Expanding Inclusivity: Tranexamic Acid for the Treatment of Melasma in Males.

Tranexamic acid (TXA) is an antifibrinolytic medication largely known for its efficacy in managing menorrhagia, or heavy periods, making it a medication predominantly used by women.

Resource Use Among Diabetes Patients Who Mainly Visit Primary Care Physicians Versus Medical Specialists: a Retrospective Cohort Study.

BACKGROUND: It is not uncommon for medical specialists to predominantly care for patients with certain chronic conditions rather than primary care physicians (PCPs), yet the resource implications from such patterns of care are not well understood. OBJECTIVE: To assess resource use of diabetes patients who predominantly visit a PCP versus a medical specialist. DESIGN: Retrospective cohort study of diabetes patients aging into the traditional Medicare program. Patients were attributed to a PCP or medical specialist annually based on a preponderance of ambulatory care visits and categorized according to whether attribution changed year to year. Propensity score weighting was used to balance baseline demographic characteristics, diabetes complications, and underlying health conditions between patients attributed to PCPs and to medical specialists. Spending and utilization were measured up to 3 patient-years. SUBJECTS: A total of 141,558 patient-years. MAIN MEASURES: Total visits, unique physicians, hospital admissions, emergency department visits, procedures, imaging, and tests. KEY RESULTS: Each year, roughly 70% of patients maintained attribution to a PCP and 15% to a medical specialist relative to the previous year. After propensity weighting, patients continuously attributed to a PCP versus medical specialist from 1 year to the next had lower average total payer payments ($10,326 [SD $57,386] versus $14,971 [SD $74,112], P<0.0001) and lower total patient out-of-pocket payments ($1,707 [SD $6,020] versus $2,443 [SD $7,984], P<0.0001). Rates of hospitalization, emergency department visits, procedures, imaging, and tests were lower among patients attributed to PCPs as well. CONCLUSIONS: Older adults with diabetes who receive more of their ambulatory care from a PCP instead of a medical specialist show evidence of lower resource use.

Using a cohort study of diabetes and peripheral artery disease to compare logistic regression and machine learning via random forest modeling.

BACKGROUND: This study illustrates the use of logistic regression and machine learning methods, specifically random forest models, in health services research by analyzing outcomes for a cohort of patients with concomitant peripheral artery disease and diabetes mellitus. METHODS: Cohort study using fee-for-service Medicare beneficiaries in 2015 who were newly diagnosed with peripheral artery disease and diabetes mellitus. Exposure variables include whether patients received preventive measures in the 6 months following their index date: HbA1c test, foot exam, or vascular imaging study. Outcomes include any reintervention, lower extremity amputation, and death. We fit both logistic regression models as well as random forest models. RESULTS: There were 88,898 fee-for-service Medicare beneficiaries diagnosed with peripheral artery disease and diabetes mellitus in our cohort. The rate of preventative treatments in the first six months following diagnosis were 52% (n = 45,971) with foot exams, 43% (n = 38,393) had vascular imaging, and 50% (n = 44,181) had an HbA1c test. The directionality of the influence for all covariates considered matched those results found with the random forest and logistic regression models. The most predictive covariate in each approach differs as determined by the t-statistics from logistic regression and variable importance (VI) in the random forest model. For amputation we see age 85 + (t = 53.17) urban-residing (VI = 83.42), and for death (t = 65.84, VI = 88.76) and reintervention (t = 34.40, VI = 81.22) both models indicate age is most predictive. CONCLUSIONS: The use of random forest models to analyze data and provide predictions for patients holds great potential in identifying modifiable patient-level and health-system factors and cohorts for increased surveillance and intervention to improve outcomes for patients. Random forests are incredibly high performing models with difficult interpretation most ideally suited for times when accurate prediction is most desirable and can be used in tandem with more common approaches to provide a more thorough analysis of observational data.

Remote learning developments in postgraduate medical education in response to the COVID-19 pandemic - A BEME systematic review: BEME Guide No. 71.

BACKGROUND: Prior reviews investigated medical education developments in response to COVID-19, identifying the pivot to remote learning as a key area for future investigation. This review synthesized online learning developments aimed at replacing previously face-to-face 'classroom' activities for postgraduate learners. METHODS: Four online databases (CINAHL, Embase, PsychINFO, and PubMed) and MedEdPublish were searched through 21 December 2020. Two authors independently screened titles, abstracts and full texts, performed data extraction, and assessed risk of bias. The PICRAT technology integration framework was applied to examine how teachers integrated and learners engaged with technology. A descriptive synthesis and outcomes were reported. A thematic analysis explored limitations and lessons learned. RESULTS: Fifty-one publications were included. Fifteen collaborations were featured, including international partnerships and national networks of program directors. Thirty-nine developments described pivots of existing educational offerings online and twelve described new developments. Most interventions included synchronous activities (n Fif5). Virtual engagement was promoted through chat, virtual whiteboards, polling, and breakouts. Teacher's use of technology largely replaced traditional practice. Student engagement was largely interactive. Underpinning theories were uncommon. Quality assessments revealed moderate to high risk of bias in study reporting and methodology. Forty-five developments assessed reaction; twenty-five attitudes, knowledge or skills; and two behavior. Outcomes were markedly positive. Eighteen publications reported social media or other outcomes, including reach, engagement, and participation. Limitations included loss of social interactions, lack of hands-on experiences, challenges with technology and issues with study design. Lessons learned highlighted the flexibility of online learning, as well as practical advice to optimize the online environment. CONCLUSIONS: This review offers guidance to educators attempting to optimize learning in a post-pandemic world. Future developments would benefit from leveraging collaborations, considering technology integration frameworks, underpinning developments with theory, exploring additional outcomes, and designing and reporting developments in a manner that supports replication.

Association Between Beta-Blockers and Mortality and Readmission in Older Patients with Heart Failure: an Instrumental Variable Analysis.

BACKGROUND: The demographics of heart failure are changing. The rate of growth of the "older" heart failure population, specifically those ≥ 75, has outpaced that of any other age group. These older patients were underrepresented in the early beta-blocker trials. There are several reasons, including a decreased potential for mortality benefit and increased risk of side effects, why the risk/benefit tradeoff may be different in this population. OBJECTIVE: We aimed to determine the association between receipt of a beta-blocker after heart failure discharge and early mortality and readmission rates among patients with heart failure and reduced ejection fraction (HFrEF), specifically patients aged 75+. DESIGN AND PARTICIPANTS: We used 100% Medicare Parts A and B and a random 40% sample of Part D to create a cohort of beneficiaries with ≥ 1 hospitalization for HFrEF between 2008 and 2016 to run an instrumental variable analysis. MAIN MEASURE: The primary measure was 90-day, all-cause mortality; the secondary measure was 90-day, all-cause readmission. KEY RESULTS: Using the two-stage least squared methodology, among all HFrEF patients, receipt of a beta-blocker within 30-day of discharge was associated with a - 4.35% (95% CI - 6.27 to - 2.42%, p < 0.001) decrease in 90-day mortality and a - 4.66% (95% CI - 7.40 to - 1.91%, p = 0.001) decrease in 90-day readmission rates. Even among patients ≥ 75 years old, receipt of a beta-blocker at discharge was also associated with a significant decrease in 90-day mortality, - 4.78% (95% CI - 7.19 to - 2.40%, p < 0.001) and 90-day readmissions, - 4.67% (95% CI - 7.89 to - 1.45%, p < 0.001). CONCLUSION: Patients aged ≥ 75 years who receive a beta-blocker after HFrEF hospitalization have significantly lower 90-day mortality and readmission rates. The magnitude of benefit does not appear to wane with age. Absent a strong contraindication, all patients with HFrEF should attempt beta-blocker therapy at/after hospital discharge, regardless of age.

The Use of Tranexamic Acid to Prevent and Treat Post-Inflammatory Hyperpigmentation.

The risk of post-inflammatory hyperpigmentation (PIH) in patients undergoing dermatologic procedures is well known. It is especially common after laser procedures and chemical peels but can be seen with any procedure. PIH is also a sequela of acne, burns, and other trauma. High-risk patients are thought to have excessive production and abnormal distribution of melanin within the skin that triggers PIH, but the exact pathophysiology is unknown.1 We define high-risk patients as Fitzpatrick skin types 3–5, those with existing PIH, or a history of PIH.1,2 Tranexamic acid (TXA) is an antifibrinolytic medication prescribed to treat bleeding and is also used off-label to treat melasma. TXA is contraindicated in patients with hypercoagulable conditions, renal impairment, vision impairment disorders, pregnancy, breast-feeding, or on hormone therapies.3,4,5 From 2015–2020, we have used TXA off-label to successfully treat and/or prevent PIH in approximately 82 high-risk patients after injuries or prior to procedures that disrupt the epidermis. We also have used TXA to prevent PIH after acute injuries such as irritant dermatitis, thermal burns, and abrasions. We now consider TXA treatment for all at risk patients prophylactically before undergoing microneedling, cryotherapy, cryolipolysis, chemical peels, and laser treatments. J Drugs Dermatol. 2021;20(3) doi:344-345. 10.36849/JDD.5622.

The natural history of urinary incontinence subtypes in the Nurses' Health Studies.

BACKGROUND: Urinary incontinence subtypes often differ by symptom severity and treatment profiles; in particular, mixed urinary incontinence is generally associated with worse symptoms and less successful treatment. Yet, limited information exists on the natural history of different urinary incontinence subtypes, which could help to better identify and treat patients prior to development of more intractable disease. OBJECTIVE: To evaluate the onset of urinary incontinence subtypes, and transitions between subtypes over 8 years, using 2 large cohorts of middle-aged and older women with incident urinary incontinence. MATERIALS AND METHODS: We identified 10,349 women with incident urinary incontinence (stress, urgency, and mixed subtypes) from the Nurses' Health Study and the Nurses' Health Study II who were 41-83 years of age, using repeated mailed questionnaires. We defined stress urinary incontinence as leakage with coughing, sneezing, or activity; urgency urinary incontinence as urine loss with a sudden feeling of bladder fullness or when a toilet was inaccessible; and mixed urinary incontinence when women reported that stress and urgency symptoms occurred equally. In subsequent questionnaires 4 and 8 years later, we continued to track symptom severity and subtypes. In addition, to obtain predicted probabilities of urinary incontinence subtypes 4 years and 8 years after urinary incontinence onset, we used multivariable-adjusted generalized estimating equations with a multinomial outcome. RESULTS: At urinary incontinence onset in 2004-2005, 56% of women reported stress urinary incontinence symptoms, 23% reported urgency urinary incontinence symptoms, and 21% reported mixed urinary incontinence symptoms. Women with stress urinary incontinence or urgency urinary incontinence at onset were likely to report the same urinary incontinence type 4 and 8 years later (stress urinary incontinence at onset: 70% and 60% reported stress urinary incontinence at years 4 and 8, respectively; urgency urinary incontinence at onset: 68% and 64% reported urgency urinary incontinence at years 4 and 8, respectively). Nonetheless, for both stress and urgency urinary incontinence, women with more severe symptoms at onset were more likely to progress to mixed urinary incontinence. Women with mixed urinary incontinence at onset had more variation over time, although the largest subset continued to report mixed urinary incontinence (45% reported mixed urinary incontinence at year 4; 43% reported mixed urinary incontinence at year 8). Few women across all urinary incontinence subtypes reported resolution of symptoms over 4-8 years of follow-up (4-12%). When considering the likelihood of remaining with or progressing to mixed urinary incontinence over follow-up, according to age, body mass index, and urinary incontinence severity, we found that older and younger women had similar predicted probability of remaining with or progressing to mixed urinary incontinence (eg, women <60 years of age at onset with severe mixed urinary incontinence had a 54% (95% confidence interval, 53-55) probability of mixed urinary incontinence 8 years later, vs 57% (95% confidence interval, 56-58) of women ≥70 years of age with severe mixed urinary incontinence at onset). Obese women were somewhat more likely to progress to mixed urinary incontinence regardless of urinary incontinence type at onset (eg, women with body mass index <25 kg/m2 at onset with severe stress urinary incontinence had a 30% predicted probability of mixed urinary incontinence 8 years after onset, vs 36% of women with body mass index of 30+ kg/m2 at onset with severe stress urinary incontinence). CONCLUSION: Most women with incident stress and urgency urinary incontinence continued to experience similar subtype symptoms over 8 years. However, obese women and those with more severe symptoms were more likely to remain with or progress to mixed urinary incontinence.

Modeling peer effect modification by network strength: The diffusion of implantable cardioverter defibrillators in the US hospital network.

We develop methodology that allows peer effects (also referred to as social influence and contagion) to be modified by the structural importance of the focal actor's position in the network. The methodology is first developed for a single peer effect and then extended to simultaneously model multiple peer-effects and their modifications by the structural importance of the focal actor. This work is motivated by the diffusion of implantable cardioverter defibrillators (ICDs) in patients with congestive heart failure across a cardiovascular disease patient-sharing network of United States hospitals. We apply the general methodology to estimate peer effects for the adoption of capability to implant ICDs, the number of ICD implants performed by hospitals that are capable, and the number of patients referred to other hospitals by noncapable hospitals. Applying our novel methodology to study ICD diffusion across hospitals, we find evidence that exposure to ICD-capable peer hospitals is strongly associated with the chance a hospital becomes ICD-capable and that the direction and magnitude of the association is extensively modified by the strength of that hospital's position in the network, even after controlling for effects of geography. Therefore, interhospital networks, rather than geography per se, may explain key patterns of regional variations in healthcare utilization.

A Randomized Control Trial of Cardiopulmonary Feedback Devices and Their Impact on Infant Chest Compression Quality: A Simulation Study.

OBJECTIVES: In effort to improve chest compression quality among health care providers, numerous feedback devices have been developed. Few studies, however, have focused on the use of cardiopulmonary resuscitation feedback devices for infants and children. This study evaluated the quality of chest compressions with standard team-leader coaching, a metronome (MetroTimer by ONYX Apps), and visual feedback (SkillGuide Cardiopulmonary Feedback Device) during simulated infant cardiopulmonary resuscitation. METHODS: Seventy voluntary health care providers who had recently completed Pediatric Advanced Life Support or Basic Life Support courses were randomized to perform simulated infant cardiopulmonary resuscitation into 1 of 3 groups: team-leader coaching alone (control), coaching plus metronome, or coaching plus SkillGuide for 2 minutes continuously. Rate, depth, and frequency of complete recoil during cardiopulmonary resuscitation were recorded by the Laerdal SimPad device for each participant. American Heart Association-approved compression techniques were randomized to either 2-finger or encircling thumbs. RESULTS: The metronome was associated with more ideal compression rate than visual feedback or coaching alone (104/min vs 112/min and 113/min; P = 0.003, 0.019). Visual feedback was associated with more ideal depth than auditory (41 mm vs 38.9; P = 0.03). There were no significant differences in complete recoil between groups. Secondary outcomes of compression technique revealed a difference of 1 mm. Subgroup analysis of male versus female showed no difference in mean number of compressions (221.76 vs 219.79; P = 0.72), mean compression depth (40.47 vs 39.25; P = 0.09), or rate of complete release (70.27% vs 64.96%; P = 0.54). CONCLUSIONS: In the adult literature, feedback devices often show an increase in quality of chest compressions. Although more studies are needed, this study did not demonstrate a clinically significant improvement in chest compressions with the addition of a metronome or visual feedback device, no clinically significant difference in Pediatric Advanced Life Support-approved compression technique, and no difference between compression quality between genders.

Comparison of treatment of early-stage breast cancer among Nurses' Health Study participants and other Medicare beneficiaries.

PURPOSE: Increasingly epidemiological cohorts are being linked to claims data to provide rich data for healthcare research. These cohorts tend to be different than the general United States (US) population. We will analyze healthcare utilization of Nurses' Health Study (NHS) participants to determine if studies of newly diagnosed incident early-stage breast cancer can be generalized to the broader US Medicare population. METHODS: Analytic cohorts of fee-for-service NHS-Medicare-linked participants and a 1:13 propensity-matched SEER-Medicare cohort (SEER) with incident breast cancer in the years 2007-2011 were considered. Screening leading to, treatment-related, and general utilization in the year following early-stage breast cancer diagnosis were determined using Medicare claims data. RESULTS: After propensity matching, NHS and SEER were statistically balanced on all demographics. NHS and SEER had statistically similar rates of treatments including chemotherapy, breast-conserving surgery, mastectomy, and overall radiation use. Rates of general utilization include those related to hospitalizations, total visits, and emergency department visits were also balanced between the two groups. Total spending in the year following diagnosis were statistically equivalent for NHS and SEER ($36,180 vs. $35,399, p = 0.70). CONCLUSIONS: NHS and the general female population had comparable treatment and utilization patterns following diagnosis of early-stage incident breast cancers with the exception of type of radiation therapy received. This study provides support for the larger value of population-based cohorts in research on healthcare costs and utilization in breast cancer.

Outpatient Evaluation and Management Visits for Urinary Incontinence in Older Women.

PURPOSE: The aims of this investigation were to examine how often outpatient visits addressing urinary incontinence in women with self-reported incontinence symptoms occur and to explore characteristics associated with an outpatient visit for incontinence. MATERIALS AND METHODS: We studied the records of 18,576 women from the Nurses' Health Study who were 65 years old or older, reported prevalent incontinence symptoms in 2012 on a mailed questionnaire and were linked with Medicare utilization data. We compared demographic, personal and clinical characteristics in women with and without claims for outpatient visits for urinary incontinence. In logistic regression models we controlled for potential confounding factors, including age, race, parity, body mass index, medical comorbidities, smoking status, health seeking behavior, disability, physical function and geographic region. RESULTS: In this linkage between symptom report and insurance claims data we found that only 16% of older women with current incontinence symptoms also had an outpatient visit addressing incontinence in the prior 2 years. In multivariable adjusted models severe vs slight incontinence (OR 3.75, 95% CI 3.10-4.53) and urgency vs stress incontinence (OR 1.80, 95% CI 1.56-2.08) were the strongest predictors of undergoing outpatient evaluation. CONCLUSIONS: Overall only a small percent of women who report urinary incontinence symptoms also have medical outpatient visits for incontinence, which is a marker of care seeking. Our study highlights the discordance between the high prevalence of incontinence in older women and the lack of clinical assessment despite symptoms even among nurses with high health care literacy.

Developing and Validating a Measure to Estimate Poverty in Medicare Administrative Data.

OBJECTIVE: To develop and validate a measure that estimates individual level poverty in Medicare administrative data that can be used in studies of Medicare claims. DATA SOURCES: A 2008 to 2013 Medicare Current Beneficiary Survey linked to 2008 to 2013 Medicare fee-for-service beneficiary summary file and census data. STUDY DESIGN AND METHODS: We used the Medicare Current Beneficiary Survey to define individual level poverty status and linked to Medicare administrative data (N=38,053). We partitioned data into a measure derivation dataset and a validation dataset. In the derivation data, we used a logistic model to regress poverty status on measures of dual eligible status, part D low-income subsidy, and demographic and administrative data, and modeled with and without linked census and nursing home data. Each beneficiary receives a predicted poverty score from the model. Performance was evaluated in derivation and validation data and compared with other measures used in the literature. We present a measure for income-only poverty as well as one for income and asset poverty. PRINCIPAL FINDINGS: A score (predicted probability of income poverty) >0.5 yielded 58% sensitivity, 94% specificity, and 84% positive predictive value in the derivation data; our score yielded very similar results in the validation data. The model's c-statistic was 0.84. Our poverty score performed better than Medicaid enrollment, high zip code poverty, and zip code median income. The income and asset version performed similarly well. CONCLUSIONS: A poverty score can be calculated using Medicare administrative data for use as a continuous or binary measure. This measure can improve researchers' ability to identify poverty in Medicare administrative data.

Understanding the Female Asian American Facial Aesthetic Patient

Background: As facial aesthetic procedures have become more widely accepted, the racial and ethnic diversity of aesthetic patient populations has increased. Asian Americans represent a growing segment of this population and have specific aesthetic concerns that should be differentiated from the broader Caucasian population. Objective: An online study was designed to survey facial aesthetic concerns, treatment priorities, and future treatment considerations among a US-based population of Asian American women. Materials and Methods: A total of 403 participants ages 30 to 65 years reported perspectives on facial aging, current facial conditions, most bothersome facial areas, most/least likely to be treated first, awareness of treatment options and consideration rates, and motives/barriers impacting the consideration rate of injectable treatments. Results: Treatment interests reflected predominant issues; uneven skin tone, wrinkles, and sun damage. Most bothersome facial areas included the periorbital area, forehead, and submental area, and also among areas designated as most likely to treat first. The majority of participants would consider injectables. However, safety/side effects, cost, and concerns about not looking natural were primary barriers. Conclusion: Understanding the aesthetic concerns and priorities specific to Asian American women may help guide treatment plans more aligned with the goals and expectations of this patient population. J Drugs Dermatol. 2019;18(7):633-641.

Assessing Variation in Implantable Cardioverter Defibrillator Therapy Guideline Adherence With Physician and Hospital Patient-sharing Networks.

BACKGROUND: Implantable cardioverter defibrillator (ICD) therapy is used for primary prevention of death among people with heart failure, and new evidence in 2005 on its effectiveness changed practice guidelines in the United States. OBJECTIVES: The objective of this study is to examine how the connectedness of physicians and hospitals, measured using network analysis, relates to guideline-consistent ICD implantation. RESEARCH DESIGN: We constructed physician and hospital networks for cardiovascular disease. Physicians were linked if they shared cardiovascular disease patients; these links were aggregated by hospital affiliation to construct a hospital network. SUBJECTS: Medicare beneficiaries who underwent ICD therapy for primary prevention from 2007 to 2011. MEASURES: The clinical outcome of interest was guideline-consistent ICD implantation, calculated using the National Cardiovascular Data Registry. The exposure variables of interest were the network measures of the ICD surgeon, the referring hospital, and the hospital where the ICD surgery occurred. RESULTS: We focused on patients who were referred between hospitals for ICD implantation because they were more likely influenced by the hospital network (n=28,179). Patients were less likely to meet guidelines if their referring hospital had more connections to other hospitals (OR, 0.49; 95% confidence interval, 0.25-0.96) and more likely to meet guidelines if their ICD surgery hospital had more connections (OR, 1.61; 95% confidence interval, 0.98-2.64). The ICD surgeon's network measures were not associated with guideline-consistent implantation. CONCLUSIONS: Associations between the hospital network measures and guideline adherence suggests new approaches to better disseminate clinical guidelines across health systems.

Leveraging Linkage of Cohort Studies With Administrative Claims Data to Identify Individuals With Cancer.

BACKGROUND: In an effort to overcome quality and cost constraints inherent in population-based research, diverse data sources are increasingly being combined. In this paper, we describe the performance of a Medicare claims-based incident cancer identification algorithm in comparison with observational cohort data from the Nurses' Health Study (NHS). METHODS: NHS-Medicare linked participants' claims data were analyzed using 4 versions of a cancer identification algorithm across 3 cancer sites (breast, colorectal, and lung). The algorithms evaluated included an update of the original Setoguchi algorithm, and 3 other versions that differed in the data used for prevalent cancer exclusions. RESULTS: The algorithm that yielded the highest positive predictive value (PPV) (0.52-0.82) and κ statistic (0.62-0.87) in identifying incident cancer cases utilized both Medicare claims and observational cohort data (NHS) to remove prevalent cases. The algorithm that only used NHS data to inform the removal of prevalent cancer cases performed nearly equivalently in statistical performance (PPV, 0.50-0.79; κ, 0.61-0.85), whereas the version that used only claims to inform the removal of prevalent cancer cases performed substantially worse (PPV, 0.42-0.60; κ, 0.54-0.70), in comparison with the dual data source-informed algorithm. CONCLUSIONS: Our findings suggest claims-based algorithms identify incident cancer with variable reliability when measured against an observational cohort study reference standard. Self-reported baseline information available in cohort studies is more effective in removing prevalent cancer cases than are claims data algorithms. Use of claims-based algorithms should be tailored to the research question at hand and the nature of available observational cohort data.

A prospective study of the natural history of urinary incontinence in women.

BACKGROUND: Symptoms of urinary incontinence are commonly perceived to vary over time; yet, there is limited quantitative evidence regarding the natural history of urinary incontinence, especially over the long term. OBJECTIVE: We sought to delineate the course of urinary incontinence symptoms over time, using 2 large cohorts of middle-aged and older women, with data collected over 10 years. STUDY DESIGN: We studied 9376 women from the Nurses' Health Study, age 56-81 years at baseline, and 7491 women from the Nurses' Health Study II, age 39-56 years, with incident urinary incontinence in 2002 through 2003. Urinary incontinence severity was measured by the Sandvik severity index. We tracked persistence, progression, remission, and improvement of symptoms over 10 years. We also examined risk factors for urinary incontinence progression using logistic regression models. RESULTS: Among women age 39-56 years, 39% had slight, 45% had moderate, and 17% had severe urinary incontinence at onset. Among women age 56-81 years, 34% had slight, 45% had moderate, and 21% had severe urinary incontinence at onset. Across ages, most women reported persistence or progression of symptoms over follow-up; few (3-11%) reported remission. However, younger women and women with less severe urinary incontinence at onset were more likely to report remission or improvement of symptoms. We found that increasing age was associated with higher odds of progression only among older women (age 75-81 vs 56-60 years; odds ratio, 1.84; 95% confidence interval, 1.51-2.25). Among all women, higher body mass index was strongly associated with progression (younger women: odds ratio, 2.37; 95% confidence interval, 2.00-2.81; body mass index ≥30 vs <25 kg/m2; older women: odds ratio, 1.93; 95% confidence interval, 1.62-2.22). Additionally, greater physical activity was associated with lower odds of progression to severe urinary incontinence (younger women: odds ratio, 0.86; 95% confidence interval, 0.71-1.03; highest vs lowest quartile of activity; older women: odds ratio, 0.68; 95% confidence interval, 0.59-0.80). CONCLUSION: Most women with incident urinary incontinence continued to experience symptoms over 10 years; few had complete remission. Identification of risk factors for urinary incontinence progression, such as body mass index and physical activity, could be important for reducing symptoms over time.

Effect of Emergency Physician-Performed Point-of-Care Ultrasound and Radiology Department-Performed Ultrasound Examinations on the Emergency Department Length of Stay Among Pregnant Women at Less Than 20 Weeks' Gestation.

OBJECTIVES: We sought to confirm retrospective studies that measured an approximately 20% reduction in emergency department (ED) length of stay (LOS) in early-gestation pregnant women who receive emergency physician-performed point-of-care ultrasound (US) examinations rather than radiology department-performed US examinations for evaluation of intrauterine pregnancy (IUP). METHODS: A randomized controlled clinical trial was performed at an urban academic safety net hospital and 2 Naval medical centers in the United States. The allocation was concealed before enrollment. Clinically stable adult pregnant women at less than 20 weeks' gestation who presented to the ED with abdominal pain or vaginal bleeding were randomized to receive a point-of-care or radiology US to assess for IUP. The primary outcome measure was the ED LOS. RESULTS: A total of 224 patients (point-of-care US, n = 118; radiology US, n = 106) were included for the analysis. The ED LOS was 20 minutes shorter in the point-of-care US arm (95% confidence interval [CI], -54 to 7 minutes). Adjusting for variability due to the location, the ED LOS was calculated to be 31 minutes shorter (95% CI, -64 to 1 minute) than for patients in the radiology US arm. Excluding patients in the point-of-care US arm who crossed over to radiology US after an inconclusive point-of-care US examination, the ED LOS was 75 minutes shorter than in the radiology US arm (95% CI, -97 to -53 minutes). CONCLUSIONS: Early-gestation pregnant ED patients requiring pelvic US were discharged earlier when point-of-care US was used rather than radiology US; however, this trial did not achieve our target of 30 minutes. Nevertheless, our data support the routine use of ED point-of-care US for IUP, saving the most time if a conclusive IUP is identified.

A Uniquely Abnormal Stool Specimen: A Case Report.

BACKGROUND: Autoamputation of the appendix is a condition associated with the Ladd's procedure, a pediatric surgical technique for correction of intestinal malrotation. A 4-year-old male patient with a history of a Ladd's procedure performed as a newborn was brought in by his mother for "passing intestine" just prior to arrival. She reported that for several weeks her son had intermittent, crampy abdominal pain that resolved after the unusual-appearing bowel movement. After reviewing an image of the bowel movement, and in consultation with pediatric surgery, it was concluded that the patient had passed a devascularized appendix in his stool immediately prior to arrival. CASE REPORT: A 4-year-old boy with a past medical history of heterotaxy syndrome (inversion of the thoraco-abdominal organs), a double outlet right ventricle, and Ladd's procedure presented to the Emergency Department (ED) after "passing intestine" in his stool. Close examination of the photo demonstrated a tubular structure with taenia, consistent with an appendix. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Autoamputation of the appendix is an uncommon presentation in the ED. Passing a devascularized appendix is a benign condition and can present with weeks of intermittent abdominal pain that resolves with passage of appendix in the stool. Remnants of the appendix can remain within the intestinal lumen years after the Ladd's procedure. Emergency physicians with a general awareness of this rare phenomenon can confidently make the diagnosis and reassure worried parents.

Case Report: Not All Genital Ulcers Are Herpetic.

BACKGROUND: The most common cause of genital lesions is herpes simplex virus (HSV) (Pediatr Dermatol. 2012;29:147-153). However, in children and adolescents who are not sexually active, several other causes need to be considered. CASE: A 13-year-old adolescent girl presented to the emergency department with genital lesions. A gynecologist was consulted at time of presentation for concerns of a primary HSV infection and concurred. Final HSV and sexually transmitted infection testing were subsequently negative. At outpatient follow-up, a child abuse pediatrician made the diagnosis of aphthous genital ulcers (AGUs). Awareness of the diagnosis of AGUs is important because alternate diagnoses such as HSV could imply child abuse. It is critical to include AGUs in the differential diagnosis and to provide the appropriate referrals.

Executive function, episodic memory, and Medicare expenditures.

INTRODUCTION: We examined the relationship between health care expenditures and cognition, focusing on differences across cognitive systems defined by global cognition, executive function, or episodic memory. METHODS: We used linear regression models to compare annual health expenditures by cognitive status in 8125 Nurses' Health Study participants who completed a cognitive battery and were enrolled in Medicare parts A and B. RESULTS: Adjusting for demographics and comorbidity, executive impairment was associated with higher total annual expenditures of $1488 per person (P < .01) compared with those without impairment. No association for episodic memory impairment was found. Expenditures exhibited a linear relationship with executive function, but not episodic memory ($584 higher for every 1 standard deviation decrement in executive function; P < .01). DISCUSSION: Impairment in executive function is specifically and linearly associated with higher health care expenditures. Focusing on management strategies that address early losses in executive function may be effective in reducing costly services.