Multicenter Randomized Sham Controlled Study of Genicular Artery Embolization for Knee Pain Secondary to Osteoarthritis.

PURPOSE: To assess the safety and efficacy of genicular artery embolization (GAE) compared with a sham procedure in the treatment of knee pain secondary to mild to moderate osteoarthritis (OA). MATERIALS AND METHODS: A multicenter, single-blinded, randomized controlled trial was conducted to evaluate knee OA symptom reduction after GAE versus sham procedure. Subjects (n = 21) with mild to moderate OA and intractable knee pain were randomized 2:1 to either GAE or a sham procedure. Subjects who were randomized to the sham procedure and did not report clinical improvement in both the total Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and visual analog scale (VAS) scores were unblinded and able to crossover to treatment at 1 month. Longitudinal data were collected for 12 months, and subjects were excluded if they required additional analgesics at follow-up. Reductions in the VAS and total WOMAC scores were compared using mixed-effects linear regression models. RESULTS: All subjects in the sham group failed to show significant improvements at 1 month and crossed over to the treatment arm. There was a statistically significantly greater pain reduction in the treatment group than in the sham group at 1 month (VAS, 50.1 mm; standard error [SE], 10.6; 95% confidence interval [CI], 29.0, 72.3; P<.01). Disability improvement was also significantly greater in the treatment group (WOMAC, 24.7 points; SE, 10.4; 95% CI, 3.5, 45.9; P=.02). Only minor adverse events were reported. Five subjects were excluded after increased analgesic use. Sensitivity analysis with all excluded patients confirmed significant improvements at 1 and 12 months. CONCLUSION: In patients with mild to moderate knee OA, GAE results in symptomatic improvement greater than the sham procedure with clinically significant reduction in pain and disability.

The association between duration of breastfeeding and childhood asthma outcomes.

BACKGROUND: Postnatal exposures, including breastfeeding, may influence asthma development. OBJECTIVE: To investigate the association between breastfeeding duration and child asthma. METHODS: We studied 2021 mother-child dyads in the ECHO PATHWAYS consortium of prospective pregnancy cohorts (GAPPS, CANDLE, TIDES). Women reported the duration of any and exclusive breastfeeding and child asthma outcomes during follow-up at child age 4 to 6 years. Outcomes included current wheeze (previous 12 months), ever asthma, current asthma (having ≥2 of current wheeze, ever asthma, medication use in past 12-24 months), and strict current asthma (ever asthma with either or both current wheeze and medication use in past 12-24 months). We used multivariable logistic regression to assess associations (odds ratios and 95% confidence intervals) between breastfeeding and asthma outcomes adjusting for potential confounders. We assessed effect modification by mode of delivery, infant sex, and maternal asthma. RESULTS: Among women, 33%, 13%, 9%, and 45% reported 0 to less than 2, 2 to 4, 5 to 6, and more than 6 months of any breastfeeding, respectively. The duration of any breastfeeding had a protective linear trend with ever asthma but no other outcomes. There was a duration-dependent protective association of exclusive breastfeeding and child asthma outcomes (eg, current asthma adjusted odds ratio [95% confidence interval], 0.64 [0.41-1.02], 0.61 [0.38-0.98], and 0.52 (0.31-0.87) for 2to 4 months, 5 to 6 months, and more than 6 months, respectively, compared with <2 months). For exclusive breastfeeding, protective associations were stronger in dyads with children born by vaginal vs cesarean delivery although interactions did not reach statistical significance (Pinteractions 0.12-0.40). CONCLUSION: Longer duration of exclusive breastfeeding had a protective association with child asthma.

Radiation safety education and diagnostic imaging in pediatric patients with surgically treated hydrocephalus: the patient and family perspective.

PURPOSE: Surgically treated hydrocephalus patients are frequently imaged with head computed tomography (CT), and risk/benefit communication with families is inconsistent and unknown. We aimed to educate patients and caregivers about radiation safety in CT and explore their communication preferences. METHODS: We conducted a pediatric CT radiation safety and diagnostic imaging educational workshop for patients and caregivers at a national conference on hydrocephalus to characterize current practice and desired communication about CT imaging. Our workshop consisted of an interactive educational intervention with pre-/post-session surveys followed by feedback from participants. RESULTS: Our session included 34 participants (100% response rate for surveys) with 28 being parents of individuals with hydrocephalus. A total of 76% (n = 26) participants showed an increase in knowledge after the session (p < 0.01). All participants (N = 34) uniformly desired risk/benefit discussions before CT scans. However, 71% stated that they were not informed of risks/benefits of CT scans by a medical professional. Following the session, the number of participants indicating that informed consent should be obtained before CT scans increased from 30 to 33. Respondents also revealed that 14% of children and young adults had received > 100 CT scans for shunt evaluation with the median being 25 scans (IQR 20). CONCLUSIONS: Caregivers desire and deserve to be empowered through education and social support, and continuously engaged through sharing decisions and co-designing care plans. The neurosurgical community is in an ideal position to collaborate with radiologists, primary care providers, and parents in the development and testing of credible, high-quality online and social media resources.

Genicular Artery Embolization for the Treatment of Knee Pain Secondary to Osteoarthritis.

PURPOSE: To evaluate the efficacy and safety of embolization of hyperemic synovial tissue for the treatment of knee pain secondary to osteoarthritis (OA). MATERIALS AND METHODS: Twenty patients with radiographic knee OA and moderate-to-severe pain refractory to conservative therapy were enrolled in a prospective, 2-site pilot study. Genicular artery embolization (GAE) was performed with 75- or 100-µm spherical particles. Patients were assessed with magnetic resonance imaging at baseline and at 1 month and with the Visual Analogue Scale (VAS) and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) at baseline and at 1, 3, and 6 months. Adverse events were recorded at all timepoints. RESULTS: Embolization of at least 1 genicular artery was achieved in 20/20 (100%) patients. Mean VAS improved from 76 mm ± 14 at baseline to 29 mm ± 27 at 6-month follow-up (P < .01). Mean WOMAC score improved from 61 ± 12 at baseline to 29 ± 27 at 6-month follow-up (P < .01). Self-limiting skin discoloration occurred in 13/20 (65%) patients. Two of 20 (10%) patients developed plantar sensory paresthesia that resolved within 14 days. CONCLUSIONS: GAE to treat knee pain secondary to OA can be performed safely and demonstrates potential efficacy. Further randomized comparative studies are needed to determine true treatment effect versus placebo effect.

Utilization of computed tomography imaging in the pediatric emergency department.

BACKGROUND: In recent years, there has been a movement toward more judicious use of computed tomography (CT) imaging in an attempt to limit exposure of pediatric patients to ionizing radiation. The Image Gently Alliance and like-minded movements began advocating for safe and high-quality pediatric imaging worldwide in the late 2000s. OBJECTIVE: In the context of these efforts, we evaluate CT utilization rates in the pediatric emergency department at a major academic medical center. MATERIALS AND METHODS: We tracked utilization in several categories of CT, magnetic resonance imaging (MRI) and ultrasonography (US) between July 2008 and June 2017 and compared them with utilization rates from 2000 to 2006. RESULTS: A total of 4,955 pediatric patients underwent a total of 5,973 CT scans, 2,775 US studies and 293 MRI scans while in the pediatric emergency department during the 2008-2017 study period. We observed decreases in CT scans across all categories, ranging from a 19% decrease in abdominal CT to a 66% decrease in chest CT. Relatively greater decreases in CT scans were observed in patients younger than 3 years of age as compared to older children and adolescents. Abdominal and pelvic US increased. Brain MRI also increased over the final two years of the study. CONCLUSION: CT utilization decreased throughout the 2008-2017 study period.

Promoting Healthier Home Food Environments Through 2-1-1: A Pilot and Feasibility Study.

Relatively few interventions target the home food environment of adults for weight gain prevention. Using a pretest/posttest design, this study describes the adaptation and pilot testing of Healthy Homes/Healthy Families, a research-tested home food environment intervention, for telephone delivery to 2-1-1 clients (n = 101). The Healthy Eating Index-2015, a measure of diet quality, improved significantly at 4-month follow-up, as did the home food environment, with energy consumption improving in the expected direction. Overall findings suggest the simplified intervention will still be effective, although results may be attenuated and additional efforts may be needed for participant retention among 2-1-1 clients.

Initial Experience with Balloon-Occlusion Prostatic Artery Embolization.

Twelve patients underwent balloon-occlusion prostatic artery embolization (PAE) at a single center. Bilateral prostatic artery catheterization was achieved in all patients, but unilateral embolization was performed in 1 patient as a result of the presence of a prostatic arteriovenous fistula. Mean International Prostate Symptom Score and quality-of-life score decreased by 15 ± 7 (P < .01) and 4 ± 1 (P < .01) points, respectively, over a mean follow-up period of 22 weeks ± 8. Only self-limiting minor complications were encountered. The initial experience with balloon-occlusion PAE suggests that it is technically feasible and can be performed safely.

Relative validation of fruit and vegetable intake and fat intake among overweight and obese African-American women.

OBJECTIVE: To compare commonly used dietary screeners for fat intake and fruit and vegetable intake with 24 h dietary recalls among low-income, overweight and obese African-American women. DESIGN: Three telephone interviews were completed; measures included two 24 h dietary recalls (a weekday and weekend day) using the Nutrition Data System for Research software, the Behavioral Risk Factor Surveillance System's (BRFSS) Fruit and Vegetable Consumption Module and the National Cancer Institute's (NCI) Percentage Energy from Fat Screener. SETTING: Participants were recruited from three federally qualified health centres in south-west Georgia, USA. SUBJECTS: Participants (n 260) were African-American women ranging in age from 35 to 65 years. About half were unemployed (49.6%) and 58.7% had a high-school education or less. Most were obese (88.5%), with 39.6% reporting a BMI ≥ 40.0 kg/m(2). RESULTS: Mean fruit and vegetable intake reported from the 24 h dietary recall was 2.66 servings/d compared with 2.79 servings/d with the BRFSS measure. The deattenuated Pearson correlation was 0.22, with notable variation by weight status, education level and age. Mean percentage of energy from fat was 35.5% as reported from the 24 h dietary recall, compared with 33.0% as measured by the NCI fat screener. The deattenuated Pearson correlation was 0.38, also with notable variation by weight status, education level and age. CONCLUSIONS: Validity of brief dietary intake measures may vary by demographic characteristics of the sample. Additional measurement work may be needed to accurately measure dietary intake in obese African-American women.

Influence of objective three-dimensional measures and movement images on surgeon treatment planning for lip revision surgery.

Objective : To determine whether a systematic evaluation of facial soft tissues of patients with cleft lip and palate, using facial video images and objective three-dimensional measurements of movement, change surgeons' treatment plans for lip revision surgery. Design : Prospective longitudinal study. Setting : The University of North Carolina School of Dentistry. Patients, Participants : A group of patients with repaired cleft lip and palate (n = 21), a noncleft control group (n = 37), and surgeons experienced in cleft care. Interventions : Lip revision. Main Outcome Measures : (1) facial photographic images; (2) facial video images during animations; (3) objective three-dimensional measurements of upper lip movement based on z scores; and (4) objective dynamic and visual three-dimensional measurement of facial soft tissue movement. Results : With the use of the video images plus objective three-dimensional measures, the operating surgeon changed the problem list of the surgical treatment plan for 86% of the patients (95% confidence interval, 0.64 to 0.97) and the surgical goals for 71% of the patients (95% confidence interval, 0.48 to 0.89). The surgeon group varied in the percentage of patients for whom the problem list was modified, ranging from 24% (95% confidence interval, 8% to 47%) to 48% (95% confidence interval, 26% to 70%) of patients, and the percentage for whom the surgical goals were modified, ranging from 14% (94% confidence interval, 3% to 36%) to 48% (95% confidence interval, 26% to 70%) of patients. Conclusions : For all surgeons, the additional assessment components of the systematic valuation resulted in a change in clinical decision making for some patients.

Facial soft tissue dynamics before and after primary lip repair.

Objectives : (1) To collect three-dimensional, dynamic facial images from two groups of infants: one group born with cleft lip and palate slated to have a primary lip repair and a second, age-matched, noncleft control group. (2) To develop analyses to determine differences in facial movement between infants with cleft lip with or without palate (CL±P) and noncleft control infants and to determine changes in facial movement before and after primary lip repair. Design : Longitudinal, prospective case-control study. Setting : Facial Animation Laboratory at the University of North Carolina School of Dentistry. Participants : Two groups of infants: one group with unrepaired CL±P slated to have primary lip repair (n = 15) and a second group of age-matched, noncleft controls (n = 15). Interventions : Movement testing before and 4 months after primary lip repair in infants with CL±P and at similar time points in noncleft infants. Main Outcome Measures : Seven measures of facial movement. Results : The range of facial movements increased by 17% for all infants during the 4-month period. Compared with the noncleft group (1) infants with unilateral CL±P had 50% less nasolabial movement, and this difference did not change due to the lip repair; and (2) infants with unilateral or bilateral CL±P had 58% and 118% greater lateral upper lip movement, respectively, and 3.67 and 3.56 times greater asymmetry of movement, respectively, before lip repair. The procedure almost entirely removed the hypermobility and decreased the asymmetry. Conclusions : Primary surgical lip repair decreased hypermobility and improved asymmetry of upper lip movement.

Pituitary adenoma associated with xanthogranuloma.

Xanthogranuloma (XG) of the sellar region is a non-neoplastic inflammatory lesion characterized histologically by recent and remote hemorrhage, necrotic debris, fibrosis, chronic inflammation, and cholesterol clefts with associated foreign-body giant cells. The inflammatory lesion was recognized by the World Health Organization in 2000. XG of the sellar region is rare. Cases of pituitary adenoma (PA) with an associated XG (PA/XG) are extremely rare, with a total of 16 cases in the literature. PA/XG lacks specific clinical and radiologic signs, making pre-operative diagnosis challenging. Herein, we report a case of PA/XG, describe the radiologic and pathologic findings, and discuss the role of so-called silent or "subclinical pituitary apoplexy" in the possible histogenesis of PA/XGs.

Maximizing Benefit and Minimizing Risk in Medical Imaging Use: An Educational Primer for Health Care Professions Students.

"I am not young enough to know everything."Oscar Wilde. BACKGROUND: There is insufficient knowledge among providers and patients/caregivers of ionizing radiation exposure from medical imaging examinations. This study used a brief, interactive educational intervention targeting the topics of best imaging practices and radiation safety early in health professions students' training. The authors hypothesized that public health, medical, and physician assistant students who receive early education for imaging appropriateness and radiation safety will undergo a change in attitude and have increased awareness and knowledge of these topics. MATERIALS AND METHODS: The authors conducted a 1.5-hour interactive educational intervention focusing on medical imaging utilization and radiation safety. Students were presented with a pre/postquestionnaire and data were analyzed using t tests and multivariate analysis of variance. RESULTS: A total of 301 students were enrolled in the study. There was 58% (P < .01) and 85% (P < .01) improvement in attitude and knowledge regarding appropriateness of imaging, respectively. The authors also found an 8% increase (P < .01) in students who thought informed consent should be obtained prior to pediatric computed tomographic imaging. Physical assistant students were more likely than medical students to prefer obtaining informed consent at baseline (P = .03). CONCLUSIONS: A brief educational session provided to health professions students early in their education showed an increased awareness and knowledge of the utility, limitations, and risks associated with medical imaging. Incorporation of a best imagining practice educational session early during medical education may promote more thoughtful imaging decisions for future medical providers.

Behavioral Economics and the Supplemental Nutrition Assistance Program:: Making the Healthy Choice the Easy Choice.

The Supplemental Nutrition Assistance Program (SNAP) serves as an important nutritional safety net program for many Americans. Given its aim to use traditional economic levers to provide access to food, the SNAP program includes minimal nutritional requirements and restrictions. As food choices are influenced by more than just economic constraints, behavioral economics may offer insights and tools for altering food purchases for SNAP users. This manuscript outlines behavioral economics strategies that have potential to encourage healthier food choices within the SNAP program.

Comparison of energy expenditure estimates from 4 physical activity questionnaires with doubly labeled water estimates in postmenopausal women.

BACKGROUND: Physical activity energy expenditure (EE) is an important determinant of health, and epidemiologists have used various methods, such as physical activity and energy intake recalls and records, to estimate energy cost. However, most epidemiologic studies have not validated these methods against the doubly labeled water (DLW) technique for measuring EE. OBJECTIVE: The aim was to compare EE estimated by 4 physical activity questionnaires with that obtained with the DLW technique in free-living postmenopausal women. DESIGN: We measured EE in kcal/d using the DLW method, the Harvard Alumni questionnaire, the Five City Project questionnaire, the Cross-Cultural Activity Participation Study (CAPS) Four Week Activity Recall, and the CAPS Typical Week Activity Survey in 65 healthy postmenopausal women. RESULTS: Compared with DLW, the Harvard Alumni questionnaire, the Five City Project questionnaire, and the CAPS Four Week Activity Recall overestimated (P < 0.05) daily EE by 62%, 16%, and 11%, respectively, whereas the CAPS Typical Week Activity Recall underestimated (P < 0.05) EE by 31%. Both the Harvard Alumni and Five City Project questionnaires overestimated EE in obese and overweight women. CONCLUSIONS: When using 3 of the 4 questionnaire methods, postmenopausal women overestimated EEs. Of all women, obese women overestimated daily EE the most.

Usefulness of body mass index as a sufficient adiposity measurement for sex hormone concentration associations in postmenopausal women.

BACKGROUND: Both obesity and sex hormones are known risk factors for postmenopausal breast cancer. Although adiposity and sex hormones have been studied in the past, previous reports in postmenopausal women have not been conducted under carefully controlled dietary conditions. In this study, we investigated the usefulness of body mass index (BMI) as a sufficient adiposity measurement to assess associations with sex hormone levels. METHODS: This study was conducted as a cross-sectional analysis within the control segment (0 g alcohol group) of a randomized, crossover design, in which 51 postmenopausal women consumed 0 (control), 15 (one drink), and 30 (two drinks) g alcohol (ethanol)/d for 8 weeks each as part of a controlled diet. Dual-energy X-ray absorptiometry scans were administered to the women during the control (0 g alcohol) segment, and a blood sample was drawn at the end of that diet period for hormone analysis. RESULTS: In multivariate analysis (adjusted for age, race, family history of breast cancer, parity, and menarche <12 years), women who were overweight or obese had significantly higher serum concentrations of estradiol, bioavailable estradiol, estrone, and estrone sulfate and lower sex hormone-binding globulin than normal weight women (all P < 0.05). In models adjusted for BMI and the covariates above, none of the dual-energy X-ray absorptiometry adiposity measures added further information (all P > 0.10) for these five analytes beyond that of BMI alone. CONCLUSIONS: In this population of postmenopausal women, under carefully controlled dietary conditions, we confirmed previous findings that higher levels of adiposity were associated with higher concentrations of estrogens and lower sex hormone-binding globulin, and we found that the use of the epidemiology-friendly BMI seems sufficient to assess associations with these hormone levels.

A Toolkit for Pediatric CT Dose Reduction in Community Hospitals.

Pediatric CT radiation dose optimization is a challenging process for pediatric-focused facilities and community hospitals alike. Ongoing experience and trial-and-error approaches to dose reduction in the large academic hospital setting may position these centers to help community hospitals that strive for CT quality improvement. We describe our hands-on approach in a pilot project to create a partnership between an academic medical center and a community hospital to develop a toolkit for implementing CT dose reduction. Our aims were to (1) assess the acceptability of an interactive educational program and electronic toolkit booklet, (2) conduct a limited test of the efficacy of the toolkit in promoting knowledge and readiness to change, and (3) assess the acceptability and practicality of a collaborative approach to implementing dose reduction protocols in community hospitals. In partnering with the community hospital, we found that they had size-specific radiation doses two to three times higher than those at our center. Survey results after a site visit with interactive educational presentations revealed an increase in knowledge, stronger opinions about the health risks of radiation from CT scans, and willingness and perceived ability to reduce pediatric CT doses.

Working Face-to-Face for Pediatric CT Dose Reduction: A Community Toolkit.

Although children are especially vulnerable to the health risks of ionizing radiation, approximately 8 million CTs are performed on children in the USA. Widespread dose variation is common, particularly in non-pediatric focused facilities. In this article we present our rationale and hands-on approach in developing and refining a toolkit aimed at helping a community hospital with pediatric CT dose reduction.

Dietary patterns differ between urban and rural older, long-term survivors of breast, prostate, and colorectal cancer and are associated with body mass index.

BACKGROUND: Older adult cancer survivors are at greater risk of cancer recurrence and other comorbidities that can be prevented through improved diet and weight management. The tertiary prevention needs of rural-dwelling survivors can be even greater, yet little is known about rural and urban differences in lifestyle factors among this high-risk population. OBJECTIVES: To compare dietary patterns of urban and rural cancer survivors and to examine associations of dietary patterns with body mass index (BMI). DESIGN: A secondary analysis was performed of baseline data from the Reach Out to Enhance Wellness (RENEW) trial, a diet and exercise intervention among overweight, long-term (≥5 years), older survivors of colorectal, breast, and prostate cancer. Survivors in the present analysis (n=729) underwent two 45- to 60-minute telephone surveys, which included two 24-hour dietary recalls. Principal components analysis and multivariable general linear models were used to derive dietary patterns and to evaluate associations between dietary patterns and BMI, respectively. RESULTS: Principal components analysis identified three primary dietary patterns among rural dwellers (high sweets and starches, high reduced-fat dairy, cereal, nuts, and fruits, and mixed) and three among urban dwellers (high fruits and vegetables, high meat and refined grains, and high sugar-sweetened beverages). Among rural survivors, greater adherence to the high reduced-fat dairy, cereal, nuts, and fruits pattern was positively associated with lower BMI (P trend <0.05), whereas higher scores on the mixed pattern was associated with greater BMI (P trend <0.05). Greater adherence to the high fruits and vegetables pattern among urban survivors was inversely associated with BMI (P trend <0.05). CONCLUSIONS: Urban and rural differences in dietary intake behavior should be considered in designing public health interventions among the increasing population of older cancer survivors. In addition, targeting overall dietary patterns might be one approach to help reduce the burden of obesity among this population.

Relationship between serum leptin levels and alcohol consumption in a controlled feeding and alcohol ingestion study.

We examined serum leptin levels in a controlled feeding and alcohol ingestion study to elucidate potential mechanisms by which alcohol may affect cancer and immunologically related health risks. A total of 53 healthy, nonsmoking postmenopausal women completed a random-order, three-period crossover design study in which each woman received zero (0 g of alcohol), one (15 g of alcohol), or two (30 g alcohol) drinks per day. After accounting for differences in body mass index, women who consumed 15 or 30 g of alcohol per day had 7.3% (95% confidence interval [CI] = 3.0% to 15.1%) and 8.9% (95% CI = 1.6% to 16.7%) higher serum leptin levels, respectively (P(trend) =.018), than women who consumed 0 g of alcohol per day. Younger women (i.e., 49-54 years) demonstrated a statistically significantly larger association of alcohol consumption level with the increase in serum leptin levels than older women (i.e., 55-79 years) (24.4%, 95% CI = 9.3% to 42.0% versus 3.7%, 95% CI = -4.1% to 12.1% increase in serum leptin levels for 30 g of alcohol per day relative to 0 g of alcohol per day for the lowest age quartile compared with the three highest age quartiles combined; P =.022). These results indicate that moderate alcohol consumption (15-30 g of alcohol per day) increases serum leptin levels in postmenopausal women and may predispose moderate drinkers to the morbidities associated with chronic elevations of this hormone including cancer.