Sleep apnea in end-stage renal disease patients: Impact on cardiovascular and neurological outcomes.

INTRODUCTION: Sleep apnea (SA) is an important comorbidity in end-stage renal disease (ESRD) patients. The association between SA and cardiac and neurological disease is known. This study investigates the relationship between SA and cardiovascular and cerebrovascular outcomes in the ESRD population. METHODS: In a retrospective cohort study, the United States Renal Data System was queried to identify ESRD patients aged 18-100 years in whom hemodialysis had been initiated between 2005 and 2013. Diagnoses of SA and clinical comorbidities were determined from International Classification of Disease-9 codes. Demographic variables were obtained from Centers for Medicare and Medicaid Services Form-2728. Logistic regression was used to examine the association of SA with myocardial infarction (MI) or with stroke, controlling for demographic and clinical variables. RESULTS: Of 858,131 subjects meeting the inclusion criteria, 587 had central SA, and 22,724 had obstructive SA. The SA cohort was younger, more likely to be male and Caucasian compared to the non-SA cohort. Patients with SA also had more tobacco and alcohol use, hypertension, heart failure, and diabetes. Central SA (aRR = 1.69, 95% CI = 1.28-2.23) and obstructive SA (aRR = 1.15, 95% CI = 1.09-1.21) were associated with an increased risk of stroke but not MI. CONCLUSION: In the ESRD population, a diagnosis of central SA or obstructive SA increased the risk of stroke, but not MI. Early identification and treatment of SA in the ESRD population may help reduce the risk of stroke in these patients.

Making the match and breaking it: values, perceptions, and obstacles of trainees applying into physician-scientist training programs.

BACKGROUND: Replenishing the physician-scientist workforce constitutes a central mission of medical education, but the loss of qualified trainees to non-academic positions remains an ongoing threat. Among the barriers facing physician-scientists today is the game-like model of U.S. medical residency matching through the National Research Matching Program (NRPM), which applies several assumptions regarding the comparability of applicant qualifications, cohort size, and the institutional breadth of applicants' training needs. METHODS: The current report therefore summarizes the survey-based views and experiences of physician-scientist trainees obtained following the 2021-2022 application cycle for research-oriented residency programs, or physician-scientist training programs (PSTPs). From among this small cohort of applicants, we obtained survey-based feedback of 27 PSTP applicants across 17 U.S. medical universities, among whom 85% (23/27) matched into a PSTP. RESULTS: Among these PSTP applicants, 25/27 (93%) recognized "scientific community" as the most important feature of a postgraduate training program, with applicants identifying as female placing a higher value on the program's infrastructure of personal and/or family support. Most (18/27) respondents found "waiting for interviews" as the most stressful phase of their application cycle, and roughly half of all respondents encountered at least one NRMP policy violation through post-interview communication. Specifically, 93% (25/27) respondents were contacted by at least one PSTP following interviews, and 1/3 of them admitted to feeling pressured into sharing their ranking preferences. CONCLUSION: We highlight many previously unrecognized priorities among applicants to PSTPs, which include fostering community among its trainees and reinforcing structured mentoring. We uncover an inconsistency among PSTPs regarding the post-interview process, which represents an opportunity to better support applicants seeking to gauge programs according to their clinical, scientific, and academic interests as physician-scientists, while still adhering to NRMP policies.

Hashimoto's thyroiditis and renal transplant rejection.

PURPOSE: Hashimoto's thyroiditis (HT) is a common autoimmune thyroid disorder that can disrupt thyroid function and homeostasis. As HT results from a dysregulated immune system, we hypothesized that these patients might be more susceptible to transplant failure; however, literature on this association is limited. The purpose of this study is to examine the association of HT with the risk of renal transplant failure. METHODS: We utilized the United States Renal Database System dataset collected from 2005 to 2014 and compared the time from first renal transplant to transplant failure in end-stage renal disease (ESRD) patients with a HT diagnosis to ESRD patients without a HT diagnosis that underwent renal transplant. RESULTS: A total of 144 ESRD patients had International Classification of Disease-9 claim codes for HT prior to renal transplant, amongst a total cohort of 90,301 renal transplant patients aged 18-100 and meeting criteria. Patients with HT were significantly more likely to be female, white, and to have a diagnosis of cytomegalovirus compared to patients without. ESRD patients with a HT diagnosis that underwent renal transplant had a significantly increased risk of renal transplant failure compared to those ESRD renal transplant patients without an HT diagnosis. There was a significantly increased adjusted hazard ratio for graft failure in patients with a HT diagnosis compared to those without. CONCLUSION: Thyroid health and HT may play a significant role in the development of the increased risk of renal transplant failure observed in this study. Additional studies are needed to investigate the underlying mechanisms for this association.

CT presentations of adult and pediatric SARS-CoV-2 patients: A review of early COVID-19 data.

OBJECTIVE: Initial COVID-19 reports described a variety of clinical presentations, but lower respiratory abnormalities are most common and chest CT findings differ between adult and pediatric patients. We aim to summarize early CT findings to inform healthcare providers on the frequency of COVID-19 manifestations specific to adult or pediatric patients, and to determine if the sensitivity of CT justifies its use in these populations. METHODS: PubMed was searched for the presence of the words "CT, imaging, COVID-19" in the title or abstract, and 17 large-scale PubMed and/or Scopus studies and case reports published between January 1, 2020 and April 15, 2020 were selected for data synthesis. RESULTS: Initial CT scans identified ground-glass opacities and bilateral abnormalities as more frequent in adults (74%, n = 698, and 89%, n = 378, respectively) than children (60%, n = 25, and 37%, n = 46). At 14+ days, CT scans evidenced varied degrees of improvement in adults but no resolution until at least 26 days after the onset of flu-like symptoms. In pediatric patients, a third (n = 9) showed additional small nodular GGOs limited to a single lobe 3-5 days after an initial CT scan. CONCLUSION: Early adult CT findings suggest the limited use of CT as a supplemental tool in diagnosing COVID-19 in symptomatic adult patients, with a particular focus on identifying right and left lower lobe abnormalities, GGOs, and interlobular septal thickening. Early pediatric CT findings suggest against the use of CT if RT-PCR is available given its significantly lower sensitivity in this population and radiation exposure.

Psychosexual distress following routine primary human papillomavirus testing: a longitudinal evaluation within the English Cervical Screening Programme.

OBJECTIVE: To assess psychosexual distress over a 12-month period among women receiving different human papillomavirus (HPV) and cytology results in the context of the English HPV primary screening pilot. DESIGN: Longitudinal, between-group study. SETTING: Five sites in England where primary HPV testing was piloted. POPULATION: Women aged 24-65 years (n = 1133) who had taken part in the NHS Cervical Screening Programme. METHODS: Women were sent a postal questionnaire soon after receiving their screening results (baseline) and 6 and 12 months later. Data were analysed using linear regression models to compare psychosexual outcomes between groups receiving six possible combinations of HPV and cytology screening results, including a control group with normal cytology and no HPV test. MAIN OUTCOME MEASURES: Psychosexual distress, assessed using six items from the Psychosocial Effects of Abnormal Pap Smears Questionnaire (PEAPS-Q). RESULTS: At all time points, there was an association between screening result group and psychosexual distress (all P < 0.001). At baseline, mean psychosexual distress score (possible range: 1-5) was significantly higher among women with HPV and normal cytology (B = 1.15, 95% CI 0.96-1.34), HPV and abnormal cytology (B = 1.02, 95% CI: 0.78-1.27) and persistent HPV (B = 0.90, 95% CI 0.70-1.10) compared with the control group (all P < 0.001). At the 6 and 12 month follow ups the pattern of results were similar, but coefficients were smaller. CONCLUSIONS: Our findings suggest receiving an HPV-positive result can cause psychosexual distress, particularly in the short-term. Developing interventions to minimise the psychosexual burden of testing HPV-positive will be essential to avoid unnecessary harm to the millions of women taking part in cervical screening. TWEETABLE ABSTRACT: Receiving an HPV-positive result following primary HPV testing can cause psychosexual distress, particularly in the short-term.

[CT Presentations of Adult and Pediatric SARS-COV-2 Patients: A Review of Early COVID-19 Data]. / Comparación de los hallazgos en la tomografía computarizada de pacientes adultos y pediátricos con COVID-19.

Objective: Initial COVID-19 reports described a variety of clinical presentations, but lower respiratory abnormalities are most common and chest CT findings differ between adult and pediatric patients. We aim to summarize early CT findings to inform healthcare providers on the frequency of COVID-19 manifestations specific to adult or pediatric patients, and to determine if the sensitivity of CT justifies its use in these populations. Methods: PubMed was searched for the presence of the words "CT, imaging, COVID-19" in the title or abstract, and 17 large-scale PubMed and/or Scopus studies and case reports published between January 1, 2020 and April 15, 2020 were selected for data synthesis. Results: Initial CT scans identified ground-glass opacities and bilateral abnormalities as more frequent in adults (74%, n = 698, and 89%, n = 378, respectively) than children (60%, n = 25, and 37%, n = 46). At 14+ days, CT scans evidenced varied degrees of improvement in adults but no resolution until at least 26 days after the onset of flu-like symptoms. In pediatric patients, a third (n = 9) showed additional small nodular GGOs limited to a single lobe 3-5 days after an initial CT scan. Conclusión: Early adult CT findings suggest the limited use of CT as a supplemental tool in diagnosing COVID-19 in symptomatic adult patients, with a particular focus on identifying right and left lower lobe abnormalities, GGOs, and interlobular septal thickening. Early pediatric CT findings suggest against the use of CT if RT-PCR is available given its significantly lower sensitivity in this population and radiation exposure.

The role of MRI pelvimetry in predicting technical difficulty and outcomes of open and minimally invasive total mesorectal excision: a systematic review.

BACKGROUND: The difficulty of performing total mesorectal excision (TME) for rectal cancer partly relies on the surgeon's subjective assessment of the individual patient's pelvic anatomy and tumour characteristics, which generally influences the choice of platform used (open, laparoscopic, robotic or trans-anal surgery). Recent studies have found associations between several anatomical pelvic measurements and surgical difficulty. The aim of this study was to systematically review existing data reporting the use of magnetic resonance imaging (MRI)-based pelvic measurements to predict technical difficulty and outcomes of TME, and determine whether pelvimetry could optimise patient-specific selection of a particular surgical approach. METHODS: MEDLINE, Embase and Cochrane Library databases were systematically searched for studies reporting MRI-based pelvic measurements in patients undergoing surgery for rectal cancer, and the effect of these measurements on surgical difficulty. RESULTS: Eleven studies reporting the association between MRI-pelvimetry measurements and rectal cancer surgical outcomes were included. Indicators for surgical difficulty used in the included studies were involved circumferential resection margin, longer operative time, incomplete TME, higher blood loss, anastomotic leak, conversion to open surgery and overall complications. Bony pelvic measurements which were associated with increased surgical difficulty in more than one study were a smaller interspinous distance, a smaller intertubercle distance, a smaller pelvic inlet and larger pubic tubercle height. Two studies identified larger mesorectal fat area as a predictor of surgical difficulty. CONCLUSIONS: Bony pelvic measurements may predict surgical difficulty during TME, however, use of different indicators of difficulty limit comparison between studies. Early data suggest MRI soft tissue measurements may predict surgical difficulty and warrants further investigation.

Barriers and facilitators to discussing HPV with head and neck cancer patients: A qualitative study using the theoretical domains framework.

OBJECTIVE: The incidence of human papillomavirus-associated head and neck cancers (HPV-HNC) is increasing worldwide. Research in other clinical contexts has shown that healthcare professionals (HCPs) can find discussing HPV with patients challenging. However, limited research has been conducted in HNC. This study aimed to investigate barriers and facilitators to, discussing HPV among HCPs caring for patients with HNC in Ireland. METHODS: Semi-structured telephone/face-to-face interviews were conducted with HCPs. Barriers and facilitators to discussing HPV with patients were identified using the Theoretical Domains Framework (TDF). RESULTS: 20 HCPs (8 clinicians, 3 nurses, 9 allied healthcare professionals) were interviewed. Barriers to discussing HPV included professionals' lack of HPV knowledge, difficulties in talking about sexual issues with patients and lack of privacy to discuss HPV in busy clinic settings. Facilitators included increasing public and patient awareness of the link between HPV and HNC and professional education and skills development. CONCLUSIONS: This is the first theoretically informed study to identify barriers and facilitators to discussing HPV with HNC patients. HCPs consider HPV discussions to be an essential part of HNC patient care. PRACTICE IMPLICATIONS: Understanding the issues associated with patient-provider HPV communication will help develop effective interventions to support HCPs in their HPV discussions.

Communicating about HPV in the context of head and neck cancer: A systematic review of quantitative studies.

OBJECTIVE: Rising incidence of HPV-positive head and neck cancers (HPV-HNC) means HPV infection is increasingly relevant to patient-provider consultations. We performed a systematic review to examine, in the context of patient-provider HNC consultations: discussions about HPV, attitudes towards discussing HPV and information needs. METHODS: We searched Embase, PsychINFO, and CINAHL + for studies to August 2018. Eligible studies included: HNC healthcare professionals (HCPs) and/or HNC patients investigated HNC patient-provider communication about HPV. RESULTS: Ten studies were identified: six including HCPs and four including HNC patients. HCPs varied in confidence in HPV discussions, which was related to their HPV knowledge. Both HCPs and patients acknowledged the need for reliable HPV information. Factors which facilitated HPV discussions included accessible HPV information for patients and HCPs and good HPV knowledge among HCPs. Barriers included the perception, among HCPs, that HPV was a challenging topic to discuss with patients. CONCLUSIONS: Information deficits, communication challenges and barriers to discussing HPV were identified in HNC patient-provider consultations. PRACTICE IMPLICATIONS: Appropriate HPV information is needed for HCPs and patients. Professional development initiatives which increase HCPs' HPV knowledge and build their communication skills would be valuable.

Osteoporotic fractures in patients with systemic lupus erythematosus and end stage renal disease.

Background The incidence of end stage renal disease (ESRD) in patients with systemic lupus erythematosus (SLE) is rising. However, the relationship between osteoporotic fractures and SLE in the setting of ESRD remains uninvestigated. The purpose of this study was to compare the frequency of incident osteoporotic fractures in patients with ESRD with and without SLE, to identify risk factors for fractures in patients with SLE and ESRD, and to examine the contribution of these fractures to mortality. Methods Retrospective cohort study of patients with SLE ( n = 716) and a 5% random sample of controls without SLE ( n = 4176) in the United States Renal Data System (USRDS) from years 2006-2008 enrolled in Medicare Part D. Results Fractures occurred in 10.6% ( n = 76) of patients with SLE and ESRD and 12.1% ( n = 507) of patients with ESRD without SLE ( p = 0.24). Older age (adjusted relative risk 1.02, 95% confidence interval 1.01-1.04) was associated with an increased risk for fracture in patients with SLE and ESRD. In multivariable analyses, vertebral and hip fractures more than doubled the risk for mortality. Conclusions The frequency of osteoporotic fractures in patients with SLE and ESRD is similar to the general population of patients with ESRD. Vertebral and hip fractures are significant contributors to mortality in patients with SLE and ESRD. Fracture prevention, in particular, for elderly patients with SLE and ESRD, should be considered. Summary SLE is not an independent risk factor for fractures in patients with ESRD. However, among patients with SLE and ESRD, vertebral and hip fractures are significant contributors to mortality.

Management of native warm-season grasses for beef cattle and biomass production in the Mid-South USA.

Native grasses, such as switchgrass (SG; L.), big bluestem (BB; Vitman), indiangrass (IG; Nash), and eastern gamagrass (EG; [L.] L.) may be capable of providing desirable summer forage for cattle as well as a source of biomass for renewable energy. To evaluate that potential, experiments were conducted at 2 locations in Tennessee comparing weaned beef () steers (268 ± 25 kg initial BW) during early-season grazing (Early; 30 d, typically corresponding to May, followed by postdormancy biomass harvest) and full-season grazing (Full, mean duration = 98 d). For Exp. 1, which compared SG, a blend of BB and IG (BBIG), and EG, ADG was greater ( < 0.05) for BBIG (1.02 kg/d) than SG (0.85 kg/d), and both were greater ( < 0.05) than EG (0.66 kg/d). Grazing days for SG and EG were similar (389 and 423 animal unit days [AUD]/ha, respectively) and exceeded ( < 0.05) that of BBIG (233 AUD/ha) during Full. In Exp. 2 (SG and BBIG only), rates of gain were comparable to that of Exp. 1, but AUD were 425 (SG) and 299 (BBIG) AUD/ha. Such rates of gain and grazing days indicate that these grasses can provide desirable summer forage for growing cattle. Early produced 211 to 324 kg BW gain/ha, depending on experiment and forage, followed by dormant-season harvests of 7.5 to 10.5 Mg/ha of biomass, indicating a potential for beef cattle forage and biomass production on the same land resource. Native grasses provided productive summer pasture and good rates of gain on growing cattle and could contribute to forage programs, especially where cool-season grasses currently predominate.

Structural insights into the ene-reductase synthesis of profens.

Reduction of double bonds of α,ß-unsaturated carboxylic acids and esters by ene-reductases remains challenging and it typically requires activation by a second electron-withdrawing moiety, such as a halide or second carboxylate group. We showed that profen precursors, 2-arylpropenoic acids and their esters, were efficiently reduced by Old Yellow Enzymes (OYEs). The XenA and GYE enzymes showed activity towards acids, while a wider range of enzymes were active towards the equivalent methyl esters. Comparative co-crystal structural analysis of profen-bound OYEs highlighted key interactions important in determining substrate binding in a catalytically active conformation. The general utility of ene reductases for the synthesis of (R)-profens was established and this work will now drive future mutagenesis studies to screen for the production of pharmaceutically-active (S)-profens.

The changing landscape of cervical screening-What does the future hold for primary care?

The landscape of cervical cancer prevention is changing in many countries thanks to the introduction of vaccination against high-risk types of human papillomavirus (HPV) and the incorporation of HPV DNA testing into cervical screening algorithms. In addition to this, uptake of screening is falling year on year in the UK and elsewhere. These factors present challenges and opportunities for health professionals working in primary care-in terms of communicating programmatic changes to women; responding to questions about the meaning and implications of HPV test results; and delivering interventions to increase screening uptake.

Physical after-effects of colposcopy and related procedures, and their inter-relationship with psychological distress: a longitudinal survey.

OBJECTIVE: To estimate prevalence of post-colposcopy physical after-effects and investigate associations between these and subsequent psychological distress. DESIGN: Longitudinal survey. SETTING: Two hospital-based colposcopy clinics. POPULATION: Women with abnormal cytology who underwent colposcopy (±related procedures). METHODS: Questionnaires were mailed to women 4, 8 and 12 months post-colposcopy. Details of physical after-effects (pain, bleeding and discharge) experienced post-colposcopy were collected at 4 months. Colposcopy-specific distress was measured using the Process Outcome-Specific Measure at all time-points. Linear mixed-effects regression was used to identify associations between physical after-effects and distress over 12 months, adjusting for socio-demographic and clinical variables. MAIN OUTCOME MEASURES: Prevalence of post-colposcopy physical after-effects. Associations between the presence of any physical after-effects, awareness of after-effects, and number of after-effects and distress. RESULTS: Five-hundred and eighty-four women were recruited (response rate = 73, 59 and 52% at 4, 8 and 12 months, respectively). Eighty-two percent of women reported one or more physical after-effect(s). Multiple physical after-effects were common (two after-effects = 25%; three after-effects = 25%). Psychological distress scores declined significantly over time. In adjusted analyses, women who experienced all three physical after-effects had on average a 4.58 (95% CI: 1.10-8.05) higher distress scored than those who experienced no after-effects. Women who were unaware of the possibility of experiencing after-effects scored significantly higher for distress during follow-up. CONCLUSIONS: The prevalence of physical after-effects of colposcopy and related procedures is high. The novel findings of inter-relationships between awareness of the possibility of after-effects and experiencing multiple after-effects, and post-colposcopy distress may be relevant to the development of interventions to alleviate post-colposcopy distress. TWEETABLE ABSTRACT: Experiencing multiple physical after-effects of colposcopy is associated with psychological distress.

Human Papillomavirus and Head and Neck Cancer: Psychosocial Impact in Patients and Knowledge of the Link - A Systematic Review.

Head and neck cancer (HNC) currently affects approximately 11 200 people in the UK, with an increasing proportion known to be caused by the human papillomavirus (HPV). We undertook a systematic review of studies measuring the psychosocial impact of HPV-related HNC and also studies measuring knowledge about the link between HPV and HNC among different populations. Searches were conducted on MEDLINE, Embase, PsycINFO, CINAHL Plus and Web of Science, with reference and forward citation searches also carried out on included studies. Studies were selected if they (i) were original peer-reviewed research (qualitative or quantitative), (ii) mentioned HPV and HNC, (iii) measured an aspect of the psychosocial impact of the diagnosis of HPV-related HNC as the dependent variable and/or (iv) measured knowledge of the association between HPV and HNC. In total, 51 papers met the inclusion criteria; 10 measuring psychosocial aspects and 41 measuring knowledge of the link between HPV and HNC. Quality of life in those with HPV-positive HNC was found to be higher, lower or equivalent to those with HPV-negative HNC. Longitudinal studies found quality of life in patients was at its lowest 2-3 months after diagnosis and some studies found quality of life almost returned to baseline levels after 12 months. Knowledge of the link between HPV and HNC was measured among different populations, with the lowest knowledge in the general population and highest in medical and dental professionals. Due to the limited studies carried out with patients measuring the psychosocial impact of a diagnosis of HPV-positive HNC, future work is needed with the partners of HPV-positive HNC patients and health professionals caring for these patients. The limited knowledge of the association between HPV and HNC among the general population also indicates the need for research to explore the information that these populations are receiving.

The cost of feeding bred dairy heifers on native warm-season grasses and harvested feedstuffs.

Heifer rearing is one of the largest production expenses for dairy cattle operations, which is one reason milking operations outsource heifer rearing to custom developers. The cost of harvested feedstuffs is a major expense in heifer rearing. A possible way to lower feed costs is to graze dairy heifers, but little research exists on this topic in the mid-south United States. The objectives of this research were to determine the cost of feeding bred dairy heifers grazing native warm-season grasses (NWSG), with and without legumes, and compare the cost of grazing with the cost of rearing heifers using 3 traditional rations. The 3 rations were corn silage with soybean meal, corn silage with dry distillers grain, and a wet distillers grain-based ration. Bred Holstein heifers between 15- and 20-mo-old continuously grazed switchgrass (SG), SG with red clover (SG+RC), a big bluestem and Indiangrass mixture (BBIG), and BBIG with red clover (BBIG+RC) in Tennessee during the summer months. Total grazing days were calculated for each NWSG to determine the average cost/animal per grazing day. The average daily gain (ADG) was calculated for each NWSG to develop 3 harvested feed rations that would result in the same ADG over the same number of grazing day as each NWSG treatment. The average cost/animal per grazing day was lowest for SG ($0.48/animal/grazing d) and highest for BBIG+RC ($1.10/animal/grazing d). For both BBIG and SG, legumes increased the average cost/animal per grazing day because grazing days did not increase enough to account for the additional cost of the legumes. No difference was observed in ADG for heifers grazing BBIG (0.85 kg/d) and BBIG+RC (0.94 kg/d), and no difference was observed in ADG for heifers grazing SG (0.71 kg/d) and SG+RC (0.70 kg/d). However, the ADG for heifers grazing SG and SG+RC was lower than the ADG for heifers grazing either BBIG or BBIG+RC. The average cost/animal per grazing day was lower for all NWSG treatments than the average cost/animal per day for all comparable feed rations at a low, average, and high yardage fee. Results of this study suggest that SG was the most cost-effective NWSG alternative to harvested feeds for bred dairy heifer rearing.