Factors Influencing Compensation of Early Career Neonatologists.

OBJECTIVE: Workforce characteristics and compensation specific to early career neonatologists remain poorly defined. Lack of transparency surrounding compensation limits benchmarking for neonatologists entering the workforce and may negatively influence individual lifetime earnings. Our objective was to provide granular data for this unique subpopulation by defining employment characteristics and factors influential to compensation of early career neonatologists. STUDY DESIGN: An anonymous 59-question cross-sectional electronic survey was distributed to eligible members of American Academy of Pediatrics Trainees and Early Career Neonatologists. A focused analysis was conducted on salary and bonus compensation data collected from the survey instrument. Respondents were classified based on primary site of employment: nonuniversity located (e.g., private practice, hospital employed, government/military, and hybrid employment groups) versus university located practice settings (e.g., work is primarily conducted in a neonatal intensive care unit (NICU) setting located within a university organization). Median quantile regression was used to conduct univariate and multivariate analyses using SAS Software version 9.4. RESULTS: We received 348 responses (26.7% response rate). Median salary was $220,000 (interquartile range: $200,000-250,000). Factors associated with salary include academic rank (instructor: $196,000; assistant professor: $220,000 [12% increase; p < 0.001]; associate professor: $260,000 [18% increase]; p = 0.027) and years of experience (p = 0.017), after adjusting for relevant factors. Employment location, practice type, group size, clinical schedule, location of medical school training, and gender identity did not significantly influence salary in multivariate quantile regression. Median annual bonus was $7,000 higher for nonuniversity located positions ($20,000 vs. 13,000; p = 0.021), with assumption of additional administrative roles and practice group seniority as most commonly cited bonus criteria (p = 0.002 and <0.001, respectively). CONCLUSION: Academic rank and years of experience may influence salary. Bonus earnings are higher for nonuniversity located positions. Employment models are evolving to incorporate academic teaching appointments while practicing in nonuniversity located NICUs. This is the first detailed compensation analysis of early career neonatologists. KEY POINTS: · Transparent compensation data specific to early career neonatologists is lacking.. · Associated factors influential to compensation of early career neonatologists remain unclear.. · This study identifies years of experience and academic rank as possible factors influencing salary earnings of early career neonatologists.. · Practicing in nonuniversity located positions was associated with greater bonus earning potential..

Workforce Characterisustics of Early Career Neonatologists and Comparison of Practice Sites.

OBJECTIVE: Transitioning into the early career physician workforce is a uniquely challenging period in a neonatologist's career. There are limited educational opportunities in fellowship regarding career progression, practice models, and benefits. Understanding these factors are key when searching for employment. This study evaluates the early career neonatologist (ECN) workforce and employment characteristics to improve identification of professional needs. STUDY DESIGN: An anonymous 59-question cross-sectional survey was distributed in July 2020 to members of the American Academy of Pediatrics Section on Neonatal Perinatal Medicine Trainees and Early Career Neonatologists (TECaN). The survey instrument was designed using SurveyMonkey and assessed search methods for identifying employers, employment contract details, and professional duties. Questions addressed clinical service time, level of acuity, protected research time, financial compensation, benefits, job search methods, and promotion requirements. Comparisons were drawn between respondents exclusively working in a university-based setting and respondents employed in nonuniversity locations. Responses were collected using SurveyMonkey and then extracted to a Microsoft Excel Workbook for analysis. Statistical analysis was performed using SAS version 9.4. RESULTS: Of 1,302 eligible members, 348 people responded (26.7%). Forty-six percent of respondents worked in a university setting and 54% worked in a nonuniversity setting. Using employment site as a discriminator, significant differences were noted in scheduling models. University-located respondents were more likely to work 2-week block schedules, fewer weekend/weeknight call, less clinical weeks per year, and more research/administrative weeks per year. Between university and nonuniversity located positions, benefits were largely comparable, while factors perceived as influential toward promotion varied depending on practice site. CONCLUSION: This study provides ECNs with a contemporary workforce description vital to graduating TECaN seeking employment or renegotiating professional obligations. While benefits were largely similar based on practice site, promotion factors and scheduling models may vary depending on location. KEY POINTS: · Data specific to informing employment decisions for graduating Trainees and Early Career Neonatologists are limited.. · This study provides benchmarks for evaluating employment opportunities presented to early career neonatologists.. · Practice site can influence promotion factors..

Combination therapy in metastatic castration sensitive prostate cancer: A Systematic review and network meta-analysis.

Introduction: Studies directly comparing the different combination therapies offered to men with metastatic castration sensitive prostate cancer (mCSPC), are not available yet. This study was designed using the network meta-analysis (NMA) framework to provide a comparison of the different available options for the treatment of men with mCSPC. Methods: A systematic search was performed and the prospective randomized controlled trials reporting the overall survival (OS) or failure-free survival (FFS) were selected for review. A total of 14 studies were included in the NMA. Results: The addition of abiraterone, apalutamide, docetaxel, and docetaxel with zoledronic acid to the androgen deprivation therapy (ADT) demonstrated a significant improvement in the OS. In indirect comparison, abiraterone had a higher impact on the OS as compared to docetaxel (hazard ratio [HR]: 1.21, 95% confidence interval [CI]: 1.0-1.46) and docetaxel with zoledronic acid (HR: 1.31, 95% CI: 1.05-1.63) but not apalutamide. Furthermore, apalutamide was not different than docetaxel or docetaxel with zoledronic acid. There was a significant improvement in the FFS with the combination of abiraterone, apalutamide, docetaxel (HR: 0.61, 95% CI: 0.46-0.81), docetaxel with zoledronic acid (HR: 0.62, 95% CI: 0.43-0.9), and enzalutamide (HR: 0.39, 95% CI: 0.25-0.61) as compared to the ADT alone. Similar to the indirect comparison of OS, abiraterone outperformed docetaxel (HR: 1.66, 95% CI: 1.12-2.47), docetaxel with zoledronic acid (HR: 1.69, 95% CI: 1.06-2.68), and enzalutamide (HR: 1.06, 95% CI: 0.63-1.80), but not apalutamide in terms of impact on the FFS. Conclusion: Overall, abiraterone demonstrated better OS and FFS outcomes as compared to all the other combination strategies in this NMA.

Risk factors predicting the loss of functional independence after obliterative procedures for pelvic organ prolapse.

INTRODUCTION AND HYPOTHESIS: To determine the risk factors associated with loss of functional independence after obliterative procedures for pelvic organ prolapse (POP). METHODS: The American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database was used to collect data on women who underwent obliterative vaginal procedures from 2011 to 2016, using current procedural terminology (CPT) codes for LeFort colpocleisis (57120) and vaginectomy (57110). The criterion for loss of functional independence was a transition from a functionally independent status to a dependent status (discharge to a post-care facility) or death within the 30-day postoperative period. Multivariate regression analysis was utilized to determine factors associated with loss of functional independence. RESULTS: A total of 1847 women were included in the analysis. A loss of functional independence was noted in 50 of the 1847 women (2.6%). The women who suffered loss of functional independence were older than those who were independent postoperatively (mean age 79.3 years, SD 7.47 vs. 76.7 years, SD 8.1, respectively). On multiple logistic regression analysis, age ≥ 80 years (OR 2.8, 95% CI 1.4-5.5), American Society of Anesthesiologists (ASA) classification ≥ 3 (OR 2.3, CI 1.1-4.7) and length of stay ≥ 5 days (OR 15.2, 95% CI 6.2-37.1) remained significantly associated with an increased risk of loss of functional independence. CONCLUSIONS: Age ≥ 80 years, ASA classification ≥ 3 and longer length of stay are associated with an increased risk of loss of functional independence after an obliterative procedure for pelvic organ prolapse. Consideration of these factors during the preoperative decision-making process may help improve outcomes in this cohort.

A Statewide Study of the Epidemiology of Emergency Medical Services' Management of Pediatric Asthma.

OBJECTIVES: Little is known about emergency medical services' (EMS') management of pediatric asthma. This study's objective was to describe the demographic, clinical, and geographic characteristics of current EMS' management of pediatric asthma in the state with the fourth-largest pediatric population. METHODS: This was a retrospective observational study of EMS patients ages 2 to 18 years with an asthma exacerbation from 2011 to 2016. Patients from Florida's EMS Tracking and Reporting System were included if their EMS chief complaint indicated respiratory distress, if they received at least 1 albuterol treatment, and if they were transported to a hospital. RESULTS: A total of 11,226 patients met the inclusion criteria. The median age was 9 years, and 49% were African-American. Geospatial analysis revealed 4 rural counties with disproportionate numbers of African-American patients. In addition to albuterol, 37% of patients received ipratropium bromide and 9% received systemic corticosteroids. Adjusted logistic regression revealed that the strongest predictors of receiving systemic corticosteroids from EMS were intravenous access (odds ratio, 33.4; 95% confidence interval, 24.4-45.6) and intravenous magnesium sulfate administration (odds ratio, 5.0; 95% confidence interval, 3.4-7.3), indicating a more severe presentation. CONCLUSIONS: This statewide study demonstrated low rates of EMS administration of ipratropium bromide and systemic corticosteroids, both evidence-based treatments for asthma exacerbations. Targeted EMS education should attempt to increase utilization of both those medications. In addition, the feasibility and efficacy of EMS administration of oral systemic corticosteroids for children should be explored.

Assessment of the American College of Surgeons National Surgical Quality Improvement Program Calculator in Predicting Outcomes and Length of Stay After Ivor Lewis Esophagectomy: A Single-Center Experience.

BACKGROUND: The American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) calculator is a useful tool used by physicians to better inform patients on the surgical risk of postoperative complications. It makes use of the NSQIP database to derive the chance for several adverse outcomes to occur postoperatively given certain patient's factors. The aim of this study was to assess its applicability in a series of patients undergoing an Ivor Lewis esophagectomy. METHODS: Data from 100 consecutive patients who underwent an Ivor Lewis esophagectomy between September 2013 and November 2017 at our institution were reviewed. Each patient was assessed using the ACS NSQIP surgical risk calculator. Actual events in this group were compared with their particular NSQIP-assessed risk. Logistic regression models were used to compare surgical risk calculator estimates binary outcomes such as incidence of postoperative complications such as cardiac events, renal events, surgical site infection, and death. Mixed linear model was used for length of stay (LOS) duration versus observed LOS. C-statistic was for predictive accuracy each binary outcome and intraclass correlation was used for LOS. RESULTS: C-statistic values were higher than the cutoff (0.75) for surgical site infection and death. The ACS NSQIP risk calculator was poorly predictive of other reported outcomes by the calculator such as cardiac or renal complications. Corroboration between observed LOS and predicted LOS was weak (8 d versus 11 d, respectively, intraclass coefficient 0.04). CONCLUSIONS: This study suggests that the risk calculator is useful for identifying risk of death or surgical site infection but poor at discriminating likelihood of other reported outcomes occurring, such as pneumonia, acute renal failure and cardiac complications for patients who underwent an Ivor Lewis esophagectomy. Estimations for procedure-specific complications for esophagectomy may need reevaluated.

Prognostic significance of venous invasion in node-negative head and neck squamous cell carcinoma.

BACKGROUND: Venous invasion (VI) is not frequently evaluated on routine histologic examination of head and neck squamous cell carcinoma (HNSCC), and the prognostic significance is largely unknown. Studies have shown that extramural venous invasion is an adverse prognostic factor in colorectal carcinoma. To our knowledge, this is the first study evaluating the prognostic significance of venous invasion in node-negative (without clinical or pathologic evidence of lymph node involvement) HNSCC, utilizing the elastic stain. METHODS: A total of 105 consecutive lymph node-negative (N0) HNSCC were evaluated for the presence of venous channel invasion by tumor utilizing the elastin stain. Clinical, demographic, and follow-up data were recorded. RESULTS: Of 37 patients with venous invasion, 19% had loco-regional recurrence, as opposed to 12% of those without. Univariate analysis revealed statistically significant decreased recurrence-free survival in the presence of venous invasion (log-rank [Mantel-Cox] test P-value .025). CONCLUSION: Identification of VI is greatly aided by elastic stain. In patients with node-negative HNSCC, presence of VI resulted in decreased recurrence-free survival on univariate analysis. The impact of VI as a prognostic marker should be further evaluated.

The effects of a brief memory enhancement course on individuals with epilepsy.

PURPOSE: The purpose of the study was to determine whether a brief memory enhancement course in persons with epilepsy (PWE) can improve cognitive abilities, quality of life, self-management, and seizure severity. METHODS: Thirty-nine PWE completed a 1-hour memory enhancement course. This was preceded by a baseline/preintervention assessment (BA/PRE), followed by postintervention assessment (POST) at 1 & 1/2 to 3 months, and a delayed postintervention assessment evaluation (DPOST) at 4 & 1/2 to 6 months after course completion. In order to assess for retesting bias, an additional 30 PWE underwent a separate BA and PRE. RESULTS: There was significant improvement on the Patient-Reported Outcomes Patient Information System version 2.0 Cognitive Function Abilities Subset and the Epilepsy Self-Management Scale (ESMS) on both POST and DPOST when compared with BA/PRE. Retesting bias did not occur. On ESMS subscale evaluation, significant improvement occurred on the Lifestyle Management subscale. There was no improvement in quality of life and seizure severity. There was good patient acceptability for the memory program. CONCLUSION: A brief memory enhancement course results in sustained improvement in cognitive functioning and self-management of PWE.

Development of a Simple Sequential Organ Failure Assessment Score for Risk Assessment of Emergency Department Patients With Sepsis.

OBJECTIVES: Sepsis-3 recommends using the quick Sequential Organ Failure Assessment (qSOFA) score followed by SOFA score for sepsis evaluation. The SOFA is complex and unfamiliar to most emergency physicians, while qSOFA is insensitive for sepsis screening and may result in missed cases of sepsis. The objective of this study was to devise an easy-to-use simple SOFA score for use in the emergency department (ED). METHODS: Retrospective study of ED patients with sepsis with in-hospital mortality as the primary outcome. A simple SOFA score was derived and validated and compared with SOFA and qSOFA. RESULTS: A total of 3297 patients with sepsis were included, and in-hospital mortality was 10.1%. Simple SOFA had a sensitivity and specificity of 88% and 44% in the derivation set and 93% and 44% in the validation set for in-hospital mortality, respectively. The sensitivity and specificity of qSOFA was 38% and 86% and for SOFA was 90% and 50%, respectively. There were 2760 (84%) of 3297 qSOFA-negative (<2) patients. In this group, simple SOFA had a sensitivity and specificity of 86% and 48% in the derivation set and 91% and 48% in the validation set, respectively. Sequential Organ Failure Assessment was 86% sensitive and 57% specific in qSOFA-negative patients. For all encounters, the areas under the receiver-operator characteristic curves (AUROC) were 0.82 for SOFA, 0.78 (derivation) and 0.82 (validation) for simple SOFA, and 0.68 for qSOFA. In qSOFA-negative patients, the AUROCs were 0.80 for SOFA and 0.76 (derivation) and 0.82 (validation) for simple SOFA. CONCLUSIONS: Simple SOFA demonstrates similar predictive ability for in-hospital mortality from sepsis compared to SOFA. External validation of these findings is indicated.

Predicting Pain-Related 30-Day Emergency Department Return Visits in Middle-Aged and Older Adults.

OBJECTIVE: The objective of this study was to determine predictive factors for pain-related emergency department returns in middle-aged and older adults. Design, Setting, and Subjects. This was a subanalysis of patients > 55 years of age enrolled in a prospective observational study of adult patients presenting within 30 days of an index visit to a large, urban, academic center. METHODS: Demographic and clinical data were collected and compared to determine significant differences between patients who returned for pain and those who did not. Multiple logistic regressions were used to determine significant predictive variables for return visits. RESULTS: The majority of the 130 enrolled patients > 55 years of age returned for pain (57%), were African American (78%), were younger (55-64 years old, 67%), had a high emergency department acuity level (level 1 or 2) at their index visit (56%), had low health literacy (Rapid Estimate of Adult Literacy in Medicine [REALM] score, 62%), lived in an area of extreme deprivation (69%), and were admitted (61%) during their index visit. Age (odds ratio [OR] = 0.9, 95% CI = 0.8-0.9, P = 0.047), health literacy (REALM scores; OR = 3.1, 95% CI = 1.3-7.5, P = 0.011), and index visit pain scores (OR = 1.1, 95% CI = 1.0-1.2, P = 0.004) were predictive of emergency department returns for pain in middle-aged and older adults. CONCLUSIONS: The likelihood of emergency department return visits for pain in middle-aged and older adults decreased with older age, increased with higher health literacy (REALM scores), and increased with increase in pain scores.

Impact of Monthly A1C Values Obtained at Home on Glycemic Control in Patients With Type 2 Diabetes: A Randomized Clinical Trial.

The purpose of this randomized controlled clinical trial was to determine whether an A1C value obtained at home by participants followed by a phone discussion of the result with a clinician would lead to 1) a more rapid and significant decrease in A1C, 2) more effective advancement of diabetes treatment, and 3) improvement in diabetes self-care behaviors. The study included 307 participants with type 2 diabetes, most of whom were of Latino origin. All study participants experienced a statistically significant reduction in mean A1C (control subjects -0.3%, P = 0.04; intervention subjects -0.5%, P = 0.0002), but there was a statistically significant difference in the number of people who achieved a reduction of ≥0.5% by 6 months, favoring the intervention (33.6 vs. 46.7%, P = 0.05).

Identification of unique characteristics and the management of blunt traumatic aortic injuries occurring at unusual locations in the descending thoracic aorta.

BACKGROUND: The usual location of thoracic blunt traumatic aortic injury (BTAI) is just distal to the left subclavian artery; however, injuries can also be found in other locations in the descending thoracic aorta (DTA). METHODS: This is a single-institution, retrospective study, using 74 consecutive BTAI in the DTA. The patients were separated into two groups based on the location of the injury. The proximal group included injuries within 5 cm of the left subclavian artery, whereas the distal group included injuries in the rest of the DTA. A total of 27 factors were compared. RESULTS: Between 2010 and July 2017, we identified 14 of 74 patients (19%) with BTAI in the distal zone. Females were 9 of the 14 (64%) in the distal zone group, whereas females were 16 of 60 (27%) in the proximal zone group (P < .012). Thoracic spine fractures occurred in 7 of the 14 patients (50%) with injuries at the distal zone, whereas they occurred in 12 of the 60 patients (20%) in the proximal zone group (P < .038). Eleven of the 14 distal zone injuries (79%) were grade 1 or 2 compared with 15 of 60 injuries (25%) at the proximal zone (P = .016). Only 2 of the 14 injuries (14%) in the distal zone required an endovascular repair as opposed to 39 of 60 (65%) in the proximal zone (P < .001). The mean hospital duration of stay in patients with BTAI at the distal zone was 8.5 days compared with 20.3 days for patients in the proximal zone group (P < .004). Mortality occurred in 5 of 14 patients (36%) in the distal zone group compared with 5 of 60 patients (8%) in the proximal zone group (P = .017). The odds of mortality from an injury in the distal zone were almost 6-fold greater than the odds of mortality from an injury in the proximal zone (odds ratio, 5.9; 95% confidence interval, 1.2-31.8). No mortalities were related to the BTAI itself. The association of location with mortality remained significant even after adjusting for other significant factors like Injury Severity Score and patient age. Patients who died from injuries in the distal zone had a shorter duration of stay (5 days vs 20 days; P = .0002). CONCLUSIONS: BTAI in the distal zone of DTA are associated with unique characteristics. They are (1) more frequently associated with thoracic spine fractures, (2) more common in women, (3) tend to be lower grade, (4) less likely to require intervention, and (5) seem to have a higher mortality owing to other associated traumatic injuries.

Effect of race and ethnicity on renal transplant referral
.

BACKGROUND: Multiple studies have revealed disparity in renal healthcare access and outcomes in racial/ethnic minorities with the socioeconomic status explaining the majority but not all of the disparity. We wanted to determine if racial/ethnic disparities existed at the first step toward renal transplantation, the renal transplant referral process. MATERIALS AND METHODS: A cohort of 200 adult end-stage renal disease patients was followed retrospectively for 2 years from January 2016 to February 2018. The study exposure was based on self-declared race/ethnicity of the patients, who were categorized as Black, White, and Hispanic. The study outcome was based on medical team patient evaluation and consisted of the patients who refused referral, who were not referred, and who were referred for transplant. Medical and demographic factors collected were age, gender, socioeconomic status, hemoglobin A1c ≥ 7, body mass index ≥ 40, left ventricular ejection fraction ≤ 40%, the presence of coronary or peripheral arterial disease, albumin level, history of smoking, cirrhosis, and cancer. The data were analyzed using univariate analyses and multinomial logistic regression. RESULTS: In the adjusted analysis, there was no difference in the likelihood of transplant referral between Black and White patients (OR = 0.71, 95% CI 0.22 - 2.3, p = 0.56). However, both Black (OR = 16, 95% CI 3.3 - 77, p = 0.0006) and White (OR = 22, 95% CI 3.4 - 150, p = 0.0013) patients were more likely to be referred for transplant when compared with Hispanic patients. Odds of transplant refusal were not different across race/ethnic groups. CONCLUSION: Hispanic patients are disadvantaged in the referral for renal transplant when compared to Black and White patients for reasons unclear at this time.

Overutilization of Computed Tomography for Odontogenic Infections.

PURPOSE: There is clear overuse of computed tomography (CT) in the emergency setting, which is associated with a long-term potential for malignancy. This study aimed to determine the rate of overuse of CT for odontogenic infection workup and the correlation of history and physical examination (H&P) findings to diagnose moderate- to high-risk infections. MATERIALS AND METHODS: A retrospective cross-sectional study was implemented to determine the rate of overuse of CT for odontogenic infections. Included patients presented through the emergency department for evaluation of an odontogenic infection. CT was deemed unnecessary if patients presented without "red-flag" signs at physical examination, which included voice change, elevated floor of mouth, signs of inflammation of deep fascial spaces, periorbital edema, nonpalpable inferior border of the mandible, dyspnea, dysphagia or odynophagia, and trismus. Patients could have no evidence of involvement of a moderate- to high-risk space or airway change at CT. Infection severity was low, moderate, or high risk based on anatomic proximity to the airway and critical structures. Sensitivity, specificity, and positive predictive and negative predictive values of H&P findings to predict moderate- to high-risk infections were calculated and included 95% confidence intervals. RESULTS: For the 470 included patients, 389 CT scans were performed, with 220 (56.6%) deemed unnecessary. Unnecessary scans were most prevalent in patients with low-risk infections, in whom 284 CT scans were performed, with 222 (78.2%) deemed unnecessary. There was a strong correlation between red-flag signs and moderate- to high-risk infections. CONCLUSION: There is overuse of CT for odontogenic infections that is most prevalent in low-risk infections without indicative findings in the workup. H&P findings can help accurately diagnose a higher-risk infection before subjecting a patient to CT.

Repeating patterns of sleep restriction and recovery: Do we get used to it?

Despite its prevalence in modern society, little is known about the long-term impact of restricting sleep during the week and 'catching up' on weekends. This common sleep pattern was experimentally modeled with three weeks of 5 nights of sleep restricted to 4h followed by two nights of 8-h recovery sleep. In an intra-individual design, 14 healthy adults completed both the sleep restriction and an 8-h control condition, and the subjective impact and the effects on physiological markers of stress (cortisol, the inflammatory marker IL-6, glucocorticoid receptor sensitivity) were assessed. Sleep restriction was not perceived to be subjectively stressful and some degree of resilience or resistance to the effects of sleep restriction was observed in subjective domains. In contrast, physiological stress response systems remain activated with repeated exposures to sleep restriction and limited recovery opportunity. Morning IL-6 expression in monocytes was significantly increased during week 2 and 3 of sleep restriction, and remained increased after recovery sleep in week 2 (p<0.05) and week 3 (p<0.09). Serum cortisol showed a significantly dysregulated 24h-rhythm during weeks 1, 2, and 3 of sleep restriction, with elevated morning cortisol, and decreased cortisol in the second half of the night. Glucocorticoid sensitivity of monocytes was increased, rather than decreased, during the sleep restriction and sleep recovery portion of each week. These results suggest a disrupted interplay between the hypothalamic-pituitary-adrenal and inflammatory systems in the context of repeated exposure to sleep restriction and recovery. The observed dissociation between subjective and physiological responses may help explain why many individuals continue with the behavior pattern of restricting and recovering sleep over long time periods, despite a cumulative deleterious physiological effect.

EFFICACY AND SAFETY OF TREATMENT OPTIONS FOR VITREOMACULAR TRACTION: A Case Series and Meta-Analysis.

PURPOSE: To evaluate treatment options for vitreomacular traction (VMT). METHODS: A retrospective, consecutive case series and a literature search with Boolean search logic. A random-effects meta-analysis was conducted to combine the rates of VMT resolution per treatment. Patients from studies analyzed were placed into cohorts based on the treatment received. CASE SERIES: Zero of 10 control, 3 of 7 intravitreal ocriplasmin (IVO, P = 0.10), 7 of 8 intravitreal expansile gas (pneumatic vitreolysis, PV, P < 0.01), and 10 of 10 pars plana vitrectomy (P < 0.01)-treated eyes experienced VMT release (VMTr) at Day 28. No patients developed retinal tears or detachment. One PV-treated (12.5%) eye developed a macular hole. Meta-analysis: Twenty-three of 131 prospective or retrospective and consecutive articles were included. Sixty-three eyes were treated with PV, 726 eyes were treated with intravitreal ocriplasmin, and 253 eyes were characterized as the control group (saline injection). The weighted rate of VMT resolution for the control group was 0.09 (95% confidence interval [CI]: 0.06-0.13), PV was 0.84 (95% CI: 0.76-0.92), and intravitreal ocriplasmin was 0.26 (95% CI: 0.23-0.29). CONCLUSION: Our analysis found that PV releases VMT in most patients and suggest that PV may be as effective or superior to nonsurgical options for VMTr at Day 28 with a similar risk profile.

Sleep characteristics as predictor variables of stress systems markers in insomnia disorder.

This study investigates the extent to which sleep characteristics serve as predictor variables for inflammatory, hypothalamic-pituitary-adrenal and autonomic systems markers. Twenty-nine participants with a diagnosis of insomnia disorder based on the Diagnostic Statistical Manual of Mental Disorders, Fifth Edition (age 25.3 ± 1.6 years, insomnia duration 6.6 ± 0.8 years) and 19 healthy control sleepers (age 25.4 ± 1.4 years) underwent a 2-week at-home evaluation keeping a sleep diary and wearing an actigraph, followed by a visit to the Research Center to measure blood pressure, and collect blood and urine samples. The actigraphy- and diary-based variables of sleep duration, sleep-onset latency, wake after sleep onset and sleep fragmentation/number of night-time awakenings were averaged and entered as dependent variables in regression analyses. Composite scores were calculated for the autonomic (blood pressure, norepinephrine), inflammatory (monocyte counts, interleukin-6, C-reactive protein) and hypothalamic-pituitary-adrenal systems (cortisol), and used as predictor variables in regression models. Compared with controls, individuals with insomnia had a shorter sleep duration (P < 0.05), and a higher hypothalamic-pituitary-adrenal and inflammatory composite score (P < 0.05). The higher inflammatory score was mainly due to higher circulating monocytes (P < 0.05), rather than differences in interleukin-6 or C-reactive protein. In persistent insomnia disorder, cortisol is upregulated and associated with actigraphy- and diary-based wake after sleep onset, suggesting that wake after sleep onset may serve as a marker to identify individuals at increased risks for disorders associated with a hyperactive hypothalamic-pituitary-adrenal system. The absence of autonomic and pro-inflammatory changes (interleukin-6, C-reactive protein), despite a substantial decrease in actigraphic sleep duration, may relate to a higher resilience to the adverse biological consequences of insomnia in this young age group.

PERIODONTAL DISEASE AND AGE-RELATED MACULAR DEGENERATION: Results From the National Health and Nutrition Examination Survey III.

PURPOSE: To study the association between periodontal disease (PD) and age-related macular degeneration (AMD). METHODS: For this cross-sectional analysis, 8,208 adults aged 40 years or older with retinal photographs graded for AMD were used from the National Health and Nutrition Examination Survey III. National Health and Nutrition Examination Survey III standardized dental measurements of PD status (defined as loss of >3 mm of attachment between the gum and tooth in at least 10% of sites measured). Participants were stratified into 60 years or younger and older than 60 years of age groups. Association between PD and AMD was assessed while controlling for sex, race, education, poverty income ratio, smoking, hypertension, body mass index, cardiovascular disease, and C-reactive protein. RESULTS: In this population, a total of 52.30% had PD, and the prevalence of AMD was 11.45%. Logistic regression model controlled for confounders and stratified by age 60 years or younger versus older than 60 years showed PD to be independently associated with an increased risk for AMD (odds ratio = 1.96, 95% confidence interval = 1.22-3.14, P = 0.006) for those aged 60 years or younger but not for subjects older than 60 years (odds ratio = 1.32, confidence interval = 0.93-1.90, P = 0.120). CONCLUSION: In this population-based study, PD is independently associated with AMD in those aged 60 years or younger.

Findings of chronic sinusitis on brain computed tomography are not associated with acute headaches.

BACKGROUND: Headache is a common complaint in emergency department (ED) patients. Nearly 15% of ED headache patients will have brain computed tomography (CT) done. One frequent finding on these scans is "chronic sinusitis." Assuming that "chronic sinusitis" is the cause of the patient's headache is a potential source of mis-diagnosis. STUDY OBJECTIVE: We hypothesized that CT findings of chronic sinusitis occur with equal frequency in patients with atraumatic headache as in control patients with minor head injury. METHODS: This is a retrospective, single-center medical record review of consecutive discharged patients who received noncontrast head CT scans in an urban ED for either minor closed head injury or atraumatic headache. Each patient's head CT radiologic report was reviewed for findings of sinusitis and classified as chronic sinusitis, indeterminate for sinusitis, air-fluid levels, or no findings of sinusitis. RESULTS: We enrolled 500 patients (234 in the atraumatic headache group, 266 in the minor head injury group). The two groups were similar except that more women were enrolled in the atraumatic headache group. CT findings of chronic sinusitis in the atraumatic headache group (22.2%) and the minor head injury group (17.7%; difference 4.5%; 95% confidence interval of -2.5-11.6%). CONCLUSION: Prevalence of CT findings of sinusitis in ED patients with atraumatic headaches and mild head injury are similar. This strongly suggests that CT findings of chronic sinusitis in patients with atraumatic headache may be incidental, and are rarely the cause of a patient's acute headache.