Diagnostic utility of CT angiography compared with endoscopy in patients with acute GI hemorrhage.

BACKGROUND AND AIMS: Because it is minimally invasive, CT angiography (CTA) has emerged as an attractive diagnostic tool for investigation of acute GI hemorrhage. METHODS: This study examined patients with acute GI bleeding who underwent CTA. RESULTS: CTA was the initial diagnostic examination in 177 patients, identifying upper and lower GI bleeding lesions in 16 and 27 patients, respectively. In 103 patients with an initial negative CTA, 78 had endoscopy (32 EGD and 46 colonoscopy/flexible sigmoidoscopy), of whom 52 (67%) had a bleeding lesion identified, including 23 with a high-risk bleeding lesion requiring therapy. Peptic ulcer disease and diverticular bleeding were the most commonly identified bleeding lesions. With endoscopy as a criterion standard, the sensitivity of CTA for the detection of a source of GI bleeding was 20%. CONCLUSIONS: CTA has very poor sensitivity for identification of a GI bleeding source or lesion, suggesting that CTA should not be used as an initial diagnostic test.

Antibody-mediated rejection in pediatric kidney transplant recipients: A report from the Pediatric Nephrology Research Consortium.

BACKGROUND: Antibody-mediated rejection (AMR) is a major cause of kidney allograft loss. There is a paucity of large-scale pediatric-specific data regarding AMR treatment outcomes. METHODS: Data were obtained from 14 centers within the Pediatric Nephrology Research Consortium. Kidney transplant recipients aged 1-18 years at transplant with biopsy-proven AMR between 2009 and 2019 and at least 12 months of follow-up were included. The primary outcome was graft failure or an eGFR <20 mL/min/1.73 m2 at 12 months following AMR treatment. AMR treatment choice, histopathology, and DSA class were also examined. RESULTS: We reviewed 123 AMR episodes. Median age at diagnosis was 15 years at a median 22 months post-transplant. The primary outcome developed in 27.6%. eGFR <30 m/min/1.73 m2 at AMR diagnosis was associated with a 5.6-fold higher risk of reaching the composite outcome. There were no significant differences in outcome by treatment modality. Histopathology scores and DSA class at time of AMR diagnosis were not significantly associated with the primary outcome. CONCLUSIONS: In this large cohort of pediatric kidney transplant recipients with AMR, nearly one-third of patients experienced graft failure or significant graft dysfunction within 12 months of diagnosis. Poor graft function at time of diagnosis was associated with higher odds of graft failure.

The Prevalence of Hip Dysplasia on Radiographs for Adolescent Idiopathic Scoliosis.

BACKGROUND: During radiographic assessment of adolescent idiopathic scoliosis (AIS), upright images frequently capture the hip. The purpose of this study was to assess the prevalence of radiographic hip dysplasia on postero-anterior (PA) scoliosis radiographs, as defined as a lateral center edge angle (LCEA) ≤25 degrees. METHODS: All patients with upright PA scoliosis radiographs over a one-year study period at a single tertiary academic medical center (2020 to 2021) were included in the study. Radiographs containing the hip joints were annotated by 3 reviewers for left and right LCEA, and triradiate cartilage (TRC) status. Inter-rater reliability was determined among the 3 reviewers. RESULTS: Two hundred fifty patients {500 hips, 75.6% female, median age 14 [interquartile range (IQR)=3]} had PA scoliosis radiographs that captured the hip, which qualified for analysis. Seventy-four hips (14.8%) demonstrated evidence of dysplasia (LCEA ≤25 deg) in 55/250 patients (22%). The median LCEA was significantly lower in the dysplastic hip cohort (23.9 deg, IQR=4.8 deg), compared with those without dysplasia (33 deg IQR=7.3 deg; P=0.001). A higher percentage of dysplastic hip patients were female than male (72.7% vs. 27.3%). Patients with bilateral dysplasia had a similar LCEA ( 22.9 deg) [to those with unilateral dysplasia (22.9 deg left, 23.9 deg right, P=0.689)]. CONCLUSIONS: In a cohort of 250 AIS patients, 22% demonstrated evidence of hip dysplasia, as defined as an LCEA ≤2 degrees. The dysplastic patients were more likely to be female. Screening for hip symptomatology in AIS patients may be of benefit, considering the frequency of radiographic hip dysplasia in this population. LEVEL OF EVIDENCE: III. Type of Evidence: diagnostic.

Impact of Donor Hemodynamics on Recipient Survival in Heart Transplantation.

BACKGROUND: Heart transplantation is the gold-standard therapy for end-stage heart failure, but rates of donor-heart use remain low due to various factors that are often not evidence based. The impact of donor hemodynamics obtained via right-heart catheterization on recipient survival remains unclear. METHODS: The United Network for Organ Sharing registry was used to identify donors and recipients from September 1999-December 2019. Donor hemodynamics data were obtained and analyzed using univariate and multivariable logistical regression, with the primary endpoints being 1- and 5-year post-transplant survival. RESULTS: Of the 85,333 donors who consented to heart transplantation during the study period, 6573 (7.7%) underwent right-heart catheterization, of whom 5531 eventually underwent procurement and transplantation. Donors were more likely to undergo right-heart catheterization if they had high-risk criteria. Recipients who had donor hemodynamic assessment had 1- and 5-year survival rates similar to those without donor hemodynamic assessment (87% vs 86%, 1 year). Abnormal hemodynamics were common in donor hearts but did not impact recipient survival rates, even when risk-adjusted in multivariable analysis. CONCLUSIONS: Donors with abnormal hemodynamics may represent an opportunity to expand the pool of viable donor hearts.

Accurate Identification of Patients with Cirrhosis and Its Complications in the Electronic Health Record.

BACKGROUND: Cirrhosis represents a significant health burden; administrative data provide an important tool for research studies. AIMS: We aimed to understand the validity of current ICD-10 codes compared to previously used ICD-9 codes to identify patients with cirrhosis and its complications. METHODS: We identified 1981 patients presenting to MUSC between 2013 and 2019 with a diagnosis of cirrhosis. To validate the sensitivity of ICD codes, we reviewed the medical records of 200 patients for each associated ICD 9 and 10 codes. Sensitivity, specificity, and positive predictive value for each ICD code (individually or when combined) were calculated and univariate binary logistic models, for cirrhosis and its complications, predicted probabilities were used to calculate C-statistics. RESULTS: Single ICD 9 and 10 codes were similarly insensitive for detection of cirrhosis, with sensitivity ranging from 5 to 94%. However, ICD-9 code combinations (when used as either/or) had high sensitivity and specificity for the detection of cirrhosis, with the combination of either 571.5 (or 456.21) or 571.2 codes having a C-statistic of 0.975. Combinations of ICD-10 codes were only slightly less sensitive and specific than ICD-9 codes for detection of cirrhosis (K76.6, or K70.31, plus K74.60 or K74.69, and K70.30 had a C-statistic of 0.927). CONCLUSIONS: ICD-9 and ICD-10 codes when used alone were inaccurate for identifying cirrhosis. ICD-10 and ICD-9 codes had similar performance characteristics. Combinations of ICD codes exhibited the greatest sensitivity and specificity for detection of cirrhosis, and thus should be used to accurately identify cirrhosis.

Same Day Discharge After Mastectomy and Immediate Implant-Based Breast Reconstruction: A Retrospective Cohort Comparison Using the National Surgical Quality Improvement Program Database.

INTRODUCTION: Currently, overnight admission after immediate implant-based breast reconstruction (IBR) is the standard of care. Our study aims to analyze the safety, feasibility, and outcomes of immediate IBR with same-day discharge as compared with the standard overnight stay. METHODS: The 2015-2020 National Surgical Quality Improvement Program database was reviewed to identify all patients undergoing mastectomy with immediate IBR for malignant breast disease. Patients were stratified into study (patients discharged day of surgery) and control (patients admitted after surgery) groups. Patient demographics, comorbidities, surgical characteristics, implant type, wound complications, readmission, and reoperation rates were collected and analyzed. Univariate and multivariate logistic regression was used to determine independent predictors of same-day discharge versus admission. In addition, Pearson χ2 test was used for comparison of proportions and t test was used for continuous variables unless distributions required subsequent nonparametric analyses. Statistical significance was defined as a P value less than 0.05. RESULTS: A total of 21,923 cases were identified. The study group included 1361 patients discharged same day and the control group included 20,562 patient s admitted for average of 1.4 days (range, 1-86). Average age was 51 years for both groups. Average body mass index for the study group 27 and 28 kg/m2 for the control group, respectively. Total wound complication rates were similar (4.5% study, 4.3% control, P = 0.72). Reoperation rates were lower with same-day discharge (5.7% study, 6.8% control, P = 0.105), though not statistically significant. However, same-day discharge patients had a significantly lower readmission rate compared with the control (2.3% study, 4.2% control, P = 0.001). CONCLUSION: National Surgical Quality Improvement Program data analysis over a 6-year period reveals that immediate IBR with same-day discharge is associated with a significantly lower readmission rate when compared with the standard overnight stay. The comparable complication profiles show that immediate IBR with same-day discharge is safe, potentially benefiting both patients and hospitals.

Transcutaneous Auricular Vagus Nerve Stimulation Attenuates Early Increases in Heart Rate Associated With the Cold Pressor Test.

INTRODUCTION: Transcutaneous auricular vagus nerve stimulation (taVNS) may be useful in treating disorders characterized by chronic parasympathetic disinhibition. Acute taVNS decreases resting heart rate in healthy individuals, but little is known regarding the effects of taVNS on the cardiac response to an acute stressor. To investigate effects on the acute stress response, we investigated how taVNS affected heart rate changes during a cold pressor test (CPT), a validated stress induction technique that reliably elicits a sympathetic stress response with marked increases in heart rate, anxiety, stress, and pain. MATERIALS AND METHODS: We recruited 24 healthy adults (ten women, mean age = 29 years) to participate in this randomized, crossover, exploratory trial. Each subject completed two taVNS treatments (one active, one sham) paired with CPTs in the same session. Order of active versus sham stimulation was randomized. Heart rate, along with ratings of anxiety, stress, and pain, was collected before, during, and after each round of taVNS/sham + CPT. RESULTS: In both stimulation conditions, heart rate was elevated from baseline in response to the CPT. Analyses also revealed a difference between active and sham taVNS during the first 40 seconds of the CPT (Δ heart rate [HR] = 12.75 ± 7.85 in the active condition; Δ HR = 16.09 ± 11.43 in the sham condition, p = 0.044). There were no significant differences in subjective ratings between active and sham taVNS. CONCLUSIONS: In this randomized, sham-controlled study, taVNS attenuated initial increases in HR in response to the CPT. Future studies are needed to investigate the effects of various taVNS doses and parameters on the CPT, in addition to other forms of stress induction. CLINICAL TRIAL REGISTRATION: The Clinicaltrials.gov registration number for the study is NCT00113453.

Electrical delays in quadripolar leads with cardiac resynchronization therapy.

BACKGROUND: Pacing at sites of late intraventricular activation (QLV) or long interventricular conduction (right ventricle [RV]-left ventricular [LV]) have been associated with improved cardiac resynchronization therapy (CRT) outcomes. Quadripolar leads improve CRT outcomes by allowing for electrical repositioning to optimize pacing sites. However, little is known regarding the effect of such repositioning on electrical delay. OBJECTIVE: Determine the relationship between different electrical bipoles from a quadripolar lead and measures of electrical delay. METHODS: Forty-six patients underwent CRT with a quadripolar lead. The RV-LV and QLV intervals were measured for both the proximal and distal bipoles and the difference (Δ) between bipoles for each measure were calculated. Multivariate analyses were performed to identify predictors of electrical delays. RESULTS: This was a typical CRT population with a mean age of 65 years and ejection fraction of 27%, with left bundle branch block (LBBB) present in 70%. The regression model for ΔQLV was significant (p = .05), with both gender (p = .008) and LBBB status (p = .020) significant predictors. The overall regression model for ΔRV-LV was not significant. ΔQLV and ΔRV-LV were significant among LBBB patients. Among non-LBBB, only ΔRV-LV was significant (mean: 7.2 ms, p = .006). ΔRV-LV versus ΔQLV were strongly correlated in LBBB (R2 = .92) but not non-LBBB (R2 = .06). CONCLUSION: In LBBB, ΔRV-LV and ΔQLV are closely correlated suggesting that the proximal bipole and thus basal LV pacing sites should be selected when feasible. Greater variation in activation pattern is present in non-LBBB, so pacing sites should be individualized.

Advanced glycation end products are elevated in estrogen receptor-positive breast cancer patients, alter response to therapy, and can be targeted by lifestyle intervention.

PURPOSE: Lifestyle factors associated with personal behavior can alter tumor-associated biological pathways and thereby increase cancer risk, growth, and disease recurrence. Advanced glycation end products (AGEs) are reactive metabolites produced endogenously as a by-product of normal metabolism. A Western lifestyle also promotes AGE accumulation in the body which is associated with disease phenotypes through modification of the genome, protein crosslinking/dysfunction, and aberrant cell signaling. Given the links between lifestyle, AGEs, and disease, we examined the association between dietary-AGEs and breast cancer. METHODS: We evaluated AGE levels in bio-specimens from estrogen receptor-positive (ER+) and estrogen receptor-negative (ER-) breast cancer patients, examined their role in therapy resistance, and assessed the ability of lifestyle intervention to reduce circulating AGE levels in ER+ breast cancer survivors. RESULTS: An association between ER status and AGE levels was observed in tumor and serum samples. AGE treatment of ER+ breast cancer cells altered ERα phosphorylation and promoted resistance to tamoxifen therapy. In a proof of concept study, physical activity and dietary intervention was shown to be viable options for reducing circulating AGE levels in breast cancer survivors. CONCLUSIONS: There is a potential prognostic and therapeutic role for lifestyle derived AGEs in breast cancer. Given the potential benefits of lifestyle intervention on incidence and mortality, opportunities exist for the development of community health and nutritional programs aimed at reducing AGE exposure in order to improve breast cancer prevention and treatment outcomes.

Interventions Promoting Physical Activity in African American Women: An Integrative Review.

BACKGROUND: Physical inactivity significantly impacts mortality worldwide. Physical inactivity is a modifiable risk factor for obesity, diabetes, cardiovascular disease, and other chronic conditions. African American women in the United States have the highest rates of physical inactivity when compared with other gender/ethnic groups. A paucity of research promoting physical activity (PA) in African American women has been previously identified. The purpose of this review was to identify intervention strategies and outcomes in studies designed to promote PA in African American women. METHODS: Interventions that promoted PA in African American women published between 2000 and May 2015 were included. A comprehensive search of the literature was performed in Health Source: Nursing/Academic Edition, PsycINFO, CINAHL Complete, and MEDLINE Complete databases. Data were abstracted and synthesized to examine interventions, study designs, theoretical frameworks, and measures of PA. RESULTS: Mixed findings (both significant and nonsignificant) were identified. Interventions included faith-based, group-based, and individually focused programs. All studies (n = 32) included measures of PA; among the studies, self-report was the predominant method for obtaining information. Half of the 32 studies focused on PA, and the remaining studies focused on PA and nutrition. Most studies reported an increase in PA or adherence to PA. This review reveals promising strategies for promoting PA. CONCLUSIONS: Future studies should include long-term follow-up, larger sample sizes, and objective measures of PA. Additional research promoting PA in African American women is warranted, particularly in studies that focus on increasing PA in older African American women.

Screening for Physical Activity and Cardiometabolic Risk Factors Among Rural African-American Women.

Physical inactivity can have major implications for cardiovascular disease and diabetes, which are leading causes of morbidity among African-American women. Recruiting in rural populations can present challenges and strategies that work in one community but may not be successful in another community. This study examined the feasibility, acceptability, and implementation of community-based screening using an abbreviated Racial and Ethnic Approaches to Community Health (REACH) Risk Factor self-report survey in a geographic region where these data were previously unavailable. Participants (N = 32) included African-American/Black women, 21 years of age or older, who attended health screening events in a rural county in South Carolina. Findings from this study demonstrated the feasibility of community-based cardiometabolic risk screenings using an abbreviated REACH Risk Factor survey and linking participants to follow-up primary care. Findings also provide insight into recruitment strategies in this geographic region.

The Lived Experience of African-American Informal Caregivers of Family Members with Alzheimer's Disease and Related Dementias.

The purpose of this qualitative study was to describe the lived experience of African-American informal caregivers of family members with Alzheimer's Disease and Related Dementias (ADRD) in a home environment. Using a qualitative, phenomenological approach, a purposive sample of 16 African-American informal caregivers completed an in-depth interview that lasted from 30 to 60 minutes. Four themes emerged: (a) a sense of obligation, (b) an arduous journey, (c) sentinel events, and (d) faith in God. Findings indicated that caregivers needed to be well-informed concerning the demands of caregiving and needed more assistance with the task of delivering care. Informal caregivers lacked support, knowledge, and guidance. Implications for the discipline of nursing include emphasis on family assessment, teaching, awareness of resources, and collaboration with healthcare teams.

Appropriateness of recommendations for surveillance colonoscopy after polypectomy - a comparison of adherence to the 2012 and 2020 USMSTF guidelines.

Background: Screening colonoscopy detects precancerous polyps, which when resected, prevents colon cancer. Recommendations for surveillance colonoscopy after polypectomy are based on the U.S. Multi-Society Task Force guidelines (USMSTF). Aim: to examine provider recommendations based on 2012 and 2020 USMSTF guidelines. Methods: A prospective analysis was performed to examine provider recommendations for index screening and surveillance colonoscopy from March 2022 to January 2023. Procedures with unknown histology or unsatisfactory bowel preparation were excluded. We recorded polyp morphology, histology, and subsequent recommendations made by endoscopists, to compare to the USMSTF guidelines. Results: 241 patients were included, with 371 endoscopies reviewed. For index screening colonoscopies, 86%, performed between 2012 and 2020, adhered to 2012 guidelines, while 71%, performed after 2020, adhered to the 2020 guidelines. For surveillance colonoscopies, 62% from 2012 and 2020, and 50% after 2020, adhered to the 2012 and 2020 guidelines, respectively (P < 0.001). For polyp types, recommendations after index colonoscopies showed low-risk adenoma (LRA) had 88% adherence to 2012 guidelines versus 73% adherence to 2020 guidelines. For surveillance colonoscopies, LRA had 73% adherence to 2012 guidelines versus 42% adherence to 2020 guidelines (P < 0.001). Recommendations after index colonoscopy showed high-risk adenoma (HRA) had 79% adherence to 2012 guidelines versus 63% adherence to 2020 guidelines. For surveillance colonoscopies, HRA had 88% adherence to the 2012 guidelines versus 69% adherence to 2020 guidelines (P < 0.001). Conclusions: Adherence declined for the introduction of 2020 guidelines and was poorer after 2nd surveillance exams. Increasing the evidence for interval recommendations may increase guideline adherence.

Delay in post-endoscopic refeeding in patients with upper GI bleeding leads to increased hospital length of stay.

BACKGROUND: Patients with acute upper gastrointestinal bleeding (UGIB) are made NPO prior to endoscopy. It is standard practice in those found to have low risk lesions to immediately resume a usual diet. Here, we evaluated refeeding practices in hospitalized patients with UGIB after endoscopy. METHODS: In this retrospective single-center cross-sectional study, we examined patients over the age of 18 with acute UGIB and low risk or no endoscopic lesion(s). Appropriate refeeding was categorically defined as resuming normal diet ≤ 4 h post-endoscopy. RESULTS: Of 230 patients (mean age, 62 years; 57% female) with acute UGIB and low-risk lesions or no lesion(s), 96 [41% (95% CI: 35% to 48%)] received their usual diet within 4 h after EGD. For the remaining 134 patients, refeeding was delayed on average from 13 (NPO until regular diet) to 31 (NPO until liquid diet, then regular diet) hours. Baseline clinical features were identical in patients who received their regular diet within 4 h after EGD and those who did not. Hospital length of stay was shorter in patients receiving usual diets promptly (5.3 days vs. 6.4 days, p = 0.03). Patients in an ICU at the time of their endoscopy had a statistically significantly higher probability of not being refed appropriately [OR 2.371, 95% CI 1.191-4.722). CONCLUSIONS: Inappropriate dietary restrictions are frequent in patients with UGIB caused by low risk lesions. This delay in refeeding leads to increased length of hospital stay - suggesting that appropriate refeeding is an opportunity to improve patient care.

Multi-prong quality improvement approach for increasing mother's own milk use for very low birth weight infants.

OBJECTIVE: Evaluate a single center quality improvement (QI) collaborative designed to increase the provision of mother's own milk (MOM) at discharge to premature infants through evidence-based practices while targeting perinatal health disparities. DESIGN: This QI initiative was designed for preterm infants admitted to a single-center NICU within 24 h of life. Interventions were implemented between March 2022 and June 2022. MOM provision rates were compared between baseline (August 2021-February 2022), and after interventions (March 2022-December 2022). RESULTS: The percentage of mothers who discontinued pumping during the infant hospitalization decreased from 49% to 35% (p < 0.01). Infant discharge diet with MOM improved from 36% to 58% (p < 0.001). Pump frequency at two weeks increased from 4.0 ± 2.6 to 5.1 ± 2.4 (p = 0.026). CONCLUSION: Our collaborative increased the percentage of preterm infants receiving MOM at discharge and reduced the number of mothers who discontinue pumping during the NICU hospitalization.

A multicenter evaluation of the HeartMate 3 risk score.

BACKGROUND: The Heartmate 3 (HM3) risk score (HM3RS) was derived and validated internally from within the Multicenter Study of MagLev Technology in Patients Undergoing Mechanical Circulatory Support Therapy with HeartMate 3 (MOMENTUM 3) trial population and provides 1- and 2-year mortality risk prediction for patients in those before HM3 left ventricular assist device (LVAD) implantation. We aimed to evaluate the HM3RS in nontrial unselected patients, including those not meeting inclusion criteria for MOMENTUM 3 trial enrollment. METHODS: Patients who underwent HM3 LVAD implant at 1 of 7 US centers between 2017 and 2021, with at least 1-year follow-up, were included in this analysis. Patients were retrospectively assessed for their eligibility for the MOMENTUM 3 trial based on study inclusion and exclusion criteria. HM3RS risk discrimination was evaluated using time-dependent receiver operating characteristic curve analysis for 1-year mortality for all patients and further stratified by MOMENTUM 3 trial eligibility. Kaplan-Meier curves were constructed using the HM3RS-based risk categories. RESULTS: Of 521 patients included in the analysis, 266 (51.1%) would have met enrollment criteria for MOMENTUM 3. The 1- and 2-year survival for the total cohort was 85% and 81%, respectively. There was no statistically significant difference in survival between those who met and did not meet enrollment criteria at 1 (87% vs 83%; p = 0.21) and 2 years postimplant (80% vs 78%; p = 0.39). For the total cohort, HM3RS predicted 1-year survival with an area under the curve (AUC) of 0.63 (95% confidence interval [CI]: 0.57-0.69, p < 0.001). HM3RS performed better in the subset of patients meeting enrollment criteria: AUC 0.69 (95% CI:0.61-0.77, p < 0.001) compared to the subset that did not: AUC 0.58 (95% CI: 0.49-0.66, p = 0.078). CONCLUSIONS: In this real-world evidence, multicenter cohort, 1- and 2-year survival after commercial HM3 LVAD implant was excellent, regardless of trial eligibility. The HM3RS provided adequate risk discrimination in "trial-like" patients, but predictive value was reduced in patients who did not meet trial criteria.

Interactive influences of ethnicity, endothelin-1 gene, and everyday discrimination upon nocturnal ambulatory blood pressure.

BACKGROUND: Everyday discrimination scale scores are associated with increased ambulatory blood pressure (BP) and reduced nocturnal dipping, and the endothelin-1 (ET-1)/Lys198Asn polymorphism is associated with increased resting BP and exaggerated BP reactivity among African Americans compared to European Americans. Combined influences of these factors on BP control are unknown. PURPOSE: This study tested the hypothesis of a three-way interaction between ethnicity, ET-1 carrier status, and everyday discrimination upon ambulatory BP and nocturnal dipping. METHODS: Baseline laboratory anthropometrics and the everyday discrimination scale were completed by 352 (175 African American) young adult normotensives, followed by 24-h ambulatory BP monitoring. RESULTS: For nocturnal dipping, multiple regression models controlling for age, sex, ethnicity, and body mass index revealed significant three-way ET-1 × everyday discrimination × ethnicity interactions. Specifically, among African American ET-1 T-allele carriers, increases in everyday discrimination led to reduced nocturnal dipping. CONCLUSIONS: African Americans that carry the ET-1/Lys198Asn T-allele and report higher everyday discrimination scores may be at particular risk for reduced nocturnal dipping.

Trends in Preterm Body Composition and Neurodevelopmental Outcomes after Discharge.

INTRODUCTION: Body composition, specifically fat-free mass (FFM), of preterm infants is associated with improved neurodevelopmental outcomes. Little is known about body composition of preterm infants after discharge. Preterm body composition was measured by air displacement plethysmography (ADP) at two time points, inpatient (35-40 weeks postmenstrual age [PMA]) and outpatient (48-58 weeks PMA), with neonatal factors and neurodevelopmental testing at 4-6 months corrected age. We hypothesized increased FFM is positively associated with neurodevelopment. METHODS: From 2007 to 2011, 510 infants admitted to the Medical University of South Carolina's neonatal intensive care unit underwent ADP. A total of 379 of 510 (74%) had anthropometrics at birth, an ADP scan with FFM, fat mass, fat percent z-scores, and an outpatient neurodevelopmental evaluation (CAT/CLAMS, Peabody Gross Motor). Variables were compared using multivariate analyses for body composition measurements. RESULTS: The infants were 32 ± 4.8 weeks gestational age at birth with an average birth weight of 1,697 ± 932 g. Most (56%) infants received maternal milk at discharge. CAT, CLAMS, and gross motor scores had positive correlations with FFM z-scores at inpatient and outpatient ADP (p < 0.05). Receiving maternal milk at discharge was positively associated with cognitive (ß = 0.22, p < 0.05) and language scores (ß = 0.26, p < 0.05). CONCLUSION: Increased FFM is associated with improved cognitive, language, and gross motor testing. Maternal milk was positively associated with language and cognitive scores.

A Multimodality Imaging Approach to Defining Risk in Patients With Acute Pulmonary Embolism.

BACKGROUND: Morbidity and mortality for acute pulmonary embolism (PE) remain high. Therapies such as catheter-directed thrombolysis may improve outcomes, but these are generally reserved for higher-risk patients. Imaging may help guide the use of the newer therapies, but current guidelines focus more on clinical factors. Our goal was to create a risk model that incorporated quantitative echocardiographic and computed tomography (CT) measures of right ventricular (RV) size and function, thrombus burden, and serum biomarkers of cardiac overload or injury. METHODS: This was a retrospective study of 150 patients evaluated by a PE response team. Echocardiography was performed within 48 hours of diagnosis. Computed tomography measures included RV/left ventricular (LV) ratio and thrombus load (Qanadli score). Echocardiography was used to obtain various quantitative measures of RV function. We compared characteristics of those who met the primary endpoint (7-day mortality and clinical deterioration) to those who did not. Receiver operating curve analysis was used to assess the performance of different combinations of clinically relevant features and the association with adverse outcomes. RESULTS: Fifty-two percent of patients were female, with age 62 ± 17 years, systolic blood pressure 123 ± 25 mm Hg, heart rate 98 ± 19, troponin 3.2 ± 35 ng/dL, and b-type natriuretic peptide (BNP) 467 ± 653. Fourteen (9.3%) were treated with systemic thrombolytics, 27 (18%) underwent catheter-directed thrombolytics, 23 (15%) were intubated or required vasopressors, and 14 (9.3%) died. Patients who met the primary endpoint (44%) versus those who did not (56%) had lower RV S' (6.6 vs 11.9 cm/sec; P < .001) and RV free wall strain (-10.9% vs -13.6%; P = .005), higher RV/LV ratio on CT, and higher serum BNP and troponin levels. Receiver operating curve analysis demonstrated an area under the curve of 0.89 for a model that included RV S', RV free wall strain and tricuspid annular plane systolic excursion/RV systolic pressure ratio from echo, thrombus load and RV/LV ratio from CT, and troponin and BNP levels. CONCLUSION: A combination of clinical, echo, and CT findings that reflect the hemodynamic effects of the embolism identified patients with adverse events related to acute PE. Optimized scoring systems that focus on reversible abnormalities attributable to PE may allow more appropriate triaging of intermediate- to high-risk patients with PE for early interventional strategy.

Safety and Efficacy of Topical Lovastatin Plus Cholesterol Cream vs Topical Lovastatin Cream Alone for the Treatment of Disseminated Superficial Actinic Porokeratosis: A Randomized Clinical Trial.

Importance: Disseminated superficial actinic porokeratosis (DSAP) is an inherited or sporadic disorder of keratinization associated with germline variations. There is no effective standard of care therapy for DSAP, but treatment with topical lovastatin combined with cholesterol cream has shown promise. Objectives: To evaluate and compare the safety and efficacy of topical lovastatin 2% plus cholesterol 2% cream (lovastatin-cholesterol) and topical lovastatin 2% cream (lovastatin) alone in adults diagnosed with DSAP. Design, Setting, and Participants: This patient- and assessor-blinded, randomized clinical trial was conducted at the Medical University of South Carolina between August 3, 2020, and April 28, 2021. Nonpregnant adults with a previous clinical or histological diagnosis of DSAP were eligible. Data were blindly analyzed after study completion. Interventions: Participants were randomized to once- or twice-daily application of either lovastatin-cholesterol cream (n = 17) or lovastatin cream (n = 14) to symptomatic regions for 12 weeks. Main Outcomes and Measures: The primary efficacy measure was the effect of the treatment on DSAP at the end of treatment (12 weeks) as measured by the DSAP General Assessment Severity Index (DSAP-GASI; scored from 0-4, with 0 indicating clear and 4 indicating severe). Treatment efficacy was based on investigator-standardized photographs provided by the participants because of the need for evaluation via telehealth during the COVID-19 pandemic. Secondary efficacy measures included patient-reported outcomes, application frequency, and adverse events (AEs). Results: Of the 87 participants screened, 32 were enrolled. One participant randomized to receive lovastatin-cholesterol did not receive the intervention, leaving 17 participants (mean [range] age, 59.2 [40-83] years; 13 females [76.5%]; all White) allocated to receive lovastatin-cholesterol treatment and 14 participants (13 female [92.9%]; mean (range) age, 53.7 [33-71] years; all White) to receive lovastatin treatment. Twelve participants in each treatment group qualified for the analysis. Disease severity decreased from week 1 to week 12 by 50.0% (from 3.08 [95% CI, 2.57-3.60] to 1.54 (95% CI, 1.04-2.05] points on the DSAP-GASI; P < .001) in the lovastatin-cholesterol group and 51.4% (from 2.92 [95% CI, 2.40-3.43] to 1.50 [95% CI, 0.99-2.01] points; P < .001) in the lovastatin group. There was no significant difference between the treatment groups according to application frequency at the end of 12 weeks. Adverse events reported included myalgia (n = 2), elevation in the creatine kinase level (n = 1), application discomfort (n = 4), and rash (n = 1). No serious AEs occurred, and all participants with an AE were able to complete the study. Conclusions and Relevance: This randomized clinical trial found improvements in DSAP severity in both treatment groups, without serious AEs, indicating a limited benefit with the addition of cholesterol. These results suggest that lovastatin cream may be a new primary treatment option for patients diagnosed with DSAP. Trial Registration: ClinicalTrials.gov Identifier: NCT04359823.