Sequential administration of peripheral nerve blocks and onabotulinumtoxinA for the treatment of chronic migraine and other headache disorders-A retrospective tolerability and safety study.

OBJECTIVE: To determine the tolerability and safety of concurrent peripheral nerve blocks and onabotulinumtoxinA treatment during a single outpatient clinic procedure visit. BACKGROUND: Procedural interventions are available for the treatment of headache disorders. OnabotulinumtoxinA and peripheral nerve blocks are used as alternatives or in addition to oral therapies to reduce the frequency and intensity of migraine attacks. There is currently a lack of safety data focusing on the sequential administration of local anesthetic via peripheral nerve blocks and onabotulinumtoxinA during a single clinical encounter for the treatment of headache. The primary aim of the study was to determine the safety and tolerability of concurrent peripheral nerve blockade and onabotulinumtoxinA injections during a single outpatient clinic procedure visit. We hypothesized that the dual intervention would be safe and well tolerated by patients with chronic migraine and other headache disorders. METHODS: A retrospective chart review was performed using clinical data from patients seen by multiple providers over a 16-month timeframe at one outpatient headache clinic. Patients were identified by procedure codes and those receiving peripheral nerve block(s) and onabotulinumtoxinA injections during a single encounter within the study period were eligible for inclusion. Inclusion criteria were (1) patients 18 years and older who were (2) receiving both peripheral nerve blocks and onabotulinumtoxinA injections for the treatment of chronic migraine. Patients were excluded if they were under age 18, received their procedure outside of the clinic (emergency room, inpatient ward), or were receiving sphenopalatine ganglion blocks. Age- and sex-matched patients who received one procedure, either peripheral nerve blocks or onabotulinumtoxinA, were used for control. The primary outcome of this safety study was the number of adverse events that occurred in the dual intervention group compared to the single intervention control arms. Information regarding adverse events was gathered via retrospective chart review. If an adverse event was recorded, it was then graded by the reviewer utilizing the Common Terminology Criteria for Adverse Events ranging from Grade 1 Mild Event to Grade 5 Death. Additionally, it was noted whether the adverse event led to treatment discontinuation. RESULTS: In total, 375 patients were considered eligible for inclusion in the study. After age and sex matching of controls, 131 patients receiving dual intervention were able to be compared to 131 patients receiving onabotulinumtoxinA alone and 104 patients receiving dual intervention were able to be compared to 104 patients receiving peripheral nerve block(s) alone. The primary endpoint analysis showed no significant difference in total adverse events between dual intervention compared to nerve blocks alone or onabotulinumtoxinA alone. The number of adverse events that led to treatment discontinuation approached but did not reach statistical significance for those receiving dual intervention versus onabotulinumtoxinA alone in the number of adverse events that led to treatment termination (4.6%, 6/131 vs. 0.8%, 1/131, p = 0.065); however, the number of patients who discontinued therapy was not significantly different between those groups (2.3%, 3/131 vs. 0.8%, 1/131; p = 0.314; odds ratio 0.3 [0-3.2]; p = 0.338). CONCLUSIONS: In this retrospective chart review, there was no significant difference in adverse events or therapy discontinuation between patients receiving sequential peripheral nerve block(s) and onabotulinumtoxinA injections versus those receiving either peripheral nerve block(s) or onabotulinumtoxinA injections alone. As a result, we concluded that the combination procedure is likely safe and well tolerated in routine clinical practice.

Implementation of a Liver Transplant-Specific TEE Guide to Expand TEE Utilization and Improve Workflow During Orthotopic Liver Transplantation.

OBJECTIVES: Transesophageal echocardiography (TEE) is being increasingly utilized during orthotopic liver transplantation to guide perioperative management. Obstacles of improving TEE utilization include the challenge of becoming familiar with the TEE machine, optimizing TEE images, and translating skills acquired in didactic or simulator center-based training into clinical use. METHODS: In an effort to expand TEE utilization and improve workflow among the liver transplantation (LT) anesthesiologists at our institution, a LT-specific TEE guide was created to serve as a reference and educational tool during LT. A 26-question survey was distributed to all LT anesthesiologists before and 6 months after implementation of the LT-specific TEE guide. RESULTS: All seven LT anesthesiologists completed the survey questions during the study period. No statistically significant difference was detected in participant-reported confidence in optimizing targeted TEE views, performing technical aspects of the exam, navigating the knobs on the TEE machine, or in ability to identify abnormal cardiac pathology during the study period. One participant became basic-TEE certified during the study period. CONCLUSIONS: Implementing a liver transplant-specific TEE guide is a strategy to expand TEE utilization, encourage longitudinal TEE education and reinforce concepts learned from hands-on education sessions; however, we did not detect a difference in participant-reported confidence of performing a TEE exam, ability to identify abnormal cardiac pathology or altering workflow. Further studies with larger sample sizes will be needed to evaluate the effectiveness of a LT-specific TEE guide.

Genome-Wide Association Study of Gallstone Disease Identifies Novel Candidate Genomic Variants in a Latino Community of Southwest USA.

Gallstone disease (GSD) is a prevalent health condition that impacts many adults and is associated with presence of stones in gallbladder cavity that results in inflammation, pain, fever, nausea and vomiting. Several genome-wide association studies (GWAS) in the past have identified genes associated with GSD but only a few were focused on Latino population. To identify genetic risk factors for GSD in Latino population living in the Southwest USA we used self-reported clinical history, physical and lab measurements data in Sangre Por Salud (SPS) cohort and identified participants with and without diagnosis of GSD. We performed a GWAS on this phenotype using GSD cases matched to normal controls based on a tight criterion. We identified several novel loci associated with GSD as well as loci that were previously identified in past GWAS studies. The top 3 loci (MATN2, GPRIN3, GPC6) were strongly associated with GSD phenotype in our combined analysis and a sex stratified analysis results in females were closest to the overall results reflecting a general higher disease prevalence in females. The top identified variants in MATN2, GPRIN3, and GPC6 remain unchanged after local ancestry adjustment in SPS Latino population. Follow-up pathway enrichment analysis suggests enrichment of GO terms that are associated with immunological pathways; enzymatic processes in gallbladder, liver, and gastrointestinal tract; and GSD pathology. Our findings suggest an initial starting point towards better and deeper understanding of differences in gallstone disease pathology, biological mechanisms, and disease progression among Southwest US Latino population.

Serologic Rebound after Stopping Azoles for Primary Pulmonary Coccidioidomycosis: A Case-Controlled Observational Study.

BACKGROUND: We sought to characterize the outcomes of patients with primary pulmonary coccidioidomycosis whose post-treatment complement fixation (CF) titer increased by more than 2 dilutions (serologic rebound) after discontinuation of antifungal treatment. METHODS: We conducted a retrospective chart review of patients with primary pulmonary coccidioidomycosis and identified immunocompetent, non-pregnant adults who received antifungal treatment and then experienced a serologic rebound after treatment discontinuation. We compared these to matched controls similarly treated who did not have serologic rebound. RESULTS: Fifty-eight patients experienced serologic rebound. Thirty (52%) of these were associated with symptoms. Nine were associated with radiographic progression. The median time to serologic rebound was 3.5 months. Antifungal treatment was reinitiated in 37 (63.7%) patients. Four of the 58 (6.9%) with rebounded serology subsequently developed extra-thoracic dissemination. Compared with matched controls, patients with rebounded serology were more likely to have post-treatment symptoms, reinitiation of antifungal therapy, and a longer duration of clinical follow-up. However, they were not more likely to experience extra-thoracic dissemination. CONCLUSION: Serological rebound, manifested in at least 2-dilution rise of CF titer following antifungal treatment of primary pulmonary coccidioidomycosis, was uncommon, but resulted in longer clinical follow-up. Continued monitoring of such patients is important to identify the patients who develop subsequent symptoms, as well as extra-thoracic dissemination.

Social Determinants of Health and Mortality After Premature and Non-premature Acute Coronary Syndrome.

Objective: To describe and compare the determinants of 1-year mortality after premature vs non-premature acute coronary syndrome (ACS). Patients and Methods: Participants presenting with ACS were enrolled in a prospective registry of 29 hospitals in 4 countries, from January 22, 2012 to January 22, 2013, with 1-year of follow-up data. The primary outcome was all-cause 1-year mortality after premature ACS (men aged <55 years and women aged <65 years) and non-premature ACS (men aged ≥55 years and women aged ≥65 years). The associations between the baseline patient characteristics and 1-year mortality were analyzed in models adjusting for the Global Registry of Acute Coronary Events (GRACE) score and reported as adjusted odds ratio (aOR) (95% CI). Results: Of the 3868 patients, 43.3% presented with premature ACS that was associated with lower 1-year mortality (5.7%) than those with non-premature ACS. In adjusted models, women experienced higher mortality than men after premature (aOR, 2.14 [1.37-3.41]) vs non-premature ACS (aOR, 1.28 [0.99-1.65]) (P interaction=.047). Patients lacking formal education vs any education had higher mortality after both premature (aOR, 2.92 [1.87-4.61]) and non-premature ACS (aOR, 1.78 [1.36-2.34]) (P interaction=.06). Lack of employment vs any employment was associated with approximately 3-fold higher mortality after premature and non-premature ACS (P interaction=.72). Using stepwise logistic regression to predict 1-year mortality, a model with GRACE risk score and 4 characteristics (education, employment, body mass index [kg/m2], and statin use within 24 hours after admission) had higher discrimination than the GRACE risk score alone (area under the curve, 0.800 vs 0.773; P comparison=.003). Conclusion: In this study, women, compared with men, had higher 1-year mortality after premature ACS. The social determinants of health (no formal education or employment) were strongly associated with higher 1-year mortality after premature and non-premature ACS, improved mortality prediction, and should be routinely considered in risk assessment after ACS.

Erector Spinae Plane Block With Liposomal Bupivacaine: Analgesic Adjunct in Adult Pectus Surgery.

INTRODUCTION: Pain management may be challenging in patients undergoing pectus excavatum (PE) bar removal surgery. To enhance recovery, opioid sparing strategies with regional anesthesia including ultrasound-guided erector spinae plane block (ESPB) have been implemented. The purpose of this study was to evaluate the safety and efficacy of bilateral ESPB with a liposomal bupivacaine/traditional bupivacaine mixture as part of an enhanced patient recovery pathway. MATERIALS AND METHODS: A retrospective review of adult patients who underwent PE bar removal from January 2019 to December 2020 was performed. Perioperative data were reviewed and recorded. Patients who received ESPB were compared to historical controls (non-ESPB patients). RESULTS: A total of 202 patients were included (non-ESPB: 124 patients; ESPB: 78 patients). No adverse events were attributed to ESPB. Non-ESPB patients received more intraoperative opioids (milligram morphine equivalents; 41.8 ± 17.0 mg versus 36.7 ± 17.1, P = 0.05) and were more likely to present to the emergency department within 7 d postoperatively (4.8% versus 0%, P = 0.05) when compared to ESPB patients. No significant difference in total perioperative milligram morphine equivalents, severe pain in postanesthesia care unit (PACU), time from PACU arrival to analgesic administration, PACU length of stay, or postprocedure admission rates between groups were observed. CONCLUSIONS: In patients undergoing PE bar removal surgery, bilateral ESPB with liposomal bupivacaine was performed without complications. ESPB with liposomal bupivacaine may be considered as an analgesic adjunct to enhance recovery in patients undergoing cardiothoracic procedures but further prospective randomized clinical trials comparing liposomal bupivacaine to traditional local anesthetics with and without indwelling nerve catheters are necessary.

Electrodiagnostic Testing for Carpal Tunnel Syndrome When Routine Median Sensory and Thenar Motor Responses Are Absent.

PURPOSE: The cardinal symptoms of carpal tunnel syndrome (CTS) include pain in the affected hand(s). The median/second lumbrical nerve (Med2ndL) seems relatively preserved in severe CTS, with previous small studies suggesting its value in electromyogram to localize a median neuropathy to the wrist when both initial routine sensory and thenar motor responses are absent. METHODS: This is a retrospective analysis of 208 hands in 183 patients with electrophysiologically markedly severe CTS (absent routine sensory and thenar motor median responses) who underwent stimulation of both the Med2ndL and ulnar/second dorsal interosseous (Uln2ndDIn) motor nerves. A Med2ndL distal latency of ≥ 0.5 milliseconds when compared with the Uln2ndDIn supported the diagnosis of CTS. The presence or absence of hand pain was recorded if these data were available. RESULTS: Some 83.7% of hands (172/208) in 183 patients with markedly severe CTS had preservation of the Med2ndL meeting criteria for CTS. In those with pain data available, 77.1% (81/105) of hands had no pain. Of those 105 hands, 87 had preservation of the Med2ndL with 79.3% (69/87) demonstrating no pain. CONCLUSIONS: This is a large study that demonstrates the relative preservation of the Med2ndL response in markedly severe CTS. Assessment of the Med2ndL should be considered to electrophysiologically support CTS when routine sensory and thenar motor responses are absent. In addition, most patients with electrophysiologically markedly severe CTS had no pain.

Evaluation of a Novel Wellness Curriculum on Medical Student Wellbeing and Engagement Demonstrates a Need for Student-Driven Wellness Programming.

PROBLEM: Medical training is stressful and has well-established implications for student wellbeing. Despite widespread efforts to reduce student burnout through wellness programming in medical schools, there is a paucity of literature examining students' perception of wellness and engagement with these programs. As such, we sought to evaluate: 1) medical students' level of engagement with a multifaceted wellness curriculum, 2) factors students perceived as important to wellbeing, and 3) associations with longitudinal measures of wellbeing and perceived stress. Intervention: A multipronged wellness curriculum was instituted at Mayo Clinic Alix School of Medicine-AZ (MCASOM-AZ) in 2017. This includes mental health services, curriculum-embedded seminars, wellness committee (composed of students, faculty, and administration) driven programming, and student proposed wellness activities that are reviewed and funded by the committee. The authors invited students at our institution to complete questionnaires at three timepoints during the 2018-2019 academic year. Questionnaires asked participants to rank eight factors from least to most important to their overall wellbeing. Participants self-reported their participation in each prong of the wellness curriculum and ranked the impact of each on their overall wellbeing. Their wellbeing and perceived stress were measured at each timepoint using validated psychological instruments. Context: As MCASOM-AZ opened in 2017, the student body at the time of study consisted of first- and second-year medical students. All students had the opportunity to engage with all aspects of the wellness curriculum and participate in this study, however participation was elective and all responses were anonymous. Of the MCASOM-AZ student body comprised of 100 students, 58 consented to participate in the study, 41.4% of which were Year 1 and 58.6% of which were Year 2 students. Participant age and gender were collected and were representative of the larger student body. Impact: Students engaged most with student-initiated wellness. They perceived unscheduled time as most impactful to their overall wellbeing with student-initiated activities as second-most impactful. Students with higher perceived stress were more likely than others to use mental health resources, which otherwise ranked lower in importance. Ranking academic performance as important to wellbeing was associated with higher wellbeing. There was no difference in wellbeing between students who participated in the wellness curriculum and those who did not. However, overall student wellbeing increased over the course of the year while perceived stress decreased. Lessons Learned: Medical school programs may benefit from allowing students to direct or contribute to the design of their own wellness curriculum. Additionally, medical education should work toward creating a more supportive learning environment with improved flexibility in order to better meet students' individual needs without compromising their education. Despite having low utilization rates overall, mental health resources remain an important aspect of student support services as they are used by students under greater amounts of perceived stress than their peers.Supplemental data for this article is available online at https://doi.org/10.1080/10401334.2021.2004415 .

Surgical site infections during the COVID-19 era: A retrospective, multicenter analysis.

BACKGROUND: Surgical site infections (SSIs) are an undesired perioperative outcome. Recent studies have shown increases in hospital acquired infections during the coronavirus disease 2019 (COVID-19) pandemic. The objective of this study was to evaluate postoperative SSIs in the COVID-19-era compared to a historical cohort at a large, multicenter, academic institution. METHODS: A retrospective review of all patients who underwent National Health and Safety Network (NHSN) inpatient surgical procedures between January 1, 2018 and December 31, 2020. Patients from the COVID-19-era (March-December 2020) were compared and matched 1:1 with historical controls (2018/2019) utilizing the standardized infection ratio (SIR) to detect difference. RESULTS/DISCUSSION: During the study period, 29,904 patients underwent NHSN procedures at our institution. When patients from the matched cohort (2018/2019) were compared to the COVID-19-era cohort (2020), a decreased risk of SSI was observed following colorectal surgery (RR = 0.94, 95% CI [0.65, 1.37], P = .76), hysterectomy (RR = 0.88, 95% CI [0.39, 1.99], P = .75), and knee prothesis surgery (RR = 0.95, 95% CI [0.52, 1.74], P = .88), though not statistically significant. An increased risk of SSI was observed following hip prosthesis surgery (RR 1.09, 95% CI [0.68, 1.75], P = .72), though not statistically significant. CONCLUSIONS: The risk of SSI in patients who underwent NHSN inpatient surgical procedures in 2020 with perioperative COVID-19 precautions was not significantly different when compared to matched controls at our large, multicenter, academic institution.

Proton therapy for isolated local regional recurrence of breast cancer after mastectomy alone.

Purpose/Objectives: To assess adverse events (AEs) and disease-specific outcomes after proton therapy for isolated local-regional recurrence (LRR) of breast cancer after mastectomy without prior radiotherapy (RT). Materials/Methods: Patients were identified from a multi-institutional prospective registry and included if diagnosed with invasive breast cancer, initially underwent mastectomy without adjuvant RT, experienced an LRR, and subsequently underwent salvage treatment, including proton therapy. Follow-up and cancer outcomes were measured from the date of RT completion. Results: Nineteen patients were included. Seventeen patients were treated with proton therapy to the chest wall and comprehensive regional lymphatics (17/19, 90%). Maximum grade AE was grade 2 in 13 (69%) patients and grade 3 in 4 (21%) patients. All patients with grade 3 AE received > 60 GyE (p=0.04, Spearman correlation coefficient=0.5). At the last follow-up, 90% of patients were alive with no LRR or distant recurrence. Conclusions: For breast cancer patients with isolated LRR after initial mastectomy without adjuvant RT, proton therapy is well-tolerated in the salvage setting with excellent loco-regional control. All grade 3 AEs occurred in patients receiving > 60 GyE.

Medical students describe their wellness and how to preserve it.

BACKGROUND: Despite widespread efforts to create wellness programming in medical schools, there is a paucity of literature examining students' perception of wellness and perceptions of these programs. With the inaugural class at the Arizona campus of Mayo Clinic Alix School of Medicine (MCASOM-AZ), an opportunity arose to establish an empirically evaluated wellness curriculum that most inclusively and effectively enables medical students to flourish for years to come. The initial wellness offerings included mental health, academic success, and disability services, curriculum-embedded seminars, wellness committee driven programming, and student-proposed wellness activities. We aimed to improve the relevance and impact of medical school wellness curricula by soliciting in-depth and longitudinal perspectives of medical students themselves. As MCASOM-AZ opened in 2017, the student body at the time of study consisted of first- and second-year medical students. METHODS: Employing a mixed methods analysis of qualitative and longitudinal quantitative data, first- and second-year students at a MCASOM-AZ were invited to respond to an anonymous, online year-long survey (baseline, six months and 12 months) during the 2018-2019 academic year and participate in a structured, in-depth and in-person, peer-to-peer interview about their conceptions of wellness and the MCASOM-AZ wellness curriculum and resources. Qualitative data was coded for themes using thematic analysis strategies by independent raters. RESULTS: Nearly half of eligible students completed the baseline survey,1/3 completed all 3 time-points, and 1/5 participated in an in-depth interview. Participant age, gender, and year of school were representative of the larger student body. Although individual conceptions varied, Wellness was consistently highly valued. Family, Academic Performance, and Friends emerged as most important to well-being across time-points. Academic work arose as the largest barrier to wellness. Analysis of qualitative data revealed five themes. Despite individual differences in approaches to wellness, wellbeing was interrelated to the learning environment; mandatory wellness efforts that didn't address the medical culture met with skepticism. CONCLUSIONS: Interview responses provided understanding and context by which to interpret questionnaire responses. Academics was critical to students' identity and wellness, while also the largest barrier. Suggested curricular improvements include restructuring academic work, seamlessly integrating wellness within coursework, and offering optional individualized approaches.

Diversity, Equity, and Inclusion Among Anesthesiology Trainees.

Background: Historically in medicine, women and minorities have been underrepresented. This trend is especially significant in the anesthesiology workforce. Objective: The goals of this study were to quantify the current state of diversity by race/ethnicity, gender, and sexual orientation among anesthesiology residents. Methods: An institutionally reviewed and validated survey was delivered through Qualtrics to 130 anesthesiology program directors. Topics addressed included gender identity, sexual orientation, racial and ethnic background, rationale for pursuing anesthesiology, and medical training experiences. The study was administered from February to April 2021; 135 anesthesiology residents responded to the survey. Results: The sample was 44.4% white (n = 60), 54.1% male (n = 73), and 83.7% (n = 113) of respondents self-reported as straight or heterosexual. Respondents indicated that role models/mentors were somewhat or very important in their desire to pursue anesthesiology (n = 85; 67.2%), 42% reported that having women/diverse faculty was somewhat or very important in their decision to pursue anesthesiology. Discrimination during the anesthesiology residency application process or as a resident ranged from 4.4% due to sexual orientation to 18.7% due to gender/gender identity and race/ethnicity. Conclusions: Experiences of discrimination based on race/ethnicity, gender, and gender identity continues to be a concern among anesthesiology trainees. Creating an environment that is inclusive and supportive of all trainees regardless of race/ethnicity, gender/gender identity, and sexual orientation is needed. Interventions and strategies to create an inclusive environment may improve diversity within anesthesiology.

Characterizing the driving dilemma among patients with psychogenic nonepileptic seizures: A single-center prospective cohort study.

OBJECTIVE: Driving is a critical topic to counsel among patients with epileptic seizures (ES) and psychogenic nonepileptic seizures (PNES), with significant legal and public health implications. This prospective cohort study examined the frequency of ES and PNES in a single institution's Epilepsy Monitoring Unit (EMU) and assessed driving-related issues between each group. METHODS: Adult patients from the Mayo Clinic Arizona Epilepsy Monitoring Unit (EMU) were given comprehensive surveys addressing driving history. Descriptive analysis and statistics were used to summarize differences between patients with ES and PNES. Differences between patients with epilepsy and PNES were determined by Pearson chi-square. RESULTS: Nearly half (n = 75/163) of all patients admitted to the EMU were diagnosed with PNES. Although the PNES group had a statistically significant higher frequency of events (p = 0.01), 87.7% of these patients reported compliance with the driving law recommendations, suggesting a trend that patients who have been counseled regarding fitness-to-drive are likely to follow the recommendation. One-third of patients with PNES reported an event while operating a motor vehicle and 8% (n = 2/25) resulted in a motor vehicle collision severe enough to require hospitalization. In contrast to those with ES, 25% of patients reported a typical event while driving and 25% (n = 2/8) of those resulted in a collision requiring hospitalization. The incidence of habitual events while driving is higher in the population with PNES (n = 25) when compared to those with ES (n = 8); however, it appears that patients with PNES were less likely to become involved in an accident resulting in seriously bodily injury than in ES. CONCLUSIONS: Compared to patients with PNES, patients with ES have less frequent events but more severe collisions. This study reinforces the need for diligent driving counseling to help prevent driving-related injuries in patients with PNES and ES.

Baseline thrombocytopenia in acute coronary syndrome: The lower, the worse.

BACKGROUND: Patients with baseline thrombocytopenia can have increased mortality and morbidity, but are typically excluded from randomized clinical trials studying acute coronary syndromes (ACS). We sought to better define the effect thrombocytopenia on clinical outcomes in ACS patients. METHODS: Patients identified from the NCDR Chest Pain registry at Mayo Clinic Arizona from Oct 2015 to Sep 2018 were retrospectively classified into two groups: TP (platelet <150 × 103 µL) and control (platelet ≥150 × 103 µL). The groups were analyzed for the clinical outcome (all-cause mortality, major adverse cardiac events (MACE), and bleeding events). The TP group was divided into moderate-severe thrombocytopenia (TPmod; platelet 50-100 × 103 µL) and mild thrombocytopenia (TPmild; platelet 100-150 × 103 µL) for further analysis. P-value <0.05 is considered significant. RESULTS: Five hundred and thirty-six patients were identified, and 72 patients (13%) had thrombocytopenia. The median follow-up time was 1.1 years. The TP group was older (TP vs. control: mean age 73 ± 13 years vs. 70 ± 13 years; P = 0.026). In patients discharged on dual-antiplatelet therapy, the TP group had higher all-cause mortality (23% vs. 7.3%; P = 0.007) but not major bleeding events (11% vs. 5.0%; P = 0.123). Only all-cause mortality increased with the severity of thrombocytopenia (TPmod vs. TPmild vs. control: 33% vs. 24% vs. 7.3%; P = 0.007). CONCLUSIONS: In patients with ACS, baseline thrombocytopenia is associated with increased all-cause mortality and all bleeding events without net MACE benefit. Further study is needed to identify the optimal antiplatelet strategy in this higher risk population.

Pregnancy and Motherhood for Trainees in Anesthesiology: A Survey of the American Society of Anesthesiologists.

BACKGROUND: Although approximately half of US medical students are now women, anesthesiology training programs have yet to achieve gender parity. Women trainees' experiences and needs, including those related to motherhood, are increasingly timely concerns for the field of anesthesiology. At present, limited data exists on the childbearing experiences of women physicians in anesthesiology training. METHODS: In March of 2018, we surveyed women members of the American Society of Anesthesiologists via email. Questions addressed pregnancy, maternity leave, lactation, and motherhood. We analyzed data from a subset of respondents who were pregnant or had children during training and graduated in the year 2000 or later. RESULTS: A total of 542 respondents who completed training in the year 2000 or after reported 752 pregnancies during anesthesia training. A maternity leave had a median length of 7 weeks and did not change significantly over time. During many pregnancies, women felt their leave was inadequate (59.6%) or felt discouraged from taking more time off (65.7%). Pregnancy and associated leave extended graduation from training in 64.1% of cases. In approximately half of pregnancies (51.3%), women met desired breastfeeding duration, with access to designated lactation space decreasing significantly over time (false-discovery adjusted P = .0004). Trainee mothers often felt discouraged from having children (51.6%) or perceived negative stigma surrounding pregnancy (60.3%). These attitudes did not change over time or in relation to female program leadership. CONCLUSIONS: Women anesthesiology trainees commonly face obstacles when attempting to balance work and motherhood. Recent policy changes have addressed some of the challenges identified in our study. Future studies will need to evaluate how these changes have impacted anesthesiology trainees.

Real-world efficacy, tolerability, and safety of ubrogepant.

OBJECTIVE: To assess the real-world efficacy, tolerability, and safety of ubrogepant in a tertiary headache center. BACKGROUND: The efficacy and safety of ubrogepant for the acute treatment of migraine were established in phase 3 randomized controlled trials. However, there is no real-world data of patient experience with ubrogepant in a population in which the majority of patients have chronic migraine, multiple prior unsuccessful treatments, complex medical comorbidities, and concurrent use of other migraine-specific medications. METHOD: This was a post-market cohort study conducted at Mayo Clinic Arizona. All patients prescribed ubrogepant were tracked and contacted 1-3 months after the prescription to answer a list of standardized questions. Demographic information and additional headache history were obtained from chart review. RESULTS: We obtained eligible questionnaire responses from 106 patients. Chronic migraine accounted for 92/106 (86.8%) of the population. Complete headache freedom (from mild/moderate/severe to no pain) and headache relief (from moderate/severe to mild/no pain or mild to no pain) for ≥75% of all treated attacks at 2 hours after taking ubrogepant were achieved in 20/105 (19.0%) and 50/105 (47.6%) patients, respectively. A total of 33/106 (31.1%) patients reported being "very satisfied" with ubrogepant. Adverse events were reported in 42/106 (39.6%) patients, including fatigue in 29/106 (27.4%), dry mouth in 8/106 (7.5%), nausea/vomiting in 7/106 (6.6%), constipation in 5/106 (4.7%), dizziness in 3/106 (2.8%), and other adverse events in 7/106 (6.6%). Predictive factors for being a "good responder" to ubrogepant, defined as headache relief for ≥75% of all treated attacks at 2 hours after taking ubrogepant, included migraine with aura, episodic migraine, <5 prior unsuccessful preventive or acute treatment trials. Additionally, prior treatment responses to a CGRP monoclonal antibody and onabotulinumtoxinA injections are predictive of treatment responses and patient satisfaction to ubrogepant. For the 62/106 (58.5%) patients concurrently using a CGRP monoclonal antibody, there was no difference in the "good responder" rate or adverse event rate compared to those who were not on a CGRP monoclonal antibody, though the rate of moderate, as opposed to mild adverse events was higher, 11/62 (47.8%) versus 3/44 (17.6%), p = 0.048. Additionally, 16 patients had a history of significant cardiovascular or cerebrovascular diseases. No severe adverse events were reported in any patient. CONCLUSION: Our study confirms and extends the efficacy profile and tolerability of ubrogepant in a real-world tertiary headache clinic and identifies factors that may predict efficacy. Adverse event rates were higher than reported in clinical trials. Further studies are needed to confirm these findings and to evaluate the long-term efficacy and safety of ubrogepant.

Risk Factors and Wellness Measures Associated with Prediabetes and Newly Diagnosed Type 2 Diabetes Mellitus in Hispanic Adults.

Background: To characterize the associations of clinical risk factors, lifestyle factors, and wellness measures with prediabetes and new type 2 diabetes mellitus (T2DM) diagnosis in Hispanic adults and guide primary prevention. Methods:Sangre Por Salud Biobank enrolled 3733 Hispanic adults from Phoenix, AZ, United States, from 2013 to 2018. This analysis included participants with euglycemia, prediabetes, or new T2DM diagnosis (i.e., no prior T2DM diagnosis) at enrollment. Participants completed a baseline questionnaire on cardiometabolic risk factors and wellness measures and provided biometric measurements. The associations of factors and measures with odds (95% confidence interval) of prediabetes and new T2DM diagnosis were analyzed in logistic regression models. Results: Among 3299 participants with euglycemia (n = 1301), prediabetes (n = 1718), and new T2DM diagnosis (n = 280) at enrollment, 72% were women (n = 2376/3299). In adjusted models, most cardiometabolic risk factors were positively associated with prediabetes and new T2DM diagnosis, with stronger associations for new T2DM diagnosis. Obesity (body mass index ≥30 kg/m2 vs. lower) was associated with higher odds of new T2DM diagnosis (3.14 [2.30-4.28]; P < 0.01) than prediabetes versus euglycemia (1.96 [1.66-2.32]; P < 0.01) and Interaction (P = 0.01). Similarly, waist circumference, family history of diabetes, and average systolic and diastolic blood pressure were associated with higher odds of new T2DM diagnosis versus euglycemia than prediabetes versus euglycemia. Using stepwise logistic regression modeling, a parsimonious model of age, family history of diabetes, waist circumference, diastolic blood pressure, passive tobacco exposure, and self-rated general health were associated with new T2DM diagnosis versus euglycemia. Conclusions: In Hispanic adults, modifiable cardiometabolic and lifestyle factors were associated with prediabetes and new T2DM diagnosis. Personalized interventions targeting these factors and measures could guide T2DM primary prevention efforts among Hispanic adults.

Artificial Intelligence Trumps TAVI2-SCORE and CoreValve Score in Predicting 1-Year Mortality Post-Transcatheter Aortic Valve Replacement.

BACKGROUND/PURPOSE: Machine learning has been used to predict procedural risk in patients undergoing various medical interventions and procedures. One-year mortality in patients after Transcatheter Aortic Valve Replacement (TAVR) has a wide range (from 8.5 to 24% in various studies). We sought to apply machine learning to determine predictors of one year mortality in patients undergoing TAVR. METHODS/MATERIALS: A retrospective study of 1055 patients who underwent TAVR (Jan 2014-June 2017) with one-year follow up was completed. Baseline demographics, clinical, electrocardiography (ECG), Computed Tomography (CT) and echocardiography data were abstracted. Variables with near zero variance or ≥50% missing data were excluded. The Gradient Boosting Machine learning (GBM) prediction model included 163 variables and was optimized using 5-fold cross-validation repeated 10-times. The receiver operator characteristic (ROC) for the GBM model was calculated to predict one-year mortality post TAVR, and then compared to the TAVI2-SCORE and CoreValve score. RESULTS: Among 1055 TAVR patients (mean age 80.9 ± 7.9 years, 42% female), 14.02% died at one year. 78% had balloon expandable valves placed. Based on GBM, the ten most predictive variables for one-year survival were cardiac power index, hemoglobin, systolic blood pressure, INR, diastolic blood pressure, body mass index, valve calcium score, serum creatinine, aortic annulus area, and albumin. The area under ROC to predict survival for the GBM model vs TAVI2-SCORE and CoreValve Score was 0.72 (95% CI 0.68-0.78) vs 0.56 (95%CI 0.51-0.62) and 0.53 (95% CI 0.47-0.59) respectively with p < 0.0001. CONCLUSION: The GBM model outperforms TAVI2-SCORE and CoreValve Score in predicting mortality one-year post TAVR.

Acute toxicities after proton beam therapy following breast-conserving surgery for breast cancer: Multi-institutional prospective PCG registry analysis.

We investigated adverse events (AEs) and clinical outcomes for proton beam therapy (PBT) after breast-conserving surgery (BCS) for breast cancer. From 2012 to 2016, 82 patients received PBT in the prospective multi-institutional Proton Collaborative Group registry. AEs were recorded prospectively at each institution. Median follow-up was 8.1 months. Median dose was 50.4 Gy in 28 fractions. Most patients received a lumpectomy bed boost (90%) and regional nodal irradiation (RNI)(83%). Six patients (7.3%) experienced grade 3 AEs (5 with dermatitis, 5 with breast pain). Body mass index (BMI) was associated with grade 3 dermatitis (P = .015). Fifty-eight patients (70.7%) experienced grade ≥2 dermatitis. PBT including RNI after BCS is well-tolerated. Elevated BMI is associated with grade 3 dermatitis.

Motherhood and Anesthesiology: A Survey of the American Society of Anesthesiologists.

BACKGROUND: The proportion of women medical school graduates in the United States has grown substantially; however, representation of women in anesthesiology lags behind. We sought to investigate factors associated with women recommending against a career in anesthesiology due to obstacles related to motherhood. METHODS: We surveyed 9525 women anesthesiologist members of the American Society of Anesthesiologists (ASA) with a web-based survey distributed via e-mail. Associations between whether women would counsel against anesthesiology due to obstacles related to motherhood and 34 related categorical variables were estimated. Fisher exact test was used for categorical binary variables, and Wilcoxon-Mann-Whitney test was used for ranked variables. RESULTS: The response rate for the primary question was 19.2%. Among the 1827 respondents to the primary question, 11.6% would counsel a female medical student against a career in anesthesiology due to obstacles pertaining to motherhood. Counseling against an anesthesiology career was not associated with ever being pregnant (P = .16), or whether a woman was pregnant during residency or fellowship training (P = .41) or during practice (P = .16). No association was found between counseling against anesthesiology and training factors: total number of weeks of maternity leave (P = .18), the percentage of women faculty (P = .96) or residents (P = .34), or the number of pregnant coresidents (P = .66). Counseling against a career in anesthesiology was significantly associated with whether respondents' desired age of childbearing/motherhood and desired number of children were adversely affected by work demands (with Bonferroni adjustment for the 34 comparisons, both P < .0001). The risk ratio of respondents whose desired childbearing age and desired number of children were affected by work demands counseling against a career in anesthesiology was 5.1 compared to women whose desired childbearing age and desired number of children were not affected (99% confidence interval [CI], 3.3-7.9; P < .0001; odds ratio, 6.2). CONCLUSIONS: In this study of 1827 women anesthesiologists, approximately 1 in 10 would counsel a student against a career in anesthesiology due to obstacles pertaining to motherhood, and this was associated with altering one's timing and number of children due to job demands. Further research is needed to understand how women's perception of a career in anesthesiology is related to factors influencing personal choices. Understanding women's perceptions of motherhood in anesthesiology may help leaders support career longevity and personal satisfaction in this growing cohort of anesthesiologists.