied even for Bayesian models with degenerate non-informative priors. Simulations in both normal and binomial settings demonstrate superior small sample performance.

Beam Energy Dependence of Fifth- and Sixth-Order Net-Proton Number Fluctuations in Au+Au Collisions at RHIC

We report the beam energy and collision centrality dependence of fifth and sixth order cumulants (C_{5}, C_{6}) and factorial cumulants (κ_{5}, κ_{6}) of net-proton and proton number distributions, from center-of-mass energy (sqrt[s_{NN}]) 3 GeV to 200 GeV Au+Au collisions at RHIC. Cumulant ratios of net-proton (taken as proxy for net-baryon) distributions generally follow the hierarchy expected from QCD thermodynamics, except for the case of collisions at 3 GeV. The measured values of C_{6}/C_{2} for 0%-40% centrality collisions show progressively negative trend with decreasing energy, while it is positive for the lowest energy studied. These observed negative signs are consistent with QCD calculations (for baryon chemical potential, μ_{B}≤110  MeV) which contains the crossover transition range. In addition, for energies above 7.7 GeV, the measured proton κ_{n}, within uncertainties, does not support the two-component (Poisson+binomial) shape of proton number distributions that would be expected from a first-order phase transition. Taken in combination, the hyperorder proton number fluctuations suggest that the structure of QCD matter at high baryon density, μ_{B}∼750  MeV at sqrt[s_{NN}]=3  GeV is starkly different from those at vanishing μ_{B}∼24  MeV at sqrt[s_{NN}]=200  GeV and higher collision energies.

Development and validation of risk prediction models for stroke and mortality among patients with type 2 diabetes in northern China

BACKGROUND

Stroke is one of the leading causes of disability and mortality in patients with type 2 diabetes mellitus (T2DM). Risk models have been developed for predicting stroke and stroke-associated mortality among patients with T2DM. Here, we evaluated risk factors of stroke for individualized prevention measures in patients with T2DM in northern China.

METHODS

In the community-based Tianjin Chronic Disease Cohort study, 58,042 patients were enrolled between January 2014 and December 2019. We used multiple imputation (MI) to impute missing variables and univariate and multivariate Cox's proportional hazard regression to screen risk factors of stroke. Furthermore, we established and validated first-ever prediction models for stroke (Model 1 and Model 2) and death from stroke (Model 3) and evaluated their performance.

RESULTS

In the derivation and validation groups, the area under the curves (AUCs) of Models 1-3 was better at 5 years than at 8 years. The Harrell's C-index for all models was above 0.7. All models had good calibration, discrimination, and clinical net benefit. Sensitivity analysis using the MI dataset indicated that all models had good and stable prediction performance.

CONCLUSION

In this study, we developed and validated first-ever risk prediction models for stroke and death from stroke in patients with T2DM, with good discrimination and calibration observed in all models. Based on lifestyle, demographic characteristics, and laboratory examination, these models could provide multidimensional management and individualized risk assessment. However, the models developed here may only be applicable to Han Chinese.

Efficacy and safety associated with immune checkpoint inhibitors in unresectable hepatocellular carcinoma: A re-analysis of a meta-analysis

We identified analytic limitations in a recent meta-analysis and re-examined the efficacy and safety associated with immune checkpoint inhibitors (ICIs) in unresectable hepatocellular carcinoma (HCC) compared with standard therapies. Our findings mostly contradict conclusions from the previous study, suggesting the need for continuing the investigation of ICIs in HCC with additional clinical evidence.

A retrospective analysis of complications associated with postpartum hemorrhage up to 1 year postpartum in mothers with and without a pre-existing mental health diagnosis

BACKGROUND/OBJECTIVES

There is limited research on the associated immediate and long-term outcomes of postpartum hemorrhage. Mothers with a pre-existing psychiatric disease prior to delivery may be especially vulnerable to postpartum hemorrhage outcomes but little is known on this topic. Barriers to studying this population exist and add to knowledge gaps. The goal of this study is to determine the clinical characteristics and frequency of complications within 1 year of a postpartum hemorrhage diagnosis and the psychiatric sequelae within 7 days of a postpartum hemorrhage diagnosis in mothers with a pre-existing mental health diagnosis prior to delivery versus those without.

METHODS/DESIGN

This is a multicenter retrospective observational cohort study using TriNetX, a de-identified electronic health record database. The following electronic health record data were collected and evaluated in postpartum females who were billed for either a vaginal or cesarean delivery: age, race, ethnicity, diagnostic codes, medication codes, and number of deaths.

RESULTS

We included 10,649 subjects (6994 (65.7%) no mental health diagnosis and 3655 (34.3%) pre-existing mental health diagnosis). Haloperidol administration (118 (3.2%) versus 129 (1.8%), p < 0.001) was more prevalent in subjects with a pre-existing mental health diagnosis. Adjusting for demographics, pre-existing mental health diagnoses were associated with complications within 1 year after postpartum hemorrhage diagnosis (OR = 1.39, 95% CI: 1.26-1.52, p < 0.001).

CONCLUSION

Having a mental health disorder history is associated with a higher odds of developing subsequent complications within 1 year of postpartum hemorrhage diagnosis. Mothers with a pre-existing mental health disorder have a significantly higher frequency of certain severe postpartum hemorrhage sequelae, including acute respiratory distress syndrome, retained placenta, sickle cell crisis, and need for mechanical ventilation/tracheostomy up to 1 year after delivery. Medications such as haloperidol were ordered more frequently within 7 days of a postpartum hemorrhage diagnosis in these mothers as well. Further research is needed to understand and manage the unique consequences of postpartum hemorrhage in this vulnerable maternal population.

Band-gap and strain engineering in GeSn alloys using post-growth pulsed laser melting

The pseudomorphic growth of Ge_1-xSn_xon Ge causes in-plane compressive strain, which degrades the superior properties of the Ge_1-xSn_xalloys. Therefore, efficient strain engineering is required. In this article, we present strain and band-gap engineering in Ge_1-xSn_xalloys grown on Ge a virtual substrate using post-growth nanosecond pulsed laser melting (PLM). Micro-Raman and x-ray diffraction (XRD) show that the initial in-plane compressive strain is removed. Moreover, for PLM energy densities higher than 0.5 J cm^-2, the Ge_0.89Sn_0.11layer becomes tensile strained. Simultaneously, as revealed by Rutherford Backscattering spectrometry, cross-sectional transmission electron microscopy investigations and XRD the crystalline quality and Sn-distribution in PLM-treated Ge_0.89Sn_0.11layers are only slightly affected. Additionally, the change of the band structure after PLM is confirmed by low-temperature photoreflectance measurements. The presented results prove that post-growth ns-range PLM is an effective way for band-gap and strain engineering in highly-mismatched alloys.