A Case of Undiagnosed Schizophrenia With Catatonia in a Hispanic Adolescent: The Significance of Social Determinants in the Diagnosis and the Efficacy of Risperidone and Lorazepam in Treatment.

Catatonia is a potentially life-threatening motor dysregulation syndrome associated with various psychiatric, medical, or developmental conditions. It is not uncommon but rarely described in the pediatric population. The timely identification of catatonia is essential as the treatment approach differs from the differential diagnoses and possible underlying conditions. The social determinants of health are factors that may negatively impact psychological well-being, increase the risk and prevalence of mental disorders, and deteriorate the prognosis for those who already have them. The comprehension of social determinants of health is essential because it provides a deeper understanding of the complexity of societal structures and how they influence the lives of children and families. This case demonstrates how social determinants of health may contribute to misdiagnosis, delayed diagnosis, and an increase in the incidence of mental health disorders. We present a case report on a Hispanic adolescent with first-episode catatonia in the presence of disorganized, psychotic thoughts. The patient was successfully treated with the lorazepam challenge in conjunction with Risperidone M-Tab treatment in three days. The origin of catatonia was rooted in undiagnosed schizophrenia that had worsened over a year originating from a first-episode break that questions an untreated substance-induced psychosis: the substance is unknown, as her parents had not brought her to the emergency department at that time. The demographics of this patient have also placed her at risk for a lack of access and sociocultural aspects in the delay of treatment. Through this case report, we aim to highlight some critical points in diagnosing and managing nonmalignant catatonia in a demographically underserved minority adolescent female. This report emphasizes the need for more data about the etiology and treatment of catatonia, especially in the pediatric population.

Development, Evaluation, and Multisite Deployment of a Machine Learning Decision Tree Algorithm To Optimize Urinalysis Parameters for Predicting Urine Culture Positivity.

PittUDT, a recursive partitioning decision tree algorithm for predicting urine culture (UC) positivity based on macroscopic and microscopic urinalysis (UA) parameters, was developed in support of a broader system-wide diagnostic stewardship initiative to increase appropriateness of UC testing. Reflex algorithm training utilized results from 19,511 paired UA and UC cases (26.8% UC positive); the average patient age was 57.4 years, and 70% of samples were from female patients. Receiver operating characteristic (ROC) analysis identified urine white blood cells (WBCs), leukocyte esterase, and bacteria as the best predictors of UC positivity, with areas under the ROC curve of 0.79, 0.78, and 0.77, respectively. Using the held-out test data set (9,773 cases; 26.3% UC positive), the PittUDT algorithm met the prespecified target of a negative predictive value above 90% and resulted in a 30 to 60% total negative proportion (true-negative plus false-negative predictions). These data show that a supervised rule-based machine learning algorithm trained on paired UA and UC data has adequate predictive ability for triaging urine specimens by identifying low-risk urine specimens, which are unlikely to grow pathogenic organisms, with a false-negative proportion under 5%. The decision tree approach also generates human-readable rules that can be easily implemented across multiple hospital sites and settings. Our work demonstrates how a data-driven approach can be used to optimize UA parameters for predicting UC positivity in a reflex protocol, with the intent of improving antimicrobial stewardship and UC utilization, a potential avenue for cost savings.

Assessment of mitochondrial respiratory capacity using minimally invasive and noninvasive techniques in persons with spinal cord injury.

PURPOSE: Muscle biopsies are the gold standard to assess mitochondrial respiration; however, biopsies are not always a feasible approach in persons with spinal cord injury (SCI). Peripheral blood mononuclear cells (PBMCs) and near-infrared spectroscopy (NIRS) may alternatively be predictive of mitochondrial respiration. The purpose of the study was to evaluate whether mitochondrial respiration of PBMCs and NIRS are predictive of respiration of permeabilized muscle fibers after SCI. METHODS: Twenty-two individuals with chronic complete and incomplete motor SCI between 18-65 years old were recruited to participate in the current trial. Using high-resolution respirometry, mitochondrial respiratory capacity was measured for PBMCs and muscle fibers of the vastus lateralis oxidizing complex I, II, and IV substrates. NIRS was used to assess mitochondrial capacity of the vastus lateralis with serial cuff occlusions and electrical stimulation. RESULTS: Positive relationships were observed between PBMC and permeabilized muscle fibers for mitochondrial complex IV (r = 0.86, P < 0.0001). Bland-Altman displayed agreement for complex IV (MD = 0.18, LOA = -0.86 to 1.21), between PBMCs and permeabilized muscles fibers. No significant relationships were observed between NIRS mitochondrial capacity and respiration in permeabilized muscle fibers. CONCLUSIONS: This is the first study to explore and support the agreement of less invasive clinical techniques for assessing mitochondrial respiratory capacity in individuals with SCI. The findings will assist in the application of PBMCs as a viable alternative for assessing mitochondrial health in persons with SCI in future clinical studies.

The virtual fracture clinic improves quality of care for patients with hand and wrist injuries: an assessment of 3709 patients.

Fracture clinic services are under significant pressures to meet patients' expectations of a high-quality service. The virtual fracture clinic has shown early promise in helping to reduce such pressures. We used the virtual fracture clinic for hand and wrist injuries treated in the orthopaedic fracture clinic and used key quality indicators to measure improvement. Over the first 21 months, key patient outcome measures and satisfaction scores for patients discharged from the virtual fracture clinic with education to self-care were excellent. Our results show that a virtual fracture clinic model can be applied to provide high-quality care for hand and wrist injuries. The main advantage of the virtual fracture clinic is its ability to direct patients to the right person for timely treatment. We conclude from our 21-month experience that this model of care allows safe, effective, patient-centred, efficient and equitable care to the patients with hand and wrist fractures.Level of evidence: IV.

Diversity among academic orthopedic shoulder and elbow surgery faculty in the United States.

BACKGROUND: The purpose of this study was to perform a cross-sectional analysis of diversity among academic shoulder and elbow surgeons in the United States. METHODS: US shoulder and elbow surgeons who participated in shoulder and elbow fellowship and/or orthopedic surgery resident education as of November 2018 were included. Demographic data (age, gender, race), practice setting, years in practice, academic rank, and leadership roles were collected through publicly available databases and professional profiles. Descriptive statistics were performed and findings were compared between different racial and gender groups. Statistical significance was set at P <.05. RESULTS: A total of 186 orthopedic shoulder and elbow surgeons were identified as participating in shoulder and elbow fellowship and/or orthopedic surgery residency education. Overall, 83.9% were white, 14.5% were Asian, 1.1% were Hispanic, 0.5% were an other race, and 0% were African American. In addition, 94.6% of surgeons were male, whereas 5.4% were female. Further, 64.5% of all surgeons had been in practice for >10 years, and 39.2% worked in an urban setting. Less than half (40.3%) of the surgeons practicing primarily at academic institutions held a professor rank. White surgeons had a significantly greater time in practice vs. nonwhite surgeons (mean 18.8 vs. 12.6 years, P < .01) and were more likely to hold a professor rank (44.0% vs. 21.7%, P = .04). CONCLUSION: Racial and gender diversity among US shoulder and elbow surgeons who participate in fellowship and residency education is lacking. Hispanic, African American, and female surgeons are underrepresented. Efforts should be made to identify the reasons for these deficiencies and address them to further advance the field of orthopedic shoulder and elbow surgery.

Union stability among mothers and stepfathers: Contributions of stepfathers and biological fathers.

A substantial proportion of unmarried mothers with young children live with new partners (stepfathers), and the stability of these unions is important to outcomes for mothers and children. This study examined effects of both step- and biological fathers' co-parenting, parenting, and financial contributions on union stability among mothers and stepfathers. Data were from the Fragile Families and Child Wellbeing Study (N = 370), and the sample included mothers with 3-year-old children who were mostly unmarried and low-income. Results from discrete-time event history analysis indicated that mothers' residential unions with stepfathers were more stable when stepfathers were working and less stable when biological fathers paid formal child support. Results from interactions in the model showed that differences in the likelihood of dissolution between working and nonworking stepfathers were greater when stepfathers had more supportive co-parenting relationships with mothers and when stepfathers engaged in activities with the child more often. Findings suggest that economic contributions of both biological and stepfathers affect the stability of mother-stepfather residential unions, and stepfathers' co-parenting and parenting contributions may provide additional protection against union dissolution, particularly when stepfathers are working. Prevention and intervention programs could benefit these fragile families by attending to economic contributions of both fathers and stepfathers and helping stepfathers develop roles as co-parents and parents in this context. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

Sexual health needs and educational intervention preferences for women with cancer.

PURPOSE: To assess sexual/vaginal health issues and educational intervention preferences in women with a history of breast or gynecologic cancer. METHODS: Patients/survivors completed a cross-sectional survey at their outpatient visits. Main outcome measures were sexual dysfunction prevalence, type of sexual/vaginal issues, awareness of treatments, and preferred intervention modalities. Descriptive frequencies were performed, and results were dichotomized by age, treatment status, and disease site. RESULTS: Of 218 eligible participants, 109 (50%) had a history of gynecologic and 109 (50%) a history of breast cancer. Median age was 49 years (range 21-75); 61% were married/cohabitating. Seventy percent (n = 153) were somewhat-to-very concerned about sexual function/vaginal health, 55% (n = 120) reported vaginal dryness, 39% (n = 84) vaginal pain, and 51% (n = 112) libido loss. Many had heard of vaginal lubricants, moisturizers, and pelvic floor exercises (97, 72, and 57%, respectively). Seventy-four percent (n = 161) had used lubricants, 28% moisturizers (n = 61), and 28% pelvic floor exercises (n = 60). Seventy percent (n = 152) preferred the topic to be raised by the medical team; 48% (n = 105) raised the topic themselves. Most preferred written educational material followed by expert discussion (66%, n = 144/218). Compared to women ≥50 years old (41%, n = 43/105), younger women (54%, n = 61/113) preferred to discuss their concerns face-to-face (p = 0.054). Older women were less interested in online interventions (52%, p < 0.001), despite 94% having computer access. CONCLUSION: Female cancer patients/survivors have unmet sexual/vaginal health needs. Preferences for receiving sexual health information vary by age. Improved physician-patient communication, awareness, and educational resources using proven sexual health promotion strategies can help women cope with treatment side effects.

Validation of Clinical Tools for Vaginal and Vulvar Symptom Assessment in Cancer Patients and Survivors.

INTRODUCTION: Health care professionals can play a pivotal role in promoting vulvovaginal health through assessment and appropriate intervention. AIM: To develop and validate brief clinical measurements to facilitate the identification of vulvovaginal symptoms in patients with and survivors of cancer. METHODS: One hundred seventy-five women survivors of cancer attending a Female Sexual Medicine and Women's Health Program from September 26, 2012 through October 31, 2014 completed the Vaginal Assessment Scale (VAS) and the Vulvar Assessment Scale (VuAS)-a modified version of the VAS that targets vulvar symptoms. Pelvic examination results were recorded using a clinical examination checklist. MAIN OUTCOME MEASURES: Internal consistency of the two scales was assessed using Cronbach α, and the correlation between scales and other outcomes was reported. RESULTS: The internal consistency measurements of the VAS and VuAS at the first visit were 0.70 and 0.68, which decreased to 0.53 and 0.66 at the last visit. The VAS composite and VuAS composite scores were moderately correlated with each other (0.42 and 0.45 at first and last visits, respectively). A strong correlation was observed between VAS pain with intercourse and Female Sexual Function Index (FSFI) pain with intercourse (-0.63 and -0.71 at the first and last visits, respectively). Worse pain with examination, worse functioning on the FSFI pain, lubrication, and total scores, and worse vulvar irritation were correlated with more severe symptoms on the VAS and VuAS. CONCLUSION: The VAS and VuAS are simple tools that can be used by clinicians to assess health concerns in women diagnosed with and treated for cancer. Validation is needed across diverse settings and groups of women.

Does Taking the Fellowship In-Service Hematopathology Examination and Performance Relate to Success on the American Board of Pathology Hematology Examination?

OBJECTIVES: The biannual Fellow In-Service Hematopathology Examination (FISHE) assesses knowledge in five content areas. We examined the relationship between taking the FISHE and performance on it with outcomes on the first attempted American Board of Pathology Hematology subspecialty certifying examination (ABP-HE). METHODS: The pass rate between the ABP-HE candidates who took the spring FISHE and those who did not were compared. The likelihood of fellows passing the ABP-HE based on their percentiles on the FISHE was also assessed. RESULTS: ABP-HE candidates who took the spring FISHE had a higher pass rate (96.4%) than those who did not (76.1%, P < .001). Spring FISHE performance, including total percentile and percentiles in four of five FISHE content areas, was only a weak predictor of passing the ABP-HE. CONCLUSIONS: Candidates who take the spring FISHE do better on the ABP-HE than those who do not. Most fellows passed the first attempted ABP-HE regardless of FISHE performance. Whether this is due to fellows making use of the FISHE as a self-evaluation tool to help identify and then correct their knowledge deficiencies remains to be determined.

Serum magnesium concentrations in patients receiving sodium picosulfate and magnesium citrate bowel preparation: an assessment of renal function and electrocardiographic conduction.

BACKGROUND: We performed a post hoc analysis of two clinical trials to assess whether sodium picosulfate and magnesium (Mg(2+)) citrate (Prepopik(®) [P/MC]), a dual-action bowel preparation for colonoscopy, has an impact on serum Mg(2+) levels and cardiac electrophysiology. Although rare, hypermagnesemia has been reported in patients consuming Mg(2+)-containing cathartics, especially patients who are elderly and have renal impairment. METHODS: Data were analyzed from two prospective, Phase III, randomized, assessor-blinded, active-control, multicenter, pivotal studies that investigated split-dose/day-before P/MC. Serum Mg(2+) and creatinine clearance (CrCl) were measured at screening, on the day of colonoscopy, and 24-48 hours, 7 days, and 4 weeks after colonoscopy; electrocardiograms also were obtained at these time points. RESULTS: In total, 304 patients received split-dose P/MC and 294 patients received day-before P/MC. Only 10% of the patients had serum Mg(2+) above the upper limit of normal (1.05 mmol/L) on the day of colonoscopy. There was a slight inverse correlation between CrCl and Mg(2+) levels on the day of colonoscopy; however, even at the lowest CrCl, serum Mg(2+) remained below clinically significant levels of 2.0 mmol/L. Increases in serum Mg(2+) were transient, with levels returning to baseline within 24-48 hours, regardless of renal function. No patients with elevated Mg(2+) experienced a corrected QT (QTc) interval >500 milliseconds or a QTc interval increase of ≥60 milliseconds from baseline. P/MC had no impact on PR or QRS interval. CONCLUSION: P/MC produces little impact on serum Mg(2+) levels with no clinically significant effect on cardiac conduction in patients, including those with mild-to-moderate renal impairment.

Factors associated with failure of nonoperative treatment in lateral epicondylitis.

BACKGROUND: Lateral epicondylitis is a common cause of elbow pain that is treated with a variety of nonoperative measures and often improves with time. Minimal research is available on patients in whom these nonoperative treatments fail. PURPOSE: To identify baseline patient and disease factors associated with the failure of nonoperative treatment of lateral epicondylitis, defined as surgery after a period of nonoperative treatment. STUDY DESIGN: Case control study; Level of evidence, 3. METHODS: A total of 580 patients treated for lateral epicondylitis at a tertiary center between 2007 and 2012 were analyzed. Disease-specific and patient demographic characteristics were compared between patient groups (nonoperative vs surgical treatment). A multivariable logistic regression model was created based on preliminary univariate testing to determine which characteristics were associated with failure of nonoperative treatment. RESULTS: Of the 580 patients, 92 (16%) underwent surgical treatment at a mean of 6 months (range, 0-31 months) from their initial visit. Univariate analysis demonstrated a potential association (P < .10) between operative management and the following factors at initial diagnosis: increased age, body mass index, duration of symptoms, presence of radial tunnel syndrome, prior injection, physical therapy, splinting, smoking, workers' compensation, a labor occupation, use of narcotics, use of antidepressant medications, and previous orthopaedic surgery. In the final multivariable model, a workers' compensation claim (odds ratio [OR], 8.1), prior injection (OR, 5.6), the presence of radial tunnel syndrome (OR, 3.1), previous orthopaedic surgery (OR, 3.2), and duration of symptoms >12 months (OR, 2.5) remained significant independent predictors of surgical treatment. CONCLUSION: This study identifies risk factors for surgical treatment for lateral epicondylitis. While these findings do not provide information regarding causal factors associated with surgery, these patient and disease-specific considerations may be helpful when counseling patients regarding treatment options and the likelihood of the success of continued nonoperative treatment.

Walking ATMs and the immigration spillover effect: The link between Latino immigration and robbery victimization.

Media reports and prior research suggest that undocumented Latino migrants are disproportionately robbed because they rely on a cash-only economy and they are reluctant to report crimes to law-enforcement (the Walking ATM phenomenon). From this we generate two specific research questions. First, we probe for an immigration spillover effect - defined as increased native and documented Latino robbery victimization due to offenders' inability to distinguish between the statuses of potential victims. Second, we examine the oft-repeated claim that Blacks robbers disproportionately target Latino victims. Using National Incident-Based Reporting System (NIBRS) data from 282 counties, results show (1) support for an immigration spillover effect but, (2) no support for the claim that Latinos are disproportionately singled out by Black robbers. We discuss the implications of our findings.

Neural network-based real-time prediction of glucose in patients with insulin-dependent diabetes.

BACKGROUND: Continuous glucose monitoring (CGM) technologies report measurements of interstitial glucose concentration every 5 min. CGM technologies have the potential to be utilized for prediction of prospective glucose concentrations with subsequent optimization of glycemic control. This article outlines a feed-forward neural network model (NNM) utilized for real-time prediction of glucose. METHODS: A feed-forward NNM was designed for real-time prediction of glucose in patients with diabetes implementing a prediction horizon of 75 min. Inputs to the NNM included CGM values, insulin dosages, metered glucose values, nutritional intake, lifestyle, and emotional factors. Performance of the NNM was assessed in 10 patients not included in the model training set. RESULTS: The NNM had a root mean squared error of 43.9 mg/dL and a mean absolute difference percentage of 22.1. The NNM routinely overestimates hypoglycemic extremes, which can be attributed to the limited number of hypoglycemic reactions in the model training set. The model predicts 88.6% of normal glucose concentrations (> 70 and < 180 mg/dL), 72.6% of hyperglycemia (≥ 180 mg/dL), and 2.1% of hypoglycemia (≤ 70 mg/dL). Clarke Error Grid Analysis of model predictions indicated that 92.3% of predictions could be regarded as clinically acceptable and not leading to adverse therapeutic direction. Of these predicted values, 62.3% and 30.0% were located within Zones A and B, respectively, of the error grid. CONCLUSIONS: Real-time prediction of glucose via the proposed NNM may provide a means of intelligent therapeutic guidance and direction.

How many founders, how large a population?

The number of population founders and the size of the population are two important variables in determining how much gene diversity can be retained in a population. A model is developed to determine the most cost-effective balance of those two variables, based on comparing the marginal costs of increasing the number of founders vs. increasing the population size. Marginal costs, in this case, are the costs of increasing the number of founders or the population size by one animal. For a goal of retaining 90% gene diversity for 10-15 generations (approximately 100 years), the current recommendation of 20 effective founders is very close to the least-cost solution when the ratio of the marginal costs is equal to one. However, when the ratio is greater or less than one that number can change considerably.

The relationship of personal assistance service utilization to other Medicaid payments among working-age adults with disabilities.

This study examined changes in Medicaid provider payments prior to and following approval for personal assistance services (PAS) among 471 PAS users compared to 295 nonusers who qualified for but did not use PAS, adjusting for differences between users and nonusers using propensity scores. PAS users showed a significantly greater increase in total monthly payments from pre- to post-PAS approval compared to nonusers (35% vs. -9) due to high average monthly payments for PAS ($1325). However, users showed a decrease in non-PAS payments compared to nonusers (1%-9% vs. -9%), with significant decreases in payments for both acute/rehabilitation hospitalizations and for nursing home/other long-term residential stays among users. While costly, savings in other areas may help reduce the net cost of PAS.

[Cholangiocarcinoma: epidemiology and global management]. / Cholangiocarcinomes: épidémiologie et prise en charge globale.

SCOPE: Cholangiocarcinoma, or biliary tract tumors, are rare tumors for which survival is short, as diagnosis is often made at an advanced stage. Indeed, diagnosis remains difficult, since symptoms are often unspecific and appear at latest stages. This article presents an update of recent data and therapeutic options. CURRENT SITUATION AND SALIENT POINTS: Several etiologic factors have been identified, but for most patients, none of these factors can be found. Prognosis is often poor, and remains difficult to establish because of the lack of sufficient large-scale studies looking at the impact on preexisting tumor characteristics on overall survival. Surgery remains when possible the gold standard. When tumor removal is impossible, due to a local extension, the appropriate care of patients remains to be defined. Chemotherapy has been proposed with evidence of objective response but limited data on its ability to prolong overall survival and to enhance quality of life. Active chemotherapies appear to be made from combination of an antimetabolite, such as 5-fluorouracile or gemcitabine, and a platinum drug. PERSPECTIVES: In the near future, indications of chemotherapy could be enlarged and targeted therapy might also be used, since several molecules have been tested in preclinical studies, and be offered to patients in clinical trials.