Assessing left atrial size and pump function in ischemic stroke patients: Is cardiac MRI superior to transthoracic echocardiography?

OBJECTIVES: Current guidelines recommend transthoracic echocardiography (TTE) following an ischemic stroke as the primary technique to identify cardiac abnormalities associated with an increased risk of cerebral embolism. It is unclear whether cardiac magnetic resonance imaging (cMRI), a technique shown to provide increased imaging resolution, may also enhance the cardiac assessment of ischemic stroke patients. We compared cMRI with TTE in the evaluation of Left Atrial (LA) size and pump function in a cohort of 44 patients with ischemic stroke. MATERIALS AND METHODS: The biplane method was utilized to acquire LA diameters as well as area measurements in both TTE and cMRI. We calculated LA volume (LAV), LAV index (LAVI), LA Global Longitudinal Strain (GLS) and LA pump function. Results were compared using paired two sample for means t-test. Lin's concordance correlation coefficient (CCC) and Bland-Altman methods quantified the agreement of measurements obtained by TTE and cMRI. RESULTS: LAVI measurements by cMRI were significantly larger (34.97 v. 28.81; p = 0.001) than by TTE. The concordance correlation demonstrated only a weak agreement between LA size measured by cMRI and TTE (ρc = 0.397; p= 0.001, 95% CI 0.16 - 0.59), and the Bland-Altman plot demonstrated that LAVI measured by cMRI averaged 6.3 ml/m2 larger magnitude than those obtained by TTE. CONCLUSIONS: Using TTE alone leads to an underestimation of LA abnormalities important in the evaluation of ischemic stroke patients. Nearly one in every five ischemic stroke patients evaluated based on the current guidelines may have a missed potential source of cardiac embolism.

Feasibility and acceptability of an online mental health intervention for pregnant women and their partners: a mixed method study with a pilot randomized control trial.

BACKGROUND: Untreated perinatal mood and anxiety disorders (PMAD) have short- and long-term health and social consequences; online cognitive behavioral therapy (CBT) interventions can reduce symptoms. Despite partner support being protective online interventions rarely target couples. This study builds on research on an existing CBT-based intervention, the Mothers and Babies Online Course (eMB), by testing its feasibility with prenatal couples. METHODS: We conducted a pilot, randomized, controlled feasibility trial using a 1:1 parallel design. To be eligible, participant dyads were pregnant people (between 13-30 weeks gestation and with a score of 10 or greater on either the GAD-7 or PHQ-9 scale indicating elevated symptoms of anxiety or depression) and their cohabitating partners, living in Missouri, with access to the internet; both in the dyad consented to participate. Recruitment occurred via Facebook ads, flyers, and a snowball approach. The intervention group received eMB, and the control group received a list of community resources. We examined retention and adherence data extracted from eMB analytics and study databases. All participants were given depression and anxiety scales at baseline, 4 and 8 weeks to test preliminary efficacy; satisfaction and acceptability were measured at trial end (i.e., eight weeks) and via interview. RESULTS: There were 441 people who responded to recruitment materials, 74 pregnant people were screened; 19 partners did not complete enrolment, and 25 dyads were ineligible. There were 15 dyads per group (N = 30) who enrolled; all completed the study. The survey response rate was 90% but partners required nearly twice the number of reminders. No participant completed all lessons. Mean depression and anxiety scores dropped over time for dyads in control (M = -1.99, -1.53) and intervention (M = -4.80, -1.99). Intervention pregnant people's anxiety significantly decreased (M = -4.05; 95% CI [0.82, 7.27]) at time two compared to control. Twelve pregnant people and four partners participated in post-intervention interviews and suggested improvements for eMB. CONCLUSION: Online dyadic interventions can potentially reduce PMAD symptoms. However, to feasibly study eMB with couples, strategies to increase program adherence are necessary. Tailoring interventions to overtly include partners may be advantageous. TRIAL REGISTRATION: ClinicalTrials.gov NCT05867680, 19/05/2023.

Isotope Labeling and Biochemical Assessment of Liver-Triacylglycerol in Patients with Different Levels of Histologically-Graded Liver Disease.

BACKGROUND: Nonalcoholic fatty liver disease (NAFLD) prevalence is rapidly growing, and fatty liver has been found in a quarter of the US population. Increased liver lipids, particularly those derived from the pathway of de novo lipogenesis (DNL), have been identified as a hallmark feature in individuals with high liver fat. This has led to much activity in basic science and drug development in this area. No studies to date have investigated the contribution of DNL across a spectrum of disease, although it is clear that inhibition of DNL has been shown to reduce liver fat. OBJECTIVES: The purpose of this study was to determine whether liver lipid synthesis increases across the continuum of liver injury. METHODS: Individuals (n = 49) consumed deuterated water for 10 d before their scheduled bariatric surgeries to label DNL; blood and liver tissue samples were obtained on the day of the surgery. Liver lipid concentrations were quantitated, and levels of protein and gene expression assessed. RESULTS: Increased liver DNL, measured isotopically, was significantly associated with liver fatty acid synthase protein content (R = 0.470, P = 0.003), total steatosis assessed by histology (R = 0.526, P = 0.0008), and the fraction of DNL fatty acids in plasma very low-density lipoprotein-triacylglycerol (R = 0.747, P < 0.001). Regression analysis revealed a parabolic relationship between fractional liver DNL (percent) and NAFLD activity score (R = 0.538, P = 0.0004). CONCLUSION: These data demonstrate that higher DNL is associated with early to mid stages of liver disease, and this pathway may be an effective target for the treatment of NAFLD and nonalcoholic steatohepatitis. This study was registered at clinicaltrials.gov as NCT03683589.

EUS-guided versus percutaneous liver biopsy: A prospective randomized clinical trial.

Background and Objectives: Prospective studies comparing EUS-guided liver biopsy (EUS-LB) to percutaneous LB (PC-LB) are scarce. We compared the efficacy and safety of EUS-LB with those of PC-LB in a prospective randomized clinical trial. Methods: Between 2020 and 2021, patients were enrolled and randomized (1:1 ratio). The primary outcome was defined as the proportion of patients with ≥11 complete portal tracts (CPTs). The sample size (n = 80) was calculated based on the assumption that 60% of those in the EUS-LB and 90% of those in the PC-LB group will have LB with ≥11 CPTs. The secondary outcomes included proportion of patients in whom a diagnosis was established, number of CPTs, pain severity (Numeric Rating Scale-Pain Intensity), duration of hospital stay, and adverse events. Results: Eighty patients were enrolled (median age, 53 years); 67.5% were female. Sixty percent of those in the EUS-LB and 75.0% of those in the PC-LB group met the primary outcome (P = 0.232). The median number of CPTs was higher in the PC-LB (17 vs 13; P = 0.031). The proportion of patients in whom a diagnosis was established was similar between the groups (92.5% [EUS-LB] vs 95.0% [PC-LB]; P = 1.0). Patients in the EUS-LB group had less pain severity (median Numeric Rating Scale-Pain Intensity, 2.0 vs 3.0; P = 0.003) and shorter hospital stay (2.0 vs 4.0 hours; P < 0.0001) compared with the PC-LB group. No patient experienced a serious adverse event. Conclusions: EUS-guided liver biopsy was safe, effective, better tolerated, and associated with a shorter hospital stay.

Spherical Aberration of Cataractous Eyes and Its Relationship With Age, Ocular Biometry, and Various IOL Platforms.

PURPOSE: To determine the median spherical aberration (SA) of the cataractous population, how it relates to biometry, and the theoretical effect of different intraocular lens (IOL) platforms. METHODS: A retrospective chart review of patients undergoing cataract surgery evaluation with a high quality Pentacam (Oculus Optikgeräte GmbH) were included. Age, gender, Q-value, mean total SA, higher order aberration root mean square wavefront error, and equivalent keratometry were collected from the Holladay report and axial length and anterior chamber depth (ACD) from the IOLMaster 700 (Carl Zeiss Meditec AG). RESULTS: Data from 1,725 eyes of 999 patients were collected. SA had a median of 0.37 µm (95% confidence interval: 0.36 to 0.38. Age (r = .136, P < .001), Q-factor (r = .743, P < .001), and higher order aberration root mean square wavefront error (r = .307, P < .001) were positively correlated with SA. Average equivalent keratometry (r = -.310, P < .001) was negatively correlated with SA. Axial length (r = -0.037, P = .120) and ACD (r = .004, P = .856) had no association with SA. Up to 1,499 (86.9%) theoretically had SA moved closer to zero with IOLs that had negative SA. Up to 102 (5.9%) had SA theoretically worsened. CONCLUSIONS: SA is not normally distributed, suggesting that there may be no "average" SA that IOLs should aim to correct. Patients might benefit from tailoring IOL choice to individual SA. Without access to SA data, eyes with steeper average keratometry or younger patients may have less SA, which could influence IOL choice. [J Refract Surg. 2023;39(2):89-94.].

The Utility and Diagnostic Accuracy of Transient Elastography in Adults with Morbid Obesity: A Prospective Study.

Patients with morbid obesity are at high risk for nonalcoholic fatty liver disease (NAFLD) complicated by liver fibrosis. The clinical utility of transient elastography (TE) by Fibroscan in patients with morbid obesity (body mass index (BMI) ≥ 40 kg/m2) is not well-defined. We examined the diagnostic accuracy of Fibroscan in predicting significant liver fibrosis (fibrosis stage ≥2) in morbidly obese patients (BMI ≥ 40 kg/m2). Patients scheduled for bariatric surgery were prospectively enrolled. Intraoperative liver biopsy, liver-stiffness measurement (LSM) by Fibroscan (XL probe), and biochemical evaluation were all performed on the same day. The endpoint was significant liver fibrosis defined as fibrosis stage ≥2 based on the Nonalcoholic Steatohepatitis Clinical Research Network. The optimal LSM cutoff value for detecting significant fibrosis was determined by using the Youden Index method. Routine clinical, laboratory, and elastography data were analyzed by stepwise logistic regression analysis to identify predictors of significant liver fibrosis and build a predictive model. An optimal cutoff point of the new model's regression formula for predicting significant fibrosis was determined by using the Youden index method. One hundred sixty-seven patients (mean age, 46.4 years) were included, of whom 83.2% were female. Histological assessment revealed the prevalence of steatohepatitis and significant fibrosis of 40.7% and 11.4%, respectively. The median LSM was found to be significantly higher in the significant fibrosis group compared to those in the no or non-significant fibrosis group (18.2 vs. 7.7 kPa, respectively; p = 0.0004). The optimal LSM cutoff for predicting significant fibrosis was 12.8 kPa, with an accuracy of 71.3%, sensitivity of 73.7%, specificity of 70.9%, positive predictive value of 24.6%, negative predictive value of 95.5%, and ROC area of 0.723 (95% CI: 0.62-0.83). Logistic regression analysis identified three independent predictors of significant fibrosis: LSM, hemoglobin A1c, and alkaline phosphatase. A risk score was developed by using these three variables. At an optimal cutoff value of the regression formula, the risk score had an accuracy of 79.6% for predicting significant fibrosis, sensitivity of 89.5%, specificity of 78.4%, positive predictive value of 34.7%, negative predictive value of 98.3%, and ROC area of 0.855 (95% CI: 0.76-0.95). Fibroscan utility in predicting significant liver fibrosis in morbidly obese subjects is limited with accuracy of 71.3%. A model incorporating hemoglobin A1c and alkaline phosphatase with LSM improves accuracy in detecting significant fibrosis in this patient population.

A Model Incorporating Serum Alkaline Phosphatase for Prediction of Liver Fibrosis in Adults with Obesity and Nonalcoholic Fatty Liver Disease.

We assessed the relationship between serum alkaline phosphatase (ALP) and liver fibrosis by histology, in addition to other noninvasive parameters, in obese patients undergoing metabolic surgery. Patients scheduled for elective bariatric surgery were prospectively recruited from a bariatric clinic. An intraoperative liver biopsy was performed, and liver histology was evaluated by a pathologist blinded to the patients' data. The endpoint was significant fibrosis defined as fibrosis stage ≥ 2. Independent predictors of fibrosis were identified by logistic regression. Two hundred ten patients were recruited. Liver histology revealed steatosis in 87.1%, steatohepatitis in 21.9%, and significant fibrosis in 10%. Independent predictors of significant fibrosis were ALP (Odds Ratio (OR) 1.03; 95% Confidence interval (CI), 1.01-1.05), alanine aminotransferase (OR 1.02; 95% CI, 1.01-1.03), HbA1c (OR 1.58; 95% CI, 1.20-2.09), and body mass index (OR 1.06; 95% CI, 1.00-1.13). A tree-based model was developed to predict significant fibrosis, with a receiver operating characteristic (ROC) area of 0.845, sensitivity of 0.857, specificity of 0.836, and accuracy of 0.931. The applicability of serum ALP as an independent biomarker of liver fibrosis should be considered in obesity surgery patients, and in the broader context of obese patients with nonalcoholic fatty liver disease.

Electrostatic Precipitation in Low Pressure Laparoscopic Hysterectomy and Myomectomy.

BACKGROUND AND OBJECTIVE: The purpose of this study was to evaluate the impact of using electrostatic precipitation to manage the surgical plume during low pressure laparoscopic gynecologic procedures. METHODS: This was a prospective, blinded, randomized controlled study of women with a clinical indication for laparoscopic hysterectomy (n = 30) or myomectomy (n = 5). Patients were randomized to either use electrostatic precipitation (EP) during the procedure, or not (No EP, hysterectomy group only). RESULTS: Low pressure surgery could be undertaken in 87% of hysterectomy cases (13/15) when using EP to manage the surgical plume, compared to only 53% (8/15) in the No EP group. Overall average rating of the visual field was excellent with EP vs fair for No EP. Average CO2 consumption was reduced by 29% when using EP (16.7L vs 23.5L, p = 0.152). The average number of procedural pauses to vent smoke was lower with EP than the No EP group (1.5 per case vs. 3.7 per case, p = 0.005). Average procedure duration for the EP vs No EP group was 40.5 min vs. 46.9 min (p = 0.987). There were no measurable differences between groups for body temperature, end-tidal CO2, and discharge pain scores. In myomectomy, all five cases could be performed at low pressure, with an excellent visual field rating. CONCLUSION: Electrostatic precipitation enhances low pressure laparoscopic hysterectomy and myomectomy. This was achieved by minimizing interruptions to surgery and exchange of CO2; providing a clear visual field throughout the procedure; and eliminating surgical smoke at the site of origin.

An index of geospatial disadvantage predicts both obesity and unmeasured body weight.

Neighborhood context impacts health. Using an index of geospatial disadvantage measures to predict neighborhood socioeconomic disparities would support area-based allocation of preventative resources, as well as the use of location as a clinical risk factor in care of individual patients. This study tested the association of the Area Deprivation Index (ADI), a neighborhood-based index of socioeconomic contextual disadvantage, with elderly obesity risk. We sampled 5066 Medicare beneficiaries at the University of Missouri between September 1, 2013 and September 1, 2014. We excluded patients with unknown street addresses, excluded body mass index (BMI) lower than 18 or higher than 62 as probable errors, and excluded patients with missing BMI data. We used a plot of simple proportions to examine the association between ADI and prevalence of obesity, defined as BMI of 30 and over. We found that obesity was significantly less prevalent in the least-disadvantaged ADI decile (decile 1) than in all other deciles (p < 0.05) except decile 7. Obesity prevalence within the other deciles (2-6 and 8-10) was not significantly distinguishable except that decile 2 was significantly lower than decile 4. Patients with missing BMI data were more likely to reside in the most disadvantaged areas. There was a positive association between neighborhood disadvantage and obesity in this Midwestern United States Medicare population. The association of missing BMI information with neighborhood disadvantage may reflect unmeasured gaps in care delivery to the most disadvantaged patients. These preliminary results support the continued study of neighborhood socioeconomic measures to identify health disparities in populations.

Functional Status in Patients Requiring Nursing Home Stay After Radical Cystectomy.

OBJECTIVE: To evaluate the ability to perform activities of daily living (ADLs) in patients who required nursing home (NH) care after radical cystectomy (RC), as this surgery can impair patients' ability to perform ADLs in the postoperative period. METHODS: Patients undergoing RC were identified in a novel database of patients with at least two NH assessments linked with Medicare inpatient claims. The NH assessment included the Minimum Data Set (MDS)-ADL Long Form (0-28; a higher score equals greater impairment), which quantifies ADLs. Paired t-tests and chi-squared analysis were used for comparisons. RESULTS: We identified 471 patients that underwent RC and had at least one MDS-ADL assessment. In total, 245 patients lived elsewhere prior to RC and went to an NH after RC, while 122 patients lived in an NH before and after RC. Mean age of the population was 80.7 years (standard deviation 5.7). Of the 245 patients who did not live in a facility before RC, 68% of patients were discharged directly to an NH and 31% were discharged to another location before NH. There was no difference in MDS-ADL score between these groups (16.4 vs 15.0, P = .09). Among the patients who lived in an NH before and after RC, the mean pre- and post-operative MDS-ADL scores were significantly different (12.1 vs 16.6, P<.0001). CONCLUSION: ADLs, as measured by the MDS-ADL Long Form score, worsen after RC. This should be an important part of the risks and benefits conversation with patients, their families, and caregivers.

An observational study of antipsychotic medication use among long-stay nursing home residents without qualifying diagnoses.

WHAT IS KNOWN ON THE SUBJECT?: In the United States, 15.5% of nursing home residents without qualifying diagnoses of schizophrenia, Huntington's' Disease, and/or Tourette Syndrome receive antipsychotic medications. Antipsychotic medications are used off-label (i.e., used in a manner the United States Food and Drug Administration's packaging insert does not specify) to treat neuropsychiatric symptoms, often before attempting nonpharmacologic interventions, despite evidence that this drug class is associated with significant adverse events including death. Less than optimal staffing resources and lack of access to geropsychiatric specialists are barriers to reducing antipsychotic use. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: Antipsychotic use occurred in 11.6% of nursing home residents without qualifying or potentially qualifying diagnoses (bipolar disorder and psychotic disorder); antipsychotic use was more prevalent in residents with a dementia diagnosis than those without. One additional registered nurse hour per resident day could reduce the odds of antipsychotic use by 52% and 56% for residents with and without a dementia diagnosis respectively. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Given the influence of total staffing and professional staff mix on risk of antipsychotic use, nursing home administrators may want to consider aspects of facility operation that impact antipsychotic use. More stringent Unites States' survey and certification standards for dementia care implemented in 2017 demand proactive person-centered care that promotes maximal well-being and functioning without risk of harm from inappropriate psychoactive medications. Mental health nurses have requisite training to provide expert person-centered care to nursing home residents with mental illness and geropsychiatric disorders. ABSTRACT: Introduction Antipsychotic use in nursing homes varies widely across the United States; inadequate staffing, skill mix, and geropsychiatric training impede sustained improvement. Aim This study identified risk factors of antipsychotic use in long-stay residents lacking qualifying or potentially qualifying diagnoses. Method This secondary analysis used 2015 Minimum Data Set and cost report data from 458 Missouri nursing homes. The full sample (N = 29,679) was split into two subsamples: residents with (N = 15,114) and without (N = 14,565) a dementia diagnosis. Separate logistic regression models were run. Results Almost 15% of the dementia subsample and 8.4% of the nondementia subsample received an antipsychotic medication in the past week. Post-traumatic stress disorder, psychosis indicators, behavioral symptoms, anxiety medication with and without anxiety diagnosis, depression medication with and without depression diagnosis, and nurse staffing were among the strongest predictors of antipsychotic use in both subsamples. Simulation analyses showed decreased odds of receiving an antipsychotic in both subsamples when registered nurse hours matched the national average. Discussion Matching nurse staffing mix to the national average may improve antipsychotic use in nursing homes. Implications Knowledge of antipsychotic use risk factors use can inform care planning and staff education to minimize use of these medications in all but severe cases.

Exploring Path Models of Disablement in Residential Care and Assisted Living Residents.

This study examined the relationships between individual and environmental factors and physical activity, and between physical activity and functional limitations and disability in residential care/assisted living (RC/AL) residents. Participants completed questionnaires and physical performance tests, and wore the Fitbit Motion Tracker® to capture physical activity. Model fit was analyzed using two-level path models with residents nested within RC/AL settings. Model parameters were estimated using the MPlus robust maximum likelihood method. A multilevel model with good fit (root mean square error of approximation = 0.07, comparative fit index [CFI] = 0.91) showed that persons with greater exercise self-efficacy were more physically active, and persons who were more physically active had better physical function and less disability. Setting-level factors did not significantly correlate with physical activity or disability. Although environmental factors may influence physical activity behavior, only individual factors were associated with physical activity in this sample of RC/AL residents.

Dynamic Electronic Health Record Note Prototype: Seeing More by Showing Less.

INTRODUCTION: Cluttered documentation may contribute adversely to physician readers' cognitive load, inadvertently obscuring high-value information with less valuable information. We test the hypothesis that a novel, collapsible assessment, plan, subjective, objective (APSO) note design would be faster, more accurate, and more satisfying to use than a conventional electronic health record (EHR) subjective, objective, assessment, plan (SOAP) note for finding information needed for ambulatory chronic disease care. METHODS: We iteratively developed physician clinic note prototypes with features designed to emphasize more important information and de-emphasize less clinically relevant information. Sixteen primary care physicians reviewed comparable clinic notes with the 4 note styles presented in random order to find key information in the notes during timed tasks. The 4 note styles were denoted A (traditional SOAP note), B (2-column APSO note), C (collapsible APSO note), and D (2-column collapsible APSO note). The 4 unique note styles were designed to have equal amounts of information in each section. We simulated their utility for clinical practice by imposing time limits and by interrupting 1 of the tasks with a typical clinical interruption. For each session, we recorded audio, computer-screen activity, eye tracking, and made field notes. We obtained usability ratings (System Usability Scale), new feature preference ratings, and performed semistructured post-task interviews with subsequent content analysis. We compared the effectiveness of the 4 note styles by measuring time on task, task success (accuracy), and effort as measured by NASA Task Load Index. RESULTS: Note styles C and D were significantly faster than A and B for the Review of Systems and Physical Examination tasks, as we expected. Notes B and C had the best success (finding requested data) scores. Users strongly endorsed all the new note features incorporated into the new note prototypes. Previously expressed concerns about temporarily hiding parts of the note (using the accordion display design pattern) were allayed. Usability ratings for note A were worst but comparably better for note styles B, C, and D. DISCUSSION: The new APSO note prototypes performed better than the traditional SOAP note format for speed, task success (accuracy), and usability for physician users acquiring information needed for a typical chronic disease visit in primary care. Moving Assessment and Plan to the top is 1 easily accomplished feature change. Innovative documentation displays of EHR data can safely improve information display without eliminating data from the record of the visit.

Combining Contrast Mining with Logistic Regression To Predict Healthcare Utilization in a Managed Care Population.

BACKGROUND: Because 5% of patients incur 50% of healthcare expenses, population health managers need to be able to focus preventive and longitudinal care on those patients who are at highest risk of increased utilization. Predictive analytics can be used to identify these patients and to better manage their care. Data mining permits the development of models that surpass the size restrictions of traditional statistical methods and take advantage of the rich data available in the electronic health record (EHR), without limiting predictions to specific chronic conditions. OBJECTIVE: The objective was to demonstrate the usefulness of unrestricted EHR data for predictive analytics in managed healthcare. METHODS: In a population of 9,568 Medicare and Medicaid beneficiaries, patients in the highest 5% of charges were compared to equal numbers of patients with the lowest charges. Contrast mining was used to discover the combinations of clinical attributes frequently associated with high utilization and infrequently associated with low utilization. The attributes found in these combinations were then tested by multiple logistic regression, and the discrimination of the model was evaluated by the c-statistic. RESULTS: Of 19,014 potential EHR patient attributes, 67 were found in combinations frequently associated with high utilization, but not with low utilization (support>20%). Eleven of these attributes were significantly associated with high utilization (p<0.05). A prediction model composed of these eleven attributes had a discrimination of 84%. CONCLUSIONS: EHR mining reduced an unusably high number of patient attributes to a manageable set of potential healthcare utilization predictors, without conjecturing on which attributes would be useful. Treating these results as hypotheses to be tested by conventional methods yielded a highly accurate predictive model. This novel, two-step methodology can assist population health managers to focus preventive and longitudinal care on those patients who are at highest risk for increased utilization.

The Effect of Neighborhood Disadvantage on Diabetes Prevalence.

Patient socioeconomic data is not usually included in medical records nor easily accessible to clinicians, yet socioeconomic disadvantage can be an important guide to disease management. This study evaluated the neighborhood-level Area Deprivation Index (ADI), a measure of neighborhood socioeconomic disadvantage, as a factor in diabetes mellitus prevalence. Electronic health records at an academic hospital system identified 4,770 Medicare beneficiaries. Logistic regression of diabetes diagnosis (ICD9=250.x) against ADI quintile, age, gender, and race/ethnicity found all these patient characteristics to be significantly associated. Diabetes prevalence was lowest in the least disadvantaged quintile of neighborhoods after adjusting for age, gender, and race/ethnicity. The positive non-linear association of diabetes prevalence with ADI demonstrates the power of this index to practically quantify socioeconomic disadvantage. The ADI may be suitable for clinical decision support, and for informing the policy changes which are needed to reduce socioeconomic disparities in diabetes prevalence and other health outcomes.

The impact of supervised weight loss and intentional weight regain on sex hormone binding globulin and testosterone in premenopausal women.

What is the impact of intentional weight loss and regain on serum androgens in women? We conducted an ancillary analysis of prospectively collected samples from a randomized controlled trial. The trial involved supervised 10% weight loss (8.5 kg on average) with diet and exercise over 4-6 months followed by supervised intentional regain of 50% of the lost weight (4.6 kg on average) over 4-6 months. Participants were randomized prior to the partial weight regain component to either continuation or cessation of endurance exercise. Analytic sample included 30 obese premenopausal women (mean age of 40 ± 5.9 years, mean baseline body mass index (BMI) of 32.9 ± 4.2 kg/m(2)) with metabolic syndrome. We evaluated sex hormone binding globulin (SHBG), total testosterone (T), free androgen index (FAI), and high molecular weight adiponectin (HMWAdp). Insulin, homeostasis model assessment (HOMA), and quantitative insulin sensitivity check index (QUICKI), and visceral adipose tissue (VAT) measured in the original trial were reanalyzed for the current analytic sample. Insulin, HOMA, and QUICKI improved with weight loss and were maintained despite weight regain. Log-transformed SHBG significantly increased from baseline to weight loss, and then significantly decreased with weight regain. LogFAI and logVAT decreased similarly and increased with weight loss followed by weight regain. No changes were found in logT and LogHMWAdp. There was no significant difference in any tested parameters by exercise between the groups. SHBG showed prominent sensitivity to body mass fluctuations, as reduction with controlled intentional weight regain showed an inverse relationship to VAT and occurred despite stable HMWAdp and sustained improvements with insulin resistance. FAI showed opposite changes to SHBG, while T did not change significantly with weight. Continued exercise during weight regain did not appear to impact these findings.

Growth characteristics in cerebral palsy subtypes: a comparative assessment.

AIM: Children with quadriplegic cerebral palsy (CP) have been found to have growth rates that differ from those of children with typical development. Little research has been performed to distinguish whether growth patterns in hemiplegic, diplegic, and quadriplegic CP differ from one another. The purpose of this study was to compare growth of children with quadriplegic, hemiplegic, and diplegic CP. METHOD: Retrospective data were collected from the electronic medical record of patients with CP at an outpatient center. Linear mixed models were used to examine growth by diagnosis, using International Classification of Diseases, Ninth Revision (ICD-9) diagnosis codes 343.0 (diplegia), 343.1 (hemiplegia), and 343.2 (quadriplegia). RESULTS: Heights and weights of children with quadriplegic CP were consistently lower than those with hemiplegic or diplegic CP. Children with hemiplegic CP had greater heights and weights than other CP subtypes. There were statistically significant differences in weight gain curves among the three diagnoses for males (p<0.05). INTERPRETATION: Our study reveals differences in growth rates between hemiplegic, diplegic, and quadriplegic CP subtypes.

The effect of the amiodarone-warfarin interaction on anticoagulation quality in a single, high-quality anticoagulation center.

Clinical trials have reported a low time in therapeutic range (TTR) in patients with atrial fibrillation treated with both warfarin andamiodarone. These trials included centers and countries with both high and low TTRs. What is the impact of amiodarone on the TTR in a single, high-quality anticoagulation clinic? TTR was assessed in amiodarone and nonamiodarone-treated patients from a University anticoagulation clinic. Baseline characteristics between patients ever-taking or never-taking amiodarone were similar, except more amiodarone patients were smokers (19.5 vs. 6.1%, P = 0.0031). The TTR calculated from 8901international normalized ratios (INRs) in 249 nonamiodarone patients with a mean follow-up of 34 ±â€Š20 months (mean INR 36 ±â€Š18) was 66 ±â€Š16.6% compared with 61.3 ±â€Š16.2% (P = 0.111) from 1455 INRs in 41 amiodarone-treated patients with a mean follow-up of 28 ±â€Š20 months (mean INR 35 ±â€Š22). Factors associated with a low TTR were male sex (P = 0.0013), smoker (P = 0.0048), and amiodarone use (P = 0.0374). A second on-treatment analysis, in which the TTR was calculated only during amiodarone therapy, resulted in similar findings; however, amiodarone did not emerge as a predictor of a low TTR. In 11 patients, the TTR prior to amiodarone (54.5 ±â€Š22.2%) was not significantly different in the first 3 months (54.6 ±â€Š33.4%) or after 3 months (67.2 ±â€Š33.7%) of amiodarone. In a single high-quality anticoagulation center, anticoagulation quality, as measured by the TTR, can be comparable in amiodarone and nonamiodarone-treated patients.

Analysis of Advance Directive Documentation to Support Palliative Care Activities in Nursing Homes.

As part of an intervention to improve health care in nursing homes with the goal of reducing potentially avoidable hospital admissions, 1,877 resident records were reviewed for advance directive (AD) documentation. At the initial phases of the intervention, 50 percent of the records contained an AD. Of the ADs in the resident records, 55 percent designated a durable power of attorney for health care, most often a child (62 percent), other relative (14 percent), or spouse (13 percent). Financial power of attorney documents were sometimes found within the AD, even though these documents focused on financial decision making rather than health care decision making. Code status was the most prevalent health preference documented in the record at 97 percent of the records reviewed. The intervention used these initial findings and the philosophical framework of respect for autonomy to develop education programs and services on advance care planning. The role of the social worker within an interdisciplinary team is discussed.

Functional status of nursing home residents before and after abdominal aortic aneurysm repair.

Although many trials have evaluated abdominal aortic aneurysm (AAA) repair, the impact of these procedures on the functional status of frail elderly patients is not well-described. The effects of elective open AAA repair (OAR) and endovascular AAA repair (EVAR) and comorbidities were evaluated for their impact on functional trajectories after discharge. Medicare inpatient claims were linked with nursing home assessment data to identify elective admissions for OAR and EVAR. A functional score (range, 0-28; higher scores indicate greater impairment) was calculated before and after interventions. Logistic regression was used to develop a propensity score for receiving EVAR because residents were not randomized. Hierarchical linear modeling determined the effect of surgery on residents' function, controlling for prehospital function, hospital length of stay (LOS), stroke, and the propensity score.Fifty-two residents underwent OAR and 161 underwent EVAR. Most (65.3%) were men and 62.0% were from 76 to 85 years old. Mean LOS was 8.3 days for OAR and 5.1 days for EVAR. Of the residents, 47.4% had good prehospital function (activities of daily living [ADL] score of 0-10), and 48.4% were moderately impaired (ADL score of 11-20). Higher baseline ADL score, increased LOS, and stroke were associated with worse trajectories. Procedure type was not significantly related to postoperative function or the subsequent rate of improvement. OAR and EVAR were associated with similar initial declines and comparable postoperative trajectories, suggesting that less invasive EVAR was not associated with improved functional preservation compared with OAR. LOS was found to be higher than expected in the frail elderly after EVAR; longer stays were associated with poorer functional trajectories. Higher baseline ADL scores were significantly associated with inferior functional status after both procedures. Evaluation of preoperative function may assist physicians in predicting outcomes in this high-risk population.