Characterizing "collateral damage" in men and women with metastatic breast cancer (mBC) from diverse racial and ethnic backgrounds in New York City.

PURPOSE: Patients from diverse racial, ethnic, and socio-economic backgrounds may be particularly vulnerable to experiencing undue social and financial burdens ("collateral damage") from a metastatic breast cancer (mBC) diagnosis; however, these challenges have not been well explored in diverse populations. METHODS: From May 2022 to May 2023, English- or Spanish-speaking adults with mBC treated at four New York-Presbyterian (NYP) sites were invited to complete a survey that assessed collateral damage, social determinants of health, physical and psychosocial well-being, and patient-provider communication. Fisher's exact and the Kruskal-Wallis rank-sum tests assessed differences by race and ethnicity. RESULTS: Of 87 respondents, 14% identified as Hispanic, 28% non-Hispanic Black (NHB), 41% non-Hispanic White (NHW), 7% Asian American Pacific Islander (AAPI), and 10% other/multiracial. While 100% of Hispanic, NHW, and AAPI participants reported stable housing, 29% of NHB participants were worried about losing housing (p = 0.002). Forty-two percent of Hispanic and 46% of NHB participants (vs. 8%, NHW and 0%, AAPI, p = 0.005) were food insecure; 18% of Hispanic and 17% of NHB adults indicated lack of reliable transportation in the last year (vs. 0%, NHW/AAPI, p = 0.033). Participants were generally satisfied with the quality of communication that they had with their healthcare providers and overall physical and mental well-being were modestly poorer relative to healthy population norms. CONCLUSIONS: In our study, NHB and Hispanic mBC patients reported higher levels of financial concern and were more likely to experience food and transportation insecurity compared to NHW patients. Systematically connecting patients with resources to address unmet needs should be prioritized to identify feasible approaches to support economically vulnerable patients following an mBC diagnosis.

Timing to Surgery and Lymph Node Upstaging in Gastric Cancer: An NCDB Analysis.

BACKGROUND: Prior studies have shown tumor specificity on the impact of longer time interval from diagnosis to surgery, however in gastric cancer (GC) this remains unclear. We aimed to determine if a longer time interval from diagnosis to surgery had an impact on lymph node (LN) upstaging and overall survival (OS) outcomes among patients with clinically node negative (cN0) GC. PATIENTS AND METHODS: Patients diagnosed with cN0 GC undergoing surgery between 2004-2018 were identified in the National Cancer Database (NCDB) and divided into intervals between time of diagnosis and surgery [short interval (SI): ≥ 4 days to < 8 weeks and long interval (LI): ≥ 8 weeks]. Multivariable regression analysis evaluated the independent impact of surgical timing on LN upstaging and a Cox proportional hazards analysis and Kaplan-Meier curves evaluated survival outcomes. RESULTS: Of 1824 patients with cN0 GC, 71.8% had a SI to surgery and 28.1% had a LI to surgery. LN upstaging was seen more often in the SI group when compared to LI group (82% versus 76%, p = 0.004). LI to surgery showed to be an independent factor protective against LN upstaging [adjusted odds ratio = 0.62, 95% CI: (0.39-0.99)]. Multivariate Cox regression analysis indicated that time to surgery was not associated with a difference in overall survival [hazard ratio (HR) = 0.91, 95% CI: (0.71-1.17)], however uncontrolled Kaplan-Meier curves showed OS difference between the SI and LI to surgery groups (p = 0.037). CONCLUSION: Timing to surgery was not a predictor of LN upstaging or overall survival, suggesting that additional medical optimization in preparation for surgery and careful preoperative staging may be appropriate in patients with node negative early stage GC without affecting outcomes.

Epidemiology of anticoagulation for children supported by extracorporeal membrane oxygenation in the United States: A Pediatric Hospital Information System database study.

INTRODUCTION: Due to the risk of thrombosis, nearly all children supported by extracorporeal membrane oxygenation (ECMO) receive systemic anticoagulation. While heparin has traditionally been used, there are reports of increased use of direct thrombin inhibitors. We sought to describe the use of anticoagulation in children supported by ECMO in the United States using a large administrative database. METHODS: We performed a retrospective cohort study of children supported by ECMO within the Pediatric Health Information System (PHIS) database. Pediatric encounters involving ECMO from 2012 to 2020 were identified. Data regarding demographics, diagnoses, anticoagulation, complications, and outcomes were extracted for eligible encounters. RESULTS: Eleven thousand five hundred ninety-five encounters that involved ECMO were identified. Fifty-four percent were male with an age range of 0-17 years and a median (IQR) age of 0 (0-2) years. Unfractionated heparin (UFH) only was used in 94% (95% CI: 93.6-94.5%) of encounters and UFH followed by bivalirudin in 5% (95% CI: 4.3-5.1%) of cases. There was a significant difference in the use of bivalirudin from 2012 to 2020 (p < 0.001). Differences in anticoagulation regimens were observed between infants and children (p = 0.004) and between those with and without cardiac indications for ECMO (p < 0.001). Four percent (95% CI: 4.1-4.8%) of encounters were associated with diagnostic coding for thrombosis and differences in occurrence of thrombosis were observed between different anticoagulant regimens (p < 0.001). CONCLUSIONS: Though the majority of children on ECMO in the United States receive heparin anticoagulation, there is an increase in use of direct thrombin inhibitors. Prospective studies must evaluate the efficacy of different anticoagulants in this patient population.

Anatomical classification of canine congenital extrahepatic portosystemic shunts based on CT angiography: A SVSTS and VIRIES multi-institutional study in 1082 dogs.

Canine congenital extrahepatic portosystemic shunt (EHPSS) morphologies have not been fully elucidated. The goal of this retrospective, multi-institutional study was to use CT angiography to create an anatomical-based nomenclature system for canine congenital EHPSS. These shunt morphologies were then evaluated to identify any significant association with patient age, sex, breed, weight, or subjective portal perfusion score. Data collected respectively from the SVSTS and VIRIES list-serves included patient DOB, sex, breed, weight, CT date, and reported diagnosis. A single author (C.W.) viewed all CT scans and classified shunts based on the shunt portal vessel(s) of origin, the shunt systemic vessel(s) of insertion, and any substantial portal vessels contributing to the shunt. Additionally, hepatic portal perfusion was subjectively scored between one (poor/none) and five (good/normal) based on the caliber of the intrahepatic portal veins. A total of 1182 CT scans were submitted from 13 different institutions. Due to exclusion criteria, 100 (8.5%) were removed, leaving 1082 CT scans to be included. Forty-five different EHPSS anatomies were identified with five classifications accounting for 85% of all shunts (left gastric-phrenic [27%], left gastric-azygos [19%], left gastric-caval [15%], aberrant left gastric-caval with right gastric vein [12%], and aberrant left gastric-caval with right gastric vein and short gastric vein [11%]). Shunt origin involved the left gastric vein in 95% of the described classifications. Significant differences were identified among the five most common shunt types with respect to age at the time of the CT scan (P < .001), sex (P = .009), breed (P < .001), weight (P < .001), and subjective portal perfusion score (P < .001). An anatomical classification system for canine EHPSS may enable improved understanding, treatment comparisons, and outcome prediction for these patients.

Anatomical classification of feline congenital extrahepatic portosystemic shunts based on CT angiography: A SVSTS and VIRIES multi-institutional study in 231 cats.

The prevalence of anatomical-based subtypes of feline congenital extrahepatic portosystemic shunts (EHPSS) has not been completely elucidated. The goal of this study was to use CT angiography to create an anatomical-based nomenclature system for feline congenital EHPSS. Additionally, subjective portal perfusion scores were generated to determine if intrinsic portal vein development was associated with different shunt conformations or patient age at the time of CT. The SVSTS and VIRIES list services were used to recruit cases. Data collected included patient DOB, gender, breed, weight, CT date, and reported diagnosis. Shunts were classified based upon (1) the shunt portal vessel(s) of origin, (2) the shunt systemic vessel(s) of insertion, and (3) any substantial portal vessels contributing to the shunt. Additionally, hepatic portal perfusion was subjectively scored between 1 (poor/none) and 5 (good/normal) based on the caliber of the intrahepatic PVs. A total of 264 CT scans were submitted from 29 institutions. Due to exclusion criteria, 33 (13%) were removed, leaving 231 CT scans to be included. Twenty-five different EHPSS anatomies were identified with five classifications accounting for 78% of all shunts (LGP [53%], LGC-post [11%], LCG [7%], LGC-pre [4%], and PC [4%]). Shunt origin involved the left gastric vein in 75% of the described classifications. Significant differences were identified among the five most common shunt types with respect to age at the time of CT scan (P = .002), breed (P < .001), and subjective portal perfusion score (P < .001). This refined anatomical classification system for feline EHPSS may enable improved understanding, treatment comparisons, and outcome prediction for cats with these anomalies.

Mammography screening beliefs and barriers through the lens of Black women during the COVID-19 pandemic.

BACKGROUND: Mammography is an effective screening tool that leads to decreased breast cancer mortality, yet minority women continue to experience barriers. The coronavirus disease 2019 (COVID-19) pandemic has been proven to have negatively affected minority communities, yet its effect on mammography screening habits in Black women is uncertain. The purpose of this study was to evaluate breast cancer mammography screening habits and barriers for Black women in two northeast communities amid the COVID-19 pandemic. METHODS: The study participants were Black women aged 40 years or older who were recruited from community outreach initiatives. Study coordinators conducted telephone surveys to determine mammography screening behaviors, perceptions, and psychosocial factors. RESULTS: Two hundred seventy-seven surveys were completed. Two hundred fifty-six patients who reported ever having a mammogram became the study population of interest. One hundred seventy-four of these patients (68%) reported having a mammogram within the past year (nondelayed), and 82 (32%) had a mammogram more than a year ago (delayed). Only thirty-one of the delayed participants (37.8%) had private insurance. There was a significant difference in the mean score for mammography screening perceived barriers for nondelayed participants (mean = 9.9, standard deviation [SD] = 3.6) versus delayed participants (mean = 11.2, SD = 4.3, p = .03). There was also a significant difference in the mean score when they were asked, "How likely is it that 'other health problems would keep you from having a mammogram'?" (p = .002). CONCLUSIONS: Barriers to mammography screening for Black women during the COVID-19 era include insurance, competing health issues, and perceptions of screening. Community outreach efforts should concentrate on building trust and collaborating with organizations to improve screening despite the COVID-19 pandemic.

Ten-year conditional probability of survival for patients with ovarian cancer: A new metric tailored to Long-term survivors.

OBJECTIVES: We assessed a conditional probability of survival (CPS) model to determine the probability of living 10 years after ovarian cancer diagnosis after having already survived 5 years. METHODS: We identified patients newly diagnosed with high-grade epithelial ovarian cancer from 1/1/2001-12/31/2009 and treated at our institution. Patients with <3 years follow-up were excluded. CPS was defined as the probability of surviving additional years (y) based on the condition a patient had already survived a given time (x): S(x + y)/S(x). Confidence intervals were estimated using a variation of Greenwood's formula. RESULTS: Of 916 patients meeting inclusion criteria, 473 (52%) were diagnosed from 2001 to 2005 and 443 (48%) from 2006 to 2009. Median age at diagnosis was 60 years (range, 25-95). The conventional 10-year OS rate for all patients was 29% (95% CI: 26%-32%)-75% (95% CI: 68%-82%) for stage I/II disease, 22% (95% CI: 19%-26%) for stage III, and 6.9% (95% CI: 3.9%-12%) for stage IV. For patients <65 years, the 10-year CPS for 5-year survivors was 65% (95% CI: 59%-70%); for those ≥65 years, it was 48% (95% CI: 38%-57%). For patients <65 years, the 10-year CPS for 5-year survivors by stage was: stage I/II, 89% (95% CI: 81%-94%); stage III, 58% (95% CI: 50%-66%); and stage IV, 26% (95% CI: 12%-42%). For patients ≥65 years, rates by stage were 78% (95% CI: 53%-91%), 42% (95% CI: 30%-53%), and 29% (95% CI: 7%-56%), respectively. CONCLUSIONS: For long-term survivors with high-grade epithelial ovarian cancer, CPS provides better prediction of survival than conventional methods.

Psychosocial well-being during the COVID-19 pandemic among women with and without breast cancer.

OBJECTIVE: Treatment delays in combination with general social distancing practices to reduce transmission may have negative impacts on the mental health of women with breast cancer who may need more social and emotional support. We sought to elucidate the psychosocial effects of the COVID-19 pandemic among women with and without breast cancer in New York City. METHODS: We conducted a prospective cohort study among women aged 18+ across the spectrum of breast health care at New York Presbyterian (NYP)-Weill Cornell, NYP-Brooklyn Methodist Hospital and NYP-Queens. Women were contacted between June and October 2021 to assess their self-reported depression, stress, and anxiety during the COVID-19 pandemic. We compared women who were recently diagnosed, those with a history of breast cancer, and women without cancer whose other health visits were delayed during the pandemic. RESULTS: There were 85 women who completed the survey. Breast cancer survivors (42%) were the least likely to report a delay in care due to COVID compared to breast cancer patients who were recently diagnosed (67%) and women without cancer (67%). Compared to women without cancer and breast cancer survivors, women recently diagnosed with breast cancer reported higher levels of anxiety and depression with a statistically significant difference in perceived stress. CONCLUSIONS: Our findings highlight the need to identify and risk-stratify patients facing a new breast cancer diagnosis in and around the COVID-19 pandemic who may benefit from additional resources to mitigate the adverse impacts of the pandemic and a breast cancer diagnosis on psychosocial health.

Posterior hypothalamic involvement on pre-operative MRI predicts hypothalamic obesity in craniopharyngiomas.

PURPOSE: Hypothalamic obesity (HO) is a complication associated with craniopharyngioma (CP). Attempts have been made to perioperatively predict the development of this complication, which can be severe and difficult to treat. METHODS: Patients who underwent first transsphenoidal surgical resection in a single center between February 2005 and March 2019 were screened; those who have had prior surgery or radiation, were aged below 18 years, or did not have follow up body mass index (BMI) after surgery were excluded. Primary end point was BMI within 2 years post-surgery. Hypothalamic involvement (HI) was graded based on preoperative and postoperative imaging with regards to anterior, posterior, left and right involvement. Data on baseline demographics, pre-operative and post-operative MRI, and endocrine function were collected. RESULTS: 45 patients met the inclusion and exclusion criteria. Most patients in our cohort underwent gross total resection (n = 35 patients). 13 patients were from no HI or anterior HI only group and 22 patients were classified as both anterior (ant) and posterior (post) HI group. There was no significant difference between the two groups in the gross total, subtotal or near total resection. Pre-operative BMI and post-operative BMI were significantly higher in patients who had ant and post HI on pre-operative MRI (p < 0.05 and p < 0.01, respectively). Similarly, post-operative BMI at 13-24 months was also significantly higher in the ant and post HI group on post-op MRI (p < 0.01). There was no significant difference between the two groups in terms of baseline adrenal insufficiency, thyroid insufficiency, gonadal insufficiency, IGF-1 levels, hyperprolactinemia, and diabetes insipidus. Diabetes insipidus was more common following surgery among those who had anterior and posterior involvement on pre-operative MRI (p < 0.05). CONCLUSIONS: HO appears to be predetermined by tumor involvement in the posterior hypothalamus observed on pre-operative MRI. Posterior HI on pre-operative MRI was also associated with the development of diabetes insipidus after surgery.

Elevated inflammatory markers are associated with poor outcomes in COVID-19 patients treated with remdesivir.

The antiviral remdesivir has been shown to decrease the length of hospital stay in coronavirus disease 2019 (COVID-19) patients requiring supplemental oxygen. However many patients decompensate despite being treated with remdesivir. To identify potential prognostic factors in remdesivir-treated patients, we performed a retrospective cohort study of patients hospitalized at NewYork-Presbyterian Hospital/Weill Cornell Medical Center between March 23, 2020 and May 27, 2020. We identified 55 patients who were treated with remdesivir for COVID-19 and analyzed inflammatory markers and clinical outcomes. C-reactive protein (CRP), d-dimer, and lactate dehydrogenase levels were significantly higher in patients who progressed to intubation or death by 14 days compared to those who remained stable. CRP levels decreased significantly after remdesivir administration in patients who remained nonintubated over the study period. To our knowledge, this is the largest study to date examining inflammatory markers before and after remdesivir administration. Our findings support further investigation into COVID-19 treatment strategies that modify the inflammatory response.

Postmastectomy Breast Reconstruction Patterns at an Urban Academic Hospital and the Impact of Surgeon Gender.

BACKGROUND: Postmastectomy breast reconstruction is an essential element of multidisciplinary breast cancer care but may be underutilized. METHODS: This retrospective study analyzed mastectomy patients (2018-2021) at an urban hospital. Multivariable logistic regression was performed, and a mixed-effects logistic regression model was constructed to determine patient-level factors (age, race, body mass index, comorbidities, smoking status, insurance, type of surgery) and provider-level factors (breast surgeon gender, participation in multidisciplinary breast clinic) that influence reconstruction. RESULTS: Overall, 167 patients underwent mastectomy. The reconstruction rate was 35%. In multivariable analysis, increasing age (odds ratio [OR] 0.95; 95% confidence interval [CI] 0.91-0.99) and Medicaid insurance (OR 0.18; 95% CI 0.06-0.53) relative to private insurance were negative predictors, whereas bilateral mastectomy was a positive predictor (OR 7.07; 95% CI 2.95-17.9) of reconstruction. After adjustment for patent age, race, insurance, and type of surgery, female breast surgeons had 3.7 times greater odds of operating on patients who had reconstruction than males (95% CI 1.20-11.42). CONCLUSION: Both patient- and provider-level factors have an impact on postmastectomy reconstruction. Female breast surgeons had nearly four times the odds of caring for patients who underwent reconstruction, suggesting that a more standardized process for plastic surgery referral is needed.

Comparison of fresh and frozen ejaculated spermatozoa in sibling oocyte recipient cycles.

RESEARCH QUESTION: Do IVF and intracytoplasmic sperm injection cycles using fresh and frozen ejaculated spermatozoa result in similar pregnancy outcomes in couples with non-male factor infertility? DESIGN: Retrospective cohort study; patients undergoing donor egg recipient cycles, in which oocytes from a single ovarian stimulation were split between two recipients, were reviewed. Two recipients of oocytes from a single donor were paired and categorized based on the type of ejaculated spermatozoa (fresh/frozen). Outcomes included delivery rate, implantation, pregnancy, pregnancy loss and fertilization rates. RESULTS: Of the 408 patients who received oocytes from a split donor oocyte cycle, 45 pairs of patients used discrepant types of ejaculated spermatozoa and were included in the study. Fertilization rate: fresh (74.8%); frozen (68.6%) (P = 0.13). Pregnancy rate: fresh (76%); frozen (67%); delivery rate: fresh (69%); frozen (44%); implantation rate was significantly higher: fresh (64%); frozen (36%) (P = 0.04). Rate of pregnancy loss was significantly higher in the frozen group compared with the fresh group (33% versus 5.9%, P = 0.013). Adjusted odds for delivery was 67% lower in the frozen group (95% CI 0.12, 0.89). Adjusted odds of pregnancy (adjusted OR 0.67, 95% CI 0.20, 2.27) and implantation (adjusted OR 0.5, 95% CI 0.12, 2.12) were not significantly different between the frozen and fresh sperm groups. CONCLUSION: In this model that controls for oocyte quality by using paired recipients from the same donor, frozen ejaculated spermatozoa resulted in lower delivery rates than those using fresh spermatozoa.

Stereotactic radiosurgery for vestibular schwannomas in neurofibromatosis type 2 patients: a systematic review and meta-analysis.

INTRODUCTION: Neurofibromatosis type 2 (NF2) is characterized by often bilateral vestibular schwannomas (VS) that result in progressive hearing loss and compression of nearby brainstem structures causing cranial nerve palsies. Treatment of these tumors remains challenging, as both surgical removal and expectant management can result in symptom progression. Stereotactic radiosurgery (SRS) has been investigated for the management of NF2-associated VS; however, the role, promises, and pitfalls of this treatment modality remain unclear. METHODS: Ovid MEDLINE, EMBASE, Web of Science, and Cochrane Reviews were searched for studies assessing SRS outcome in NF2-associated VS only. Primary endpoints included tumor control, serviceable hearing, presence of tinnitus, and cranial nerve V and VII symptoms. RESULTS: A total of 16 studies (589 patients harboring 750 tumors) were analyzed. Clinical tumor control was achieved in 88% of cases (95% CI 80-95%); salvage surgery was needed in 8% (95% CI 4-13%) of cases. Treatment resulted in a worsening of pre-treatment serviceable hearing (OR = 0.26, p < 0.01), increased facial nerve (OR = 1.62, p < 0.01) and trigeminal nerve (OR = 1.42, p = 0.07) impairment. The incidence of vestibular symptoms and hydrocephalus were not consistently reported and thus could not be assessed. CONCLUSIONS: The treatment of NF2-associated VS continues to pose a challenge, as current SRS regimens result in impaired hearing and worse cranial nerve comorbidities, despite achieving high tumor control. It remains unclear if these findings have to be regarded as treatment complications or, rather, continued disease progression.

Video-Based Stop the Bleed Training: A New Era in Education.

INTRODUCTION: Uncontrolled bleeding is a leading cause of preventable death. The "Stop the Bleed" (StB) program trains laypersons in hemorrhage control. This study evaluated the efficacy of video-based StB training. METHODS: Participants watched two different videos: a didactic video (DdV) and a technical video (TeV) demonstrating proper techniques for StB skills (i.e., direct pressure [DP], wound packing [WP], and tourniquet application [TA]). Then, they completed a standardized skills examination (SE). Participants were surveyed at three different time points (baseline, post-DdV, and post-SE) for comparison. We compared paired categorical and continuous variables with the McNemar-Bowker test and Wilcoxon signed-rank test, respectively. Alpha was set at 0.05. RESULTS: One hundred six participants were enrolled: 52% were female and the median age was 23 y (22, 24). At baseline, 29%, 8%, and 13% reported being somewhat or extremely confident with DP, WP, and TA, respectively. These percentages increased to 92%, 79%, and 76%, respectively, after the DdV (all, P < 0.0001). After the TeV and SE, percentages increased further to 100%, 96%, and 100% (all, P < 0.0001). During the SE, 96%, 99%, and 89% of participants were able to perform DP, WP, and TA without prompting. Among participants, 98% agreed that the video course was effective and 79% agreed that the DdV and TeV were engaging. CONCLUSIONS: We describe a novel paradigm of video-based StB learning combined with an in-person, standardized SE. Confidence scores in performing the three crucial StB tasks increased significantly during and after course completion. Through remote learning, StB could be disseminated more widely.

The Safety of Continuous Infusion Propofol in Mechanically Ventilated Adults With Coronavirus Disease 2019.

BACKGROUND: Propofol is commonly used to achieve ventilator synchrony in critically ill patients with coronavirus disease 2019 (COVID-19), yet its safety in this patient population is unknown. OBJECTIVE: To evaluate the safety, in particular the incidence of hypertriglyceridemia, of continuous infusion propofol in patients with COVID-19. METHODS: This was a retrospective study at 1 academic medical center and 1 affiliated teaching hospital in New York City. Adult, critically ill patients with COVID-19 who received continuous infusion propofol were included. Patients who received propofol for <12 hours, were transferred from an outside hospital while on mechanical ventilation, or did not have a triglyceride concentration obtained during the infusion were excluded. RESULTS: A total of 252 patients were included. Hypertriglyceridemia (serum triglyceride concentration ≥ 400 mg/dL) occurred in 38.9% of patients after a median cumulative dose of 4307 mg (interquartile range [IQR], 2448-9431 mg). The median time to triglyceride elevation was 3.8 days (IQR, 1.9-9.1 days). In the multivariable regression analysis, obese patients had a significantly greater odds of hypertriglyceridemia (odds ratio = 1.87; 95% CI = 1.10, 3.21). There was no occurrence of acute pancreatitis. The incidence of possible propofol-related infusion syndrome was 3.2%. CONCLUSION AND RELEVANCE: Hypertriglyceridemia occurred frequently in patients with COVID-19 who received propofol but did not lead to acute pancreatitis. Elevated triglyceride concentrations occurred more often and at lower cumulative doses than previously reported in patients without COVID-19. Application of these data may aid in optimal monitoring for serious adverse effects of propofol in patients with COVID-19.

Dysglycemia screening with oral glucose tolerance test in adolescents with polycystic ovary syndrome and relationship with obesity.

BACKGROUND: Adolescents with polycystic ovary syndrome (PCOS) are at increased risk of impaired glucose tolerance (IGT) and type 2 diabetes mellitus. The aim of this study is to evaluate dysglycemia and biochemical differences based on BMI status and assess the prognostic ability of elevated hemoglobin A1c (HbA1c) in predicting an abnormal 2 hour oral glucose tolerance test (OGTT). METHODS: Retrospective cohort of female patients aged 11-18 years who underwent 75-g OGTT and were evaluated for PCOS at an urban tertiary care hospital between January 2002 to December 2017. RESULTS: In 106 adolescents with PCOS who had OGTT results available, IGT was markedly pronounced in the ≥95th percentile BMI group (17 out of 72; 23.6%) compared with <95th percentile BMI group (4 out of 34; 11.7%). One patient with obesity met the criteria for type 2 diabetes. Patients with obesity had significantly higher homeostasis model assessment (HOMA-IR) and lower whole body insulin sensitivity index (WBISI) (p < 0.001) compared to patients without obesity. Free testosterone levels were also higher in patients with obesity (p< 0.03) and were significantly associated with HOMA-IR when controlling for body mass index (BMI). HbA1c did not demonstrate a strong ability to predict abnormal OGTT on receiver operating characteristic (ROC) curve analysis [Area under the curve (AUC) = 0.572, 95% CI: 0.428, 0.939]). CONCLUSIONS: In a study to assess glucose abnormalities in adolescents with PCOS, IGT was found to be markedly increased in patients with obesity, with abnormal glucose metabolism identified in over one-fifth of the patients. HbA1c alone may be a poor test to assess IGT and we recommend that adolescents diagnosed with PCOS and obesity undergo formal oral glucose tolerance testing.

Skin Failure Among Critically Ill Patients Afflicted with Coronavirus Disease 2019 (COVID-19).

Objective: To characterize skin integrity among coronavirus disease 2019 (COVID-19) patients treated in the intensive care unit (ICU), and identify risk factors for skin failure (SF) in these patients. Design: The characteristic, profound pro-inflammatory, hypercoagulable state of COVID-19 is manifested by the high severity of illness and extensive organ dysfunction observed in these patients. SF in critically ill patients, although described previously, exhibits a uniquely complex pathogenesis in this population. Patients: Retrospective review of all COVID-19 patients (confirmed positive for severe acute respiratory syndrome coronavirus-2 [SARS-CoV-2]) admitted to a single surgical ICU for at least 48 hours between March-June 2020. Interventions: Data were extracted from a COVID-19 institutional data repository that harvested data from electronic health records and other clinical data sources. Demographics; coagulation/inflammation biomarkers; number, location, and stage of SF lesions; resource utilization; and outcomes were captured. Measurements and Main Results: 64 patients met inclusion criteria; 51 (80%) developed SF (SF+ ). Forty-three (85%) developed stage 3 or higher SF (χ2 = 22.66, P < .0001). Thirty-nine of 51 (76%) SF+ patients developed more than one SF lesion (χ2 = 13.26, P = .0003). SF+ patients manifested a profound pro-inflammatory, hypercoagulable phenotype (lower serum albumin and higher ferritin, interleukin [IL]-6 and D-dimer concentrations [all, P < .001]). Durations of mechanical ventilation, vasopressor therapy, and ICU length of stay were significantly longer (all, P < .05) in the SF + patients. Conclusions: The unique characteristics of COVID-19 dermatopathology and the strong correlation between markers of inflammation and development of SF reflect COVID-19-related organ dysfunction and its deleterious effects on the microcirculation. Considering that skin is invaded directly by SARS-CoV-2 and affected by COVID-19-related immune complex deposition and microthrombosis, SF may reflect disease as opposed to pressure injuries related to processes of care. In the context of COVID-19 critical illness, SF should not be considered a "never event."

Testing the Effects of Individual Residents' Retrieval Practice on Standardized Examination Scores.

Background: Residents have limited time and much to learn. Retrieval practice-studying using exam-style review questions-is a powerful educational tool for aggregate groups of learners, but it has not been tested for individual graduate medical education (GME) trainees. Methods: We conducted a retrospective observational study examining how individual residents' self-directed retrieval practice affected their learning. We used linear regression models to compare the number of exam-style multiple-choice practice questions each resident answered per year to their scores on annual In-Training Exams (ITE). Results: We found that the higher a resident's ITE score was at the start of a year, the fewer practice questions they answered that year for both first- (p = 0.023) and second-year (p = 0.020) trainees. Then, the more questions a resident answered in a year, the more their ITE score increased over that year for both first- and second-year trainees (p = 0.026 and 0.025, respectively). Residents' prior ITE scores also independently predicted their subsequent ITE scores (p = 0.024 in the first and 0.007 in the second year), and the effect of their baseline scores was larger than the effect of the number of practice questions they answered. Conclusions: Individual residents' prior exam scores significantly predict their future exam scores, and their independent retrieval practice using exam-style review questions also significantly predicts the annual improvement in their scores. These findings add to the growing evidence supporting retrieval practice in GME, and they can inform individualized educational coaching for GME trainees.