Self-Reported Dementia-Related Diagnosis Underestimates the Prevalence of Older Americans Living with Possible Dementia.

BACKGROUND: Dementia screening is an important step for appropriate dementia-related referrals to diagnosis and treat possible dementia. OBJECTIVE: We sought to estimate the prevalence of no reported dementia-related diagnosis in a nationally representative sample of older Americans with a cognitive impairment consistent with dementia (CICD). METHODS: The weighted analytical sample included 6,036,224 Americans aged at least 65 years old that were identified as having a CICD without history of stroke, cancers, neurological conditions, or brain damage who participated in at least one-wave of the 2010-2016 Health and Retirement Study. The adapted Telephone Interview of Cognitive Status assessed cognitive functioning. Those with scores≤6 were considered as having a CICD. Healthcare provider dementia-related diagnosis was self-reported. Age, sex, educational achievement, and race and ethnicity were also self-reported. RESULTS: The overall estimated prevalence of no reported dementia-related diagnosis for older Americans with a CICD was 91.4%(95%confidence interval (CI): 87.7%-94.1%). Persons with a CICD who identified as non-Hispanic black had a high prevalence of no reported dementia-related diagnosis (93.3%; CI: 89.8%-95.6%). The estimated prevalence of no reported dementia-related diagnosis was greater in males with a CICD (99.7%; CI: 99.6%-99.8%) than females (90.2%; CI: 85.6%-93.4%). Moreover, the estimated prevalence of no reported dementia-related diagnosis for non-high school graduates with a CICD was 93.5%(CI: 89.3%-96.1%), but 90.9%(CI: 84.7%-94.7%) for those with at least a high school education. CONCLUSION: Dementia screening should be encouraged during routine geriatric health assessments. Continued research that evaluates the utility of self-reported dementia-related measures is also warranted.

Trends and timing of risk-reducing mastectomy uptake in unaffected BRCA1 and BRCA2 carriers in Slovenia.

OBJECTIVES: Risk-reducing mastectomy (RRM) is one of key prevention strategies in female carriers of germline BRCA pathogenic/likely pathogenic variants (PV/LPV). We retrospectively investigated the rate, timing and longitudinal trends of bilateral RRM uptake and the incidence and types of cancers among unaffected BRCA carriers who underwent genetic counseling at the Institute of Oncology Ljubljana in Slovenia. MATERIALS AND METHODS: Female BRCA carriers without personal history of cancer were included in the study. Clinical data on PV/LPV type, date of RRM, type of reconstructive procedure, occult carcinoma and histopathology results was collected and analyzed. RESULTS: Of the 346 unaffected BRCA carriers (median age 43 years, 70% BRCA1, 30% BRCA2, median follow-up 46 months) who underwent genetic testing between October 1999 and December 2019, 25.1% had a RRM (range 35-50 years, median age at surgery 38 years). A significant difference in time to prophylactic surgery between women undergoing RRM only vs. women undergoing RRM combined with risk-reducing salpingo-oophorectomy was observed (22.6 vs 8.7 months, p = 0.0009). We observed an upward trend in the annual uptake in line with the previously observed Angelina Jolie effect. In 5.7% of cases, occult breast cancer was detected. No women developed breast cancer after RRM. Women who did not opt for surgical prevention developed BRCA1/2-related cancers (9.3%). CONCLUSION: The uptake of RRM among unaffected BRCA carriers is 25.1% and is similar to our neighboring countries. No women developed breast cancer after RRM while women who did not opt for surgical prevention developed BRCA1/2 related cancers in 9.3% of cases. The reported data may provide meaningful aid for carriers when deciding on an optimal prevention strategy.

An Exploratory Screening Study for Type 2 Diabetes in Hospitalized Adult Medicine Patients.

OBJECTIVES: Literature from stroke and cardiac hospital admissions demonstrate a higher prevalence of undiagnosed type 2 diabetes compared with the general population. Fewer diabetes screening studies exist in the general medicine population, none of which have been based in Canada. Our primary objective in this study was to determine the prevalence of probable undiagnosed diabetes (glycated hemoglobin [A1C]≥6.5%) in hospitalized medicine patients. Secondary objectives were to identify the prevalence of undiagnosed dysglycemia (A1C≥6.0%) and the subsequent management of emergent cases. METHODS: In this prospective cohort study, adult patients admitted to internal medicine at a tertiary hospital in Ontario were screened for diabetes using an A1C test over a 3-month period. Baseline demographics and outcomes were compared using t tests, chi-square tests and Fisher's exact tests for normoglycemia, undiagnosed dysglycemia and probable undiagnosed diabetes. A regression analysis was performed to identify any relationships between various cardiovascular-related risk factors and A1C. RESULTS: A total of 53 adult patients were enrolled. The prevalence of probable undiagnosed diabetes and undiagnosed dysglycemia was 7.5% (n=4) and 30.2% (n=16), respectively. Implementation of diabetes management strategies and/or documentation of the finding occurred in 4 of 16 patients. Regression analysis showed no relationship between either cardiovascular-related risk factors or admission glucose with A1C. CONCLUSIONS: A broader screening approach may capture previously undiagnosed cases of diabetes that do not belong to traditionally at-risk populations. Future studies should focus on identifying risk factors for undiagnosed dysglycemia in hospitalized patients, including ethnicity and barriers to community access, so that appropriate screening programs can be developed.

Previously Undetected Obstructive Sleep Apnea in Patients With New-Onset Atrial Fibrillation.

Obstructive sleep apnea-hypopnea syndrome (OSA) compromises the efficacy of atrial fibrillation (AF) control strategies. Continuous positive airway pressure (CPAP) may ameliorate arrhythmia control especially in early AF stages (new-onset AF). We investigated a practical screening strategy to determine the likelihood of CPAP indication in new-onset AF patients. Seventy-seven consecutive patients with new-onset (<1 month) AF were prospectively evaluated. Of them, 4 were excluded due to previously diagnosed OSA. The remaining 73 (68% persistent AF) fulfilled the Epworth, Berlin and STOP-BANG questionnaires, an ambulatory polysomnography being performed thereafter in all them in order to determine the apnea-hipopnea index (AHI). CPAP was indicated following conventional criteria. The variables associated with the diagnosis of OSA, with the AHI value and with CPAP indication were investigated by means of descriptive, univariate and multivariate analysis. The prevalence of OSA of any degree and CPAP indication was 82% and 37%, respectively. The variables associated (p < 0.05) with a higher AHI were male gender, body mass index, obesity, hypertension, and high-risk scoring at the Berlin and STOP-BANG questionnaires. In the multivariate analysis, the STOP-BANG scoring proved superior to conventional risk factors and became the only variable predicting CPAP indication (odds ratio 4.5 [1.9 to 10.6]; p = 0.01), an optimized cutoff value of ≥4 being newly established (sensitivity/specificity 76/65%). In conclusion, in patients referred with new-onset AF we documented a high risk of OSA and of need for CPAP. A STOP-BANG scoring of ≥4 in our population was a practical screening alternative to direct polysomnography in this setting.

Exome and genome sequencing in adults with undiagnosed disease: a prospective cohort study.

BACKGROUND: Exome and genome sequencing have been demonstrated to increase diagnostic yield in paediatric populations, improving treatment options and providing risk information for relatives. There are limited studies examining the clinical utility of these tests in adults, who currently have limited access to this technology. METHODS: Patients from adult and cancer genetics clinics across Toronto, Ontario, Canada were recruited into a prospective cohort study evaluating the diagnostic utility of exome and genome sequencing in adults. Eligible patients were ≥18 years of age and suspected of having a hereditary disorder but had received previous uninformative genetic test results. In total, we examined the diagnostic utility of exome and genome sequencing in 47 probands and 34 of their relatives who consented to participate and underwent exome or genome sequencing. RESULTS: Overall, 17% (8/47) of probands had a pathogenic or likely pathogenic variant identified in a gene associated with their primary indication for testing. The diagnostic yield for patients with a cancer history was similar to the yield for patients with a non-cancer history (4/18 (22%) vs 4/29 (14%)). An additional 24 probands (51%) had an inconclusive result. Secondary findings were identified in 10 patients (21%); three had medically actionable results. CONCLUSIONS: This study lends evidence to the diagnostic utility of exome or genome sequencing in an undiagnosed adult population. The significant increase in diagnostic yield warrants the use of this technology. The identification and communication of secondary findings may provide added value when using this testing modality as a first-line test.

The neglected perioperative population of undiagnosed diabetics - a retrospective cohort study.

BACKGROUND: Diabetes is known to increase morbidity and 30-day mortality in adults undergoing non-cardiac surgery, but longer term outcomes are less studied. This study was done to explore how undiagnosed and known diabetes affect 30-day and one-year morbidity and mortality outcomes. The secondary aim was to study the prevalence of undiagnosed diabetics in our perioperative Asian surgical population. METHODS: A retrospective cohort study of 2106 patients aged > 45 years undergoing non-cardiac surgery in a single tertiary hospital was performed. Undiagnosed diabetics were identified (HbA1c ≥6.5% or fasting blood glucose ≥126 mg/dL) and relevant demographic, clinical and surgical data were analyzed to elicit the relationship to adverse outcomes. Univariate analysis was first performed to identify significant variables with p-values ≤0.1, which were then analyzed using multiple logistic regression to calculate the adjusted odds ratio. RESULTS: The prevalence of undiagnosed diabetes was 7.4%. The mean and median HbA1c of known diabetics were 7.9 and 7.5%, while the mean and median HbA1c for undiagnosed diabetics were 7.2 and 6.8% respectively. 36.4% of known diabetics and 20.5% of undiagnosed diabetics respectively had a random blood glucose > 200 mg/dL. Undiagnosed diabetics had a three-fold increase in 1-year mortality compared to non-diabetics (adjusted OR 3.46(1.80-6.49) p < 0.001) but this relationship was not significant between known and non-diabetics. Compared to non-diabetics, known diabetics were at increased risks of new-onset atrial fibrillation (aOR 2.48(1.01-6.25) p = 0.047), infection (aOR 1.49(1.07-2.07) p = 0.017), 30-day readmission (aOR 1.62(1.17-2.25) p = 0.004) and 30-day mortality (aOR 3.11(1.16-8.56) p = 0.025). CONCLUSIONS: Although undiagnosed diabetics have biochemically less severe disease compared to known diabetics at the point of testing, they are at a one-year mortality disadvantage which is not seen among known diabetics. This worrying trend highlights the importance of identifying and treating diabetes. Congruent to previous studies, known diabetics have higher morbidity and 30-day mortality compared to non-diabetics.

IgG Seroprevalence of COVID-19 among Individuals without a History of the Coronavirus Disease Infection in Daegu, Korea.

BACKGROUND: Seroprevalence studies of coronavirus disease 2019 (COVID-19) from many countries have shown that the number of undiagnosed missing cases is much larger than that of confirmed cases, irrespective of seroprevalence levels. Considering the strategy of Korea entailing massive testing and contact tracing from the beginning of epidemic, the number of undiagnosed missing cases in Korea may be negligible. This study was conducted to estimate the seroprevalence of COVID-19 among individuals who were never diagnosed with COVID-19 in Daegu, the epicenter of COVID-19 epidemic in Korea. METHODS: Serologic testing for immunoglobulin G antibody based on immunochromatographic assay was conducted in 103 patients and 95 guardians aged 18 to 82 years without any history of COVID-19 diagnosis, who visited outpatient clinics of a single university-affiliated hospital from May 25 to June 5, 2020. RESULTS: The estimated seroprevalence was 7.6% (95% confidence interval, 4.3%-12.2%) with 15 positive cases. Among them, only one had a polymerase chain reaction (PCR)-confirmed case among their close contacts and 13 did not experience COVID-19-related symptoms. Seroprevalence was similar between patients and guardians. Based on this figure, the number of undiagnosed missing cases in Daegu was estimated to be a dozen times more than the number of confirmed cases based on PCR testing. CONCLUSION: Despite the limitation of a small and unrepresentative sample, this is the first study on seroprevalence of COVID-19 in Korea. Our study suggested that the number of undiagnosed missing cases was substantial even with the stringent strategy adopted in Korea, similar to that of other countries.

Physical Activity and Risk of Diagnosed and Undiagnosed Prediabetes among Males and Females in the National Health and Nutrition Examination Survey, 2007-2014.

AIMS: The purpose of the study was to assess the effect of leisure and occupational physical activity on the risk of diagnosed and undiagnosed prediabetes among females and males. METHODS: A sample of 17,871 non-pregnant adults was drawn from the 2007-2014 National Health and Nutrition Examination Survey. Multinomial logistic regression tested associations between moderate-to-vigorous physical activity (MVPA) and risk of diagnosed prediabetes and undiagnosed prediabetes, compared to no prediabetes. RESULTS: Females and males who met guidelines for total MVPA (i.e., ≥10 MET-hrs/week) had a statistically significant lower risk of undiagnosed prediabetes (OR range: 0.50-0.65) as compared to those with no MVPA, however findings were no longer statistically significant after adjustment for diabetes risk factors. In terms of diagnosed prediabetes, females meeting guidelines had lower risk (OR range: 0.65-0.76), while only males engaging in the most MVPA had lower risk; findings were no longer significant after adjustment. Patterns were similar for leisure-time MVPA, but conflicting for occupational PA; females with 10-20 MET-hrs/week had a higher risk of diagnosed prediabetes (OR =1.71, 95% CI 1.11-2.61) and males with >20 MET-hrs/week had a higher risk for undiagnosed prediabetes (OR =1.17, 95% CI 1.02-1.35) after adjustment. CONCLUSIONS: This study adds to the sparse body of literature on physical activity and prediabetes, particularly with its inclusion of occupational MVPA.

How often do we incidentally find a fetal abnormality at the routine third-trimester growth scan? A population-based study.

BACKGROUND: Third-trimester scans are increasingly used to try to prevent adverse outcomes associated with abnormalities of fetal growth. Unexpected fetal malformations detected at third-trimester growth scans are rarely reported. OBJECTIVE: To determine the incidence and type of fetal malformations detected in women attending a routine third-trimester growth scan. STUDY DESIGN: This was a population-based study of all women with singleton pregnancy attending antenatal care over a 2-year period in Oxfordshire, UK. Women who had a viable singleton pregnancy at dating scan were included. Women had standard obstetrical care including the offer of a routine dating scan and combined screening for trisomies; a routine anomaly scan at 18 to 22 weeks; and a routine third-trimester growth scan at 36 weeks. The third-trimester scan comprises assessment of fetal presentation, amniotic fluid, biometry, umbilical and middle cerebral artery Dopplers, but no formal anatomic assessment is undertaken. Scans are performed by certified sonographers or clinical fellows (n=54), and any suspected abnormalities are evaluated by a team of fetal medicine specialists. We assessed the frequency and type of incidental congenital malformations identified for the first time at this third-trimester scan. All babies were followed-up after birth for a minimum of 6 months. RESULTS: There were 15,244 women attending routine antenatal care. Anomalies were detected in 474 (3.1%) fetuses as follows: 103 (21.7%) were detected before the anomaly scan, 174 (36.7%) at the anomaly scan, 11 (2.3%) after the anomaly scan and before the third-trimester scan, 43 (9.1%) at the third-trimester scan and 143 (30.2%) after birth. The 43 abnormalities were found in a total of 13,023 women who had a 36 weeks scan, suggesting that in 1 out of 303 (95% confidence interval, 233-432) women attending such a scan, a new malformation was detected. Anomalies detected at the routine third-trimester scan were of the urinary tract (n=30), central nervous system (5), simple ovarian cysts (4), chromosomal (1), splenic cyst (1), skeletal dysplasia (1), and cutaneous lymphangioma (1). Most urinary tract anomalies were renal pelvic dilatation, which showed spontaneous resolution in 57% of the cases. CONCLUSION: When undertaking a program of routine third-trimester growth scans in women who have had previous screening scans, an unexpected congenital malformation is detected in approximately 1 in 300 women.

Long-term Consequences of Undiagnosed Celiac Seropositivity.

INTRODUCTION: Diagnosed celiac disease (CD) is associated with lymphoproliferative malignancy and gastrointestinal cancer, but little is known about the long-term consequences of undiagnosed CD. We aimed to investigate long-term consequences of undiagnosed CD for mortality and incidence of cancer and other chronic diseases. METHODS: We screened biobank serum samples for immunoglobulin (Ig) A and IgG tissue transglutaminase (TTG) and IgG deamidated gliadin peptide in a study of 8 population-based cohort studies comprising 16,776 participants examined during 1976-2012 and followed with >99% complete follow-up in Danish nationwide registries until December 31, 2017, regarding vital status and incidence of diseases. Undiagnosed CD was defined as antibody positivity (IgA-TTG or IgG-TTG ≥ 7 U/mL and/or IgG deamidated gliadin peptide ≥ 10 U/mL) in individuals without a diagnosis of CD recorded in the National Patient Register. Hazard ratios (HRs) with 95% confidence intervals (CIs) were estimated by Cox regression analyses with age as the underlying time scale. RESULTS: The prevalence of undiagnosed CD was 1.0% with no statistically significant increase over time. Undiagnosed CD was associated with increased risk of cancer overall (HR, 1.57; 95% CI, 1.16-2.11), gastrointestinal cancer (HR, 2.33; 95% CI, 1.35-4.04), cancer of the uterus (HR, 3.95; 95% CI, 1.46-10.69), breast cancer (HR, 1.98; 95% CI, 1.02-3.82), head and neck cancer (HR, 3.12; 95% CI, 1.15-8.43), and cardiovascular disease (HR, 1.37; 95% CI, 1.01-1.85). We found no statistically significant association between undiagnosed CD and mortality (HR, 1.19; 95% CI, 0.87-1.61). DISCUSSION: Undiagnosed CD was associated with increased risk of cardiovascular disease and cancer suggesting that untreated CD has serious long-term health consequences not only affecting the gastrointestinal tract (see Visual Abstract, Supplementary Digital Content, http://links.lww.com/AJG/B566).

A Best Practice Alert for Identifying Hepatitis B-Infected Patients.

We developed and evaluated the Global Health Wizard Hepatitis B Best Practice Alert (BPA) to increase primary care provider adherence to evidence-based guidelines for hepatitis B virus (HBV) infection screening in non-U.S.-born patients. We conducted a pilot study using nine clinics to test BPA effectiveness. Eligible patients were aged ≥ 12 years, from a country of origin with ≥ 2% HBV prevalence, had no electronic health record documentation of HBV screening, and were seen for primary care during July 2012-March 2013. The BPA triggered for > 4,500 patients and identified six previously unrecognized HBV-infected patients. The pilot project demonstrated BPA effectiveness and continued to be used at pilot clinics until 2018 and was expanded to additional clinics in 2019; 29 additional HBV-infected patients were identified. Although successful, BPA usage steadily decreased over time. Poor BPA usage limits the power to achieve the goal of improved population-based HBV screening.

Alternative type 2 diabetes screening tests may reduce the number of U.S. adults with undiagnosed diabetes.

AIM: To evaluate the U.S. population-level impact of two alternatives for initial type 2 diabetes screening [opportunistic random plasma glucose (RPG) > 6.7 mmol/l and a 1-h 50-g glucose challenge test (GCT) > 8.9 mmol/l] compared with American Diabetes Association (ADA)-recommended tests. METHODS: Using a sample (n = 1471) from the National Health and Nutrition Examination Survey (NHANES) 2013-2014 that represented 145 million U.S. adults at high risk for developing type 2 diabetes, we simulated a two-test screening process. We compared ADA-recommended screening tests [fasting plasma glucose (FPG), 2-h 75-g oral glucose tolerance test (OGTT), HbA1c ] vs. initial screening with opportunistic RPG or GCT (followed by FPG, OGTT or HbA1c ). After simulation, participants were entered into an individual-level Monte Carlo-based Markov lifetime outcomes model. Primary outcomes were representative number of U.S. adults correctly identified with type 2 diabetes, societal lifetime costs and quality-adjusted life years (QALYs). RESULTS: In NHANES 2013-2014, 100 individuals had undiagnosed diabetes [weighted estimate: 8.4 million, standard error (se): 1.1 million]. Among ADA-recommended screening tests, FPG followed by OGTT (FPG-OGTT) was most sensitive, identifying 35 individuals with undiagnosed diabetes (weighted estimate: 3.2 million, se: 0.9 million). Four alternative screening strategies performed superior to FPG-OGTT, with RPG followed by OGTT being the most sensitive overall, identifying 72 individuals with undiagnosed diabetes (weighted estimate: 6.1 million, se: 1.0 million). There was no increase in average lifetime costs and comparable QALYs. CONCLUSIONS: Initial screening using opportunistic RPG or a GCT may identify more U.S. adults with type 2 diabetes without increasing societal costs.

Consistent high prevalence of undiagnosed blood-borne virus infection in patients attending large urban emergency departments in England.

Understanding local viral hepatitis and HIV epidemiology is essential if WHO elimination targets are to be achieved. We demonstrate a consistently high prevalence of undiagnosed active infection in urban emergency department attendees in England, with variations in local risk groups crucial to informing targeted testing initiatives.

Prescription of antimicrobials in primary health care as a marker to identify people living with undiagnosed HIV infection, Denmark, 1998 to 2016.

BackgroundDevelopment of additional diagnostic strategies for earlier HIV diagnosis are needed as approximately 50% of newly diagnosed HIV-infected individuals continue to present late for HIV care.AimWe aimed to analyse antimicrobial consumption in the 3 years preceding HIV diagnosis, assess whether there was a higher consumption in those diagnosed with HIV compared with matched controls and whether the level of consumption was associated with the risk of HIV infection.MethodsWe conducted a nested case-control study, identifying all individuals (n = 2,784 cases) diagnosed with HIV in Denmark from 1998 to 2016 and 13 age-and sex-matched population controls per case (n = 36,192 controls) from national registers. Antimicrobial drug consumption was estimated as defined daily doses per person-year. We used conditional logistic regression to compute odds ratios and 95% confidence intervals.ResultsIn the 3 years preceding an HIV diagnosis, we observed more frequent and higher consumption of antimicrobial drugs in cases compared with controls, with 72.4% vs 46.3% having had at least one prescription (p < 0.001). For all antimicrobial classes, the association between consumption and risk of subsequent HIV diagnosis was statistically significant (p < 0.01). The association was stronger with higher consumption and with shorter time to HIV diagnosis.ConclusionHIV-infected individuals have a significantly higher use of antimicrobial drugs in the 3 years preceding HIV diagnosis than controls. Prescription of antimicrobial drugs in primary healthcare could be an opportunity to consider proactive HIV testing. Further studies need to identify optimal prescription cut-offs that could endorse its inclusion in public health policies.

Study protocol for enhanced CJD surveillance in the 65+ years population group in Scotland: an observational neuropathological screening study of banked brain tissue donations for evidence of prion disease.

INTRODUCTION: Creutzfeldt-Jakob disease (CJD) is a human prion disease that occurs in sporadic, genetic and acquired forms. Variant CJD (vCJD) is an acquired form first identified in 1996 in the UK. To date, 178 cases of vCJD have been reported in the UK, most of which have been associated with dietary exposure to the bovine spongiform encephalopathy agent. Most vCJD cases have a young age of onset, with a median age at death of 28 years. In the UK, suspected cases of vCJD are reported to the UK National Creutzfeldt-Jakob Disease Research & Surveillance Unit (NCJDRSU). There is, however, a concern that the national surveillance system might be missing some cases of vCJD or other forms of human prion disease, particularly in the older population, perhaps because of atypical clinical presentation. This study aims to establish whether there is unrecognised prion disease in people aged 65 years and above in the Scottish population by screening banked brain tissue donated to the Edinburgh Brain Bank (EBB). METHODS: Neuropathological screening of prospective and retrospective brain tissue samples is performed. This involves histopathological and immunohistochemical analysis and prion protein biochemical analysis. During the study, descriptive statistics are used to describe the study population, including the demographics and clinical, pathological and referral characteristics. Controlling for confounders, univariate and multivariate analyses will be used to compare select characteristics of newly identified suspect cases with previously confirmed cases referred to the NCJDRSU. ETHICS AND DISSEMINATION: Brain tissue donations to EBB are made voluntarily by the relatives of patients, with consent for use in research. The EBB has ethical approval to provide tissue samples to research projects (REC reference 16/ES/0084). The findings of this study will be disseminated in meetings, conferences, workshops and as peer-reviewed publications. TRIAL REGISTRATION NUMBERS: 10/S1402/69 and 10/S1402/70.

Risk factors and consequences of undiagnosed cesarean scar pregnancy: a cohort study in China.

BACKGROUND: The historically high cesarean section rate and the recent change in second-child policy could increase the risk of cesarean scar pregnancy (CSP) in China. This study aims to assess risk factors and consequences of undiagnosed CSP in China. METHODS: We conducted a retrospective cohort study between January 2013 and December 2017 in Qingyuan, Guangdong, China. Independent risk factors for undiagnosed CSP at the first contact with healthcare providers were assessed by log binomial regression analysis. Occurrence of serious complications was compared between undiagnosed and diagnosed CSP cases. RESULTS: A total of 195 women with CSP were included in the analysis. Of them, 81 (41.5%) women were undiagnosed at the first contact with healthcare providers. Women initially cared in primary or secondary hospitals were at increased risk for undiagnosed CSP: adjusted relative risks (95% confidence intervals) were 3.28 (2.06, 5.22) and 1.91 (1.16, 3.13), respectively, compared with women initially cared in the tertiary hospital. Undiagnosed CSP cases had higher incidences in serious complications (11 versus 0) and post-surgery anemia (23 (28.4%) versus 8 (7.0%)), stayed longer in hospital, and cost higher than diagnosed CSP cases. CONCLUSIONS: Initial care provided at primary or secondary maternity care facilities is an important risk factor for undiagnosed CSP, with serious consequences to the affected women.

Rethinking the Issue of Power Morcellation of Uterine Fibroids: Is Morcellation the Real Problem or Is this Another Symptom of Disparity in Healthcare Provision?

Power morcellation remains one of the most significant developments in minimal access surgery over the past decade, allowing many more patients to benefit from the least invasive surgical route. However, its use is not without controversy, particularly with regards to the risks of an undiagnosed leiomyosarcoma. Increased media and, in particular, on-going social media coverage since events in 2014 have only served to intensify the debate, culminating in the Food and Drug Administration essentially 'banning' its use in the USA. Practice however continues to vary and this technique remains widely used in Europe and in particular the UK. The aim of this article was to review the development of power morcellation in gynaecology and the underlying risks, including that of undiagnosed leiomyosarcoma, as well as appraise the evolving literature on patient awareness and informed consent and the wider implications of morcellation restriction.

Hidden Burden of Electronic Health Record-Identified Familial Hypercholesterolemia: Clinical Outcomes and Cost of Medical Care.

Background Familial hypercholesterolemia ( FH ), is a historically underdiagnosed, undertreated, high-risk condition that is associated with a high burden of cardiovascular morbidity and mortality. In this study, we use a population-based approach using electronic health record ( EHR )-based algorithms to identify FH . We report the major adverse cardiovascular events, mortality, and cost of medical care associated with this diagnosis. Methods and Results In our 1.18 million EHR- eligible cohort, International Classification of Diseases, Ninth Revision ( ICD -9) code-defined hyperlipidemia was categorized into FH and non- FH groups using an EHR algorithm designed using the modified Dutch Lipid Clinic Network criteria. Major adverse cardiovascular events, mortality, and cost of medical care were analyzed. A priori associated variables/confounders were used for multivariate analyses using binary logistic regression and linear regression with propensity score-based weighted methods as appropriate. EHR FH was identified in 32 613 individuals, which was 2.7% of the 1.18 million EHR cohort and 13.7% of 237 903 patients with hyperlipidemia. FH had higher rates of myocardial infarction (14.77% versus 8.33%; P<0.0001), heart failure (11.82% versus 10.50%; P<0.0001), and, after adjusting for traditional risk factors, significantly correlated to a composite major adverse cardiovascular events variable (odds ratio, 4.02; 95% CI, 3.88-4.16; P<0.0001), mortality (odds ratio, 1.20; CI, 1.15-1.26; P<0.0001), and higher total revenue per-year (incidence rate ratio, 1.30; 95% CI, 1.28-1.33; P<0.0001). Conclusions EHR -based algorithms discovered a disproportionately high prevalence of FH in our medical cohort, which was associated with worse outcomes and higher costs of medical care. This data-driven approach allows for a more precise method to identify traditionally high-risk groups within large populations allowing for targeted prevention and therapeutic strategies.

Prevalence and Risk Factors of Brain Infarcts and Associations With Cognitive Performance in Tenants of Marginal Housing.

Background Homeless and vulnerably housed individuals are at increased risk for multimorbidity compared with the general population. We assessed prevalence of brain infarcts on neuroimaging and associations with vascular risk factors and cognitive performance in a prospective study of residents living in marginal housing. Methods and Results Two hundred twenty-eight participants underwent structured clinical interviews, targeted clinical, laboratory, and neuropsychological assessments, and magnetic resonance imaging with T1, T2-fluid-attenuated inversion recovery and susceptibility-weighted images. Subjects underwent cognitive testing to assess premorbid IQ , verbal learning and memory, inhibition, sustained attention, mental flexibility, and decision making. In this sample (mean age 44.0 years [ SD 9.4], 77% male), prevalence of conventional vascular risk factors was lower than in the general population apart from tobacco use (94%). Ten-year Framingham risk for any cardiovascular event was 11.4%±9.2%. Brain infarcts were present in 25/228 (11%). All were ischemic (40% cortical, 56% lacunar, 4% both). Participants with infarcts were older than those without (48.9±9.4 versus 43.4±9.2, P=0.006). In a multivariable regression analysis, only age remained a significant predictor of brain infarcts (odds ratio 1.08, 95% CI 1.02-1.14, P=0.004). After controlling for age and education, the presence of infarct was a significant predictor of impaired decision making on the Iowa Gambling Task of decision making (ß -28.2, 95% CI -42.7 to -14.1, P<0.001). Conclusions Prevalence of infarcts on neuroimaging in this disadvantaged, community-dwelling cohort was much higher than expected for age and was associated with impaired decision making. Further research is needed to identify individuals at highest risk who may benefit from targeted preventative strategies.

Do changes in health reveal the possibility of undiagnosed pancreatic cancer? Development of a risk-prediction model based on healthcare claims data.

BACKGROUND AND OBJECTIVE: Early detection methods for pancreatic cancer are lacking. We aimed to develop a prediction model for pancreatic cancer based on changes in health captured by healthcare claims data. METHODS: We conducted a case-control study on 29,646 Medicare-enrolled patients aged 68 years and above with pancreatic ductal adenocarcinoma (PDAC) reported to the Surveillance Epidemiology an End Results (SEER) tumor registries program in 2004-2011 and 88,938 age and sex-matched controls. We developed a prediction model using multivariable logistic regression on Medicare claims for 16 risk factors and pre-diagnostic symptoms of PDAC present within 15 months prior to PDAC diagnosis. Claims within 3 months of PDAC diagnosis were excluded in sensitivity analyses. We evaluated the discriminatory power of the model with the area under the receiver operating curve (AUC) and performed cross-validation by bootstrapping. RESULTS: The prediction model on all cases and controls reached AUC of 0.68. Excluding the final 3 months of claims lowered the AUC to 0.58. Among new-onset diabetes patients, the prediction model reached AUC of 0.73, which decreased to 0.63 when claims from the final 3 months were excluded. Performance measures of the prediction models was confirmed by internal validation using the bootstrap method. CONCLUSION: Models based on healthcare claims for clinical risk factors, symptoms and signs of pancreatic cancer are limited in classifying those who go on to diagnosis of pancreatic cancer and those who do not, especially when excluding claims that immediately precede the diagnosis of PDAC.