Appendiceal intussusception presenting as a caecal mass.

INTRODUCTION: The differential diagnosis of caecal mass is broad and the inclusion of appendiceal pathologies is an important element. CASE REPORT: We report a 37-year-old woman with recurrent right iliac fossa pain. Computed tomography scan revealed a caecal mass suggesting complete inversion or intussusception of the appendix, which was confirmed by pathologic microscopic examination. This case report discusses appendiceal intussusception with emphasis on diagnosis and treatment options. DISCUSSION: Appendiceal intussusception is a rare entity and the complete type typically presents as a polypoid lesion located at the appendiceal orifice in the caecum. It is imperative to include this entity in the differential diagnosis of caecal mass, especially during colonoscopy, as the removal of this polypoid lesion can result in a devastating caecal perforation or haemorrhage.

Cognitive decline in the middle-aged after surgery and anaesthesia: results from the Wisconsin Registry for Alzheimer's Prevention cohort.

Surgery and anaesthesia might affect cognition in middle-aged people without existing cognitive dysfunction. We measured memory and executive function in 964 participants, mean age 54 years, and again four years later, by when 312 participants had had surgery and 652 participants had not. Surgery between tests was associated with a decline in immediate memory by one point (out of a maximum of 30), p = 0.013: memory became abnormal in 77 out of 670 participants with initially normal memory, 21 out of 114 (18%) of whom had had surgery compared with 56 out of 556 (10%) of those who had not, p = 0.02. The number of operations was associated with a reduction in immediate memory on retesting, beta coefficient (SE) 0.08 (0.03), p = 0.012. Working memory decline was also associated with longer cumulative operations, beta coefficient (SE) -0.01 (0.00), p = 0.028. A reduction in cognitive speed and flexibility was associated with worse ASA physical status, beta coefficient (SE) 0.55 (0.22) and 0.37 (0.17) for ASA 1 and 2 vs. 3, p = 0.035. However, a decline in working memory was associated with better ASA physical status, beta coefficient (SE) -0.48 (0.21) for ASA 1 vs. 3, p = 0.01.

Surgery alters parameters of vitamin D status and other laboratory results.

Fracture liaison services often perform laboratory testing, but these results may be altered by surgery. In 40 hip arthroplasty patients, many laboratory parameters of bone health relevance were reduced by 8-22% on the first post-operative day. Laboratory results obtained in the immediate post-surgery interval do not reliably ascertain baseline status. INTRODUCTION: As secondary causes of osteoporosis are common, fracture liaison services often perform laboratory testing in the immediate post-fracture interval. We hypothesized that laboratory results obtained shortly after surgery may not accurately ascertain baseline status. If true, such alterations might confound subsequent fracture prevention efforts. METHODS: Patients undergoing elective total hip arthroplasty were studied as a surrogate for hip fracture patients. Blood and urine were obtained 2 weeks before surgery, before anesthetic induction, on post-operative day one, and 6 weeks after surgery. Serum total and free 25-hydroxyvitamin D (25(OH)D), vitamin D-binding protein (DBP), calcium, creatinine, albumin (Alb), alkaline phosphatase (ALP), plasma hemoglobin (Hgb) and urinary DBP/creatinine ratio (UDBP/Cr) were measured. RESULTS: Forty volunteers (28 women; 12 men) with mean age of 65.7 [8.7] years were studied. Laboratory results were stable from 2 weeks before to the day of surgery. On the first day after surgery, total 25(OH)D, DBP, calcium, creatinine, ALP, and Alb declined 8-22% (p < 0.0001); free 25(OH)D and Hgb declined by 8 and 15% (p < 0.01), respectively; and UDBP/Cr increased 32% (p < 0.01). Using a 25(OH)D <30 ng/mL threshold, vitamin D inadequacy prevalence increased from 38% before surgery to 68% the day after (p < 0.001). All laboratory values returned to baseline at 6 weeks after surgery. CONCLUSIONS: Laboratory values are reduced immediately following elective total hip arthroplasty. Testing at that time does not accurately ascertain baseline status and may lead to elevated estimates of vitamin D inadequacy, incorrect interventions, and misallocation of healthcare resources.

BedMachine v3: Complete Bed Topography and Ocean Bathymetry Mapping of Greenland From Multibeam Echo Sounding Combined With Mass Conservation.

Greenland's bed topography is a primary control on ice flow, grounding line migration, calving dynamics, and subglacial drainage. Moreover, fjord bathymetry regulates the penetration of warm Atlantic water (AW) that rapidly melts and undercuts Greenland's marine-terminating glaciers. Here we present a new compilation of Greenland bed topography that assimilates seafloor bathymetry and ice thickness data through a mass conservation approach. A new 150 m horizontal resolution bed topography/bathymetric map of Greenland is constructed with seamless transitions at the ice/ocean interface, yielding major improvements over previous data sets, particularly in the marine-terminating sectors of northwest and southeast Greenland. Our map reveals that the total sea level potential of the Greenland ice sheet is 7.42 ± 0.05 m, which is 7 cm greater than previous estimates. Furthermore, it explains recent calving front response of numerous outlet glaciers and reveals new pathways by which AW can access glaciers with marine-based basins, thereby highlighting sectors of Greenland that are most vulnerable to future oceanic forcing.

Vitamin D deficiency in anesthesia department caregivers at the end of winter.

BACKGROUND: To test whether the vitamin D status of anesthesia department caregivers practicing at high Northern latitudes is compatible with current recommendations, the 25-hydroxyvitamin D (25(OH)D) levels of caregivers at hospitals in Iceland (64°08' N) and in Wisconsin (43°07' N) were compared at the end of winter. METHODS: Anesthesia department faculty and resident physicians, non-physician anesthetists, and critical care nurses completed a questionnaire, and provided blood samples for analysis of 25(OH)D by reverse-phase high performance liquid chromatography. RESULTS: One hundred and six participants in Iceland and 124 participants in Wisconsin were enrolled. No difference in mean serum 25(OH)D levels between Iceland [70.53 nmol/l, standard deviation (SD) 30.87 nmol/l] and Wisconsin (70.0 nmol/l, SD 30.0 nmol/l) was observed. In Iceland and Wisconsin, 25(OH)D levels below 25 nmol/l were observed in 4.7% and 4.0%, below 50 nmol/l in 34.9% and 25.0%, and below 75 nmol/l in 56.6% and 61.3% of caregivers, respectively. CONCLUSIONS: 25(OH)D levels below the 50 nmol/l (20 ng/ml) threshold recommended by the Institute of Medicine and the European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis, and below the 75 nmol/l (30 ng/ml) threshold recommended by The Endocrine Society, are highly prevalent among anesthesia caregivers working at two Northern hospitals at the end of winter who may otherwise not meet criteria to be tested. Anesthesia and critical care providers may wish to determine their 25(OH)D levels and use effective, safe, and low cost supplementation to target a 25(OH)D level compatible with optimal health.

Short communication: Prevalence of methicillin resistance in coagulase-negative staphylococci and Staphylococcus aureus isolated from bulk milk on organic and conventional dairy farms in the United States.

The objective of this study was to evaluate the presence of methicillin-resistant Staphylococcus aureus and coagulase-negative Staphylococcus spp. in bulk tank milk samples from 288 organic and conventional dairy farms located in New York, Wisconsin, and Oregon from March 2009 to May 2011. Due to recent publications reporting the presence mecC (a mecA homolog not detected by traditional mecA-based PCR methods), a combination of genotypic and phenotypic approaches was used to enhance the recovery of methicillin-resistant organisms from bulk tank milk. In total, 13 isolates were identified as methicillin resistant: Staph. aureus (n=1), Staphylococcus sciuri (n=5), Staphylococcus chromogenes (n=2), Staphylococcus saprophyticus (n=3), Staphylococcus agnetis (n=1), and Macrococcus caseolyticus (n=1). The single methicillin-resistant Staph. aureus isolate was identified from an organic farm in New York, for an observed 0.3% prevalence at the farm level. The methicillin-resistant coagulase-negative staphylococci prevalence was 2% in the organic population and 5% in the conventional population. We did not identify mecC in any of the isolates from our population. Of interest was the relatively high number of methicillin-resistant Staph. sciuri recovered, as the number of isolates from our study was considerably higher than those recovered from other recent studies that also assessed milk samples. Our research suggests that the presence of a potential methicillin-resistant Staphylococcus reservoir in milk, and likely the dairy farm population in the United States, is independent of the organic or conventional production system.

Comparison of selected animal observations and management practices used to assess welfare of calves and adult dairy cows on organic and conventional dairy farms.

Differences in adoption of selected practices used in welfare assessment and audit programs were contrasted among organic (ORG; n=192) herds and similarly sized conventional grazing herds (CON-GR; n=36), and conventional nongrazing herds (CON-NG; n=64). Criteria from 3 programs were assessed: American Humane Association Animal Welfare Standards for Dairy Cattle, Farmers Assuring Responsible Management (FARM), and the Canadian Codes of Practice (CCP). Data were collected by trained study personnel during a herd visit and included information about neonatal care, dehorning, pain relief, calf nutrition, weaning, record keeping, use of veterinarians, and animal observations. Associations of management type (ORG, CON-GR, or CON-NG) with adoption of selected practice were assessed. Almost all farms (97%) met criteria suggested for age at weaning but fewer CON-NG farmers weaned calves at ≥5 wk of age compared with ORG and CON-GR farmers. Only 23% of farms met program requirements for use of pain relief during dehorning, and fewer CON-NG farmers used pain relief for calves after dehorning compared with ORG and CON-GR farmers. Calves on ORG farms were fed a greater volume of milk and were weaned at an older age than calves on CON-GR and CON-NG farms. Calves on CON-GR farms were dehorned at a younger age compared with calves on ORG and CON-NG farms. The calving area was shared with lactating cows for a larger proportion of ORG herds compared with conventional herds. About 30% of herds met welfare program criteria for body condition score but only about 20% met criteria for animal hygiene scores. The least proportion of cows with hock lesions was observed on ORG farms. Regular use of veterinarians was infrequent for ORG herds. Results of this study indicate that most of the organic and conventional farms enrolled in this study would have been unlikely to achieve many criteria of audit and assessment programs currently used in the US dairy industry.

Probiotics for adults with major depressive disorder compared with antidepressants: a systematic review and network meta-analysis.

CONTEXT: Despite recent advances in antidepressants in treating major depression (MDD), their usage is marred by adverse effects and social stigmas. Probiotics may be an efficacious adjunct or standalone treatment, potentially circumventing the aforementioned issues with antidepressants. However, there is a lack of head-to-head clinical trials between these 2 interventions. OBJECTIVE: A systematic review and network meta-analysis was conducted to compare the efficacy and acceptability of these 2 interventions in treating MDD. DATA SOURCES: Six databases and registry platforms for the clinical trial were systematically searched to identify the eligible double-blinded, randomized controlled trials published between 2015 and 2022. DATA EXACTION: Two authors selected independently the placebo-controlled trials of antidepressants and microbiota-targeted interventions (prebiotics, probiotics, and synbiotics) used for the treatment of MDD in adults (≥18 years old). Standardized mean differences (SMDs) of depressive symptom scores from individual trials were pooled for network meta-analysis (PROSPERO no. CRD42020222305). RESULTS: Forty-two eligible trials covering 22 interventions were identified, of which 16 were found to be effective in MDD treatment and the certainty of evidence was moderate to very low. When all trials were considered, compared with placebo, SMDs of interventions ranged from -0.16 (95% credible interval: -0.30, -0.04) for venlafaxine to -0.81 (-1.06, -0.52) for escitalopram. Probiotics were superior to brexpiprazole (SMD [95% credible interval]: -0.42 [-0.68, -0.17]), cariprazine (-0.44 [-0.69, -0.24]), citalopram (-0.37 [-0.66, -0.07]), duloxetine (-0.26, [-0.51, -0.04]), desvenlafaxine (-0.38 [-0.63, -0.14]), ketamine (-0.32 [-0.66, -0.01]), venlafaxine (-0.47 [-0.73, -0.23]), vilazodone (-0.37 [-0.61, -0.12]), vortioxetine (-0.39 [-0.63, -0.15]), and placebo (-0.62 [-0.86, -0.42]), and were noninferior to other antidepressants. In addition, probiotics ranked the second highest in the treatment hierarchy after escitalopram. Long-term treatment (≥8 weeks) using probiotics showed the same tolerability as antidepressants. CONCLUSION: Probiotics, compared with antidepressants and placebo, may be efficacious as an adjunct or standalone therapy for treating MDD. SYSTEMATIC REVIEW REGISTRATION: PROSPERO registration no. CRD42020222305.

Associations of risk factors with somatic cell count in bulk tank milk on organic and conventional dairy farms in the United States.

In the past decade, the demand for organic agricultural products has increased rapidly in the United States and worldwide. Milk quality research is of major interest to both consumers and dairy farmers alike. However, scientific data on milk quality, herd management methods, and animal welfare on organic farms in the United States has been lacking before the research from this study. The objective of this study was to evaluate the association of bulk tank milk somatic cell count (SCC) with management characteristics on organic and conventional dairy farms in New York, Oregon, and Wisconsin. Data from similarly sized organic farms (n=192), conventional nongrazing farms (n=64), and conventional grazing farms (n=36) were collected at a single farm visit. Of the 292 farms visited, 290 bulk tank milk samples were collected. Overall, no difference in SCC was observed between the conventional and organic grazing systems. Two models were created to assess the effects of various management and herd characteristics on the logarithmic transformation of the SCC (LSCC), one using data from all herds and one using data from organic herds only. From the total herd model, more grain fed per cow per day was negatively associated with LSCC, whereas a positive bulk tank culture for Staphylococcus aureus and years that a farmer reported being in the dairy business were both positively associated with LSCC. In the organic herd model, a seasonal effect indicated that LSCC tended to increase in the summer and decrease in the winter. Grain fed per cow per day, the use of anionic salts in transition-cow diets, the use of gloves during milking, and regular use of a quarantine unit at milking were all negatively associated with LSCC. Similar to the total herd model, a Staph. aureus-positive bulk tank culture was positively associated with LSCC in the organic model. Standard plate count was also positively associated with LSCC in the organic model. Several variables that were associated with management using external resources were combined to create an external input score. In the total herd model, use of more external resources was negatively associated with LSCC. Conventional herds in the study tended to use more outside management resources than organic herds.

Risk factors associated with bulk tank standard plate count, bulk tank coliform count, and the presence of Staphylococcus aureus on organic and conventional dairy farms in the United States.

The purpose of this study was to assess the association of bulk tank milk standard plate counts, bulk tank coliform counts (CC), and the presence of Staphylococcus aureus in bulk tank milk with various management and farm characteristics on organic and conventional dairy farms throughout New York, Wisconsin, and Oregon. Data from size-matched organic farms (n=192), conventional nongrazing farms (n=64), and conventional grazing farms (n=36) were collected at a single visit for each farm. Of the 292 farms visited, 290 bulk tank milk samples were collected. Statistical models were created using data from all herds in the study, as well as exclusively for the organic subset of herds. Because of incomplete data, 267 of 290 herds were analyzed for total herd modeling, and 173 of 190 organic herds were analyzed for the organic herd modeling. Overall, more bulk tanks from organic farms had Staph. aureus cultured from them (62% of organic herds, 42% conventional nongrazing herds, and 43% of conventional grazing herds), whereas fewer organic herds had a high CC, defined as ≥50 cfu/mL, than conventional farms in the study. A high standard plate count (×1,000 cfu/mL) was associated with decreased body condition score of adult cows and decreased milk production in both models. Several variables were significant only in the model created using all herds or only in organic herds. The presence of Staph. aureus in the bulk tank milk was associated with fewer people treating mastitis, increased age of housing, and a higher percentage of cows with 3 or fewer teats in both the organic and total herd models. The Staph. aureus total herd model also showed a relationship with fewer first-lactation animals, higher hock scores, and less use of automatic takeoffs at milking. High bulk tank CC was related to feeding a total mixed ration and using natural service in nonlactating heifers in both models. Overall, attentive management and use of outside resources were useful with regard to CC on organic farms. In all models except the organic CC model, we observed an association with the average reported somatic cell count from 3 mo before the herd visit, indicating that many of the regularly tested milk quality parameters are interconnected. In conclusion, we found that conventional and organic farms are similar in regard to overall herd management, but each grazing system faces unique challenges when managing milk quality.

Assessment of herd management on organic and conventional dairy farms in the United States.

The objective of this study was to evaluate management characteristics on organic and similarly sized conventional dairy farms located in New York, Wisconsin, and Oregon. Data from 192 organic farms (ORG), 64 conventional nongrazing farms (CON-NG), and 36 conventional grazing farms (CON-GR) were collected during farm visits and were size-matched and analyzed. The average lactation number of animals on ORG and CON-GR farms was 2.6 lactations, which was greater than that on CON-NG farms (2.3 lactations). A greater percentage of first-lactation heifers were found on conventional farms than on ORG farms. Facilities used by adult animals, including housing and milking facilities, did not differ among the grazing systems. Cattle on conventional farms were fed approximately twice as much grain as cattle on ORG farms and had greater milk production. Little difference was found for the average reported somatic cell count and standard plate count, suggesting that milk quality is not dependent on grazing system. Milking procedures were similar across all 3 grazing systems, indicating that an industry standard now exists for milking and that milk quality problems will need to be addressed with other management problems in mind. Although some disease prevention measures were commonly utilized on ORG farms, such as keeping a closed herd and having a written record of treatments administered to the animals, the use of outside support and vaccinations were found to be less prevalent on organic farms than on conventional farms.

Musculoskeletal injuries in US Air Force Tactical Air Control Party trainees: an 11-year longitudinal retrospective cohort study and presentation of a musculoskeletal injury classification matrix.

INTRODUCTION: Little is known of the epidemiology of musculoskeletal injuries (MSKIs) in US Air Force Special Warfare (AFSPECWAR) Tactical Air Control Party trainees. The purpose of this longitudinal retrospective cohort study was to (1) report the incidence and type of MSKI sustained by AFSPECWAR trainees during and up to 1 year following training, (2) identify factors associated with MSKI, and (3) develop and present the MSKI classification matrix used to identify and categorise injuries in this study. METHODS: Trainees in the Tactical Air Control Party Apprentice Course between fiscal years 2010-2020 were included. Diagnosis codes were classified as MSKI or non-MSKI using a classification matrix. Incidence rates and incidence proportion for injury types and regions were calculated. Measures were compared for differences between those who did and did not sustain an MSKI during training. A Cox proportional hazards model was used to identify factors associated with MSKI. RESULTS: Of the 3242 trainees, 1588 (49%) sustained an MSKI during training and the cohort sustained MSKIs at a rate of 16 MSKI per 100 person-months. Overuse/non-specific lower extremity injuries predominated. Differences were seen in some baseline measures between those who did and did not sustain an MSKI. Factors retained in the final Cox regression model were age, 1.5-mile run times and prior MSKI. CONCLUSION: Slower run times and higher age were associated with an increased likelihood of MSKI. Prior MSKI was the strongest predictor of MSKI during training. Trainees sustained MSKIs at a higher rate than graduates in their first year in the career field. The MSKI matrix was effective in identifying and categorising MSKI over a prolonged (12-year) surveillance period and could be useful for future injury surveillance efforts in the military or civilian settings. Findings from this study could inform future injury mitigation efforts in military training environments.

Presumed primary cardiac mast cell tumor, pericardial effusion, and arrhythmia in a dog.

A 13-year-old female spayed border collie cross presented for pericardial effusion, arrhythmia, and a suspected cardiac mass. Echocardiogram revealed severe thickening and hypokinesis of the interventricular septum with a heterogenous, cavitated myocardium, concerning for neoplasia. Electrocardiogram revealed predominantly accelerated idioventricular rhythm with frequent periods of nonsustained ventricular tachycardia. Occasional prolonged PR intervals terminating in an aberrantly conducted QRS complex were present. These beats were postulated to represent either first-degree atrioventricular block with aberrant QRS conduction or atrioventricular dissociation. Cytology of the pericardial effusion revealed atypical, suspected neoplastic, mast cells. The patient was euthanized, and postmortem examination confirmed full-thickness infiltration of the interventricular septum by a mast cell tumor, with metastasis to the tracheobronchial lymph node and spleen. Given the anatomic location of the mass, the observed atrioventricular nodal conduction delay may represent neoplastic infiltration of the atrioventricular node. Neoplastic infiltration of the ventricle was suspected to cause the accelerated idioventricular rhythm and ventricular tachycardia. To the authors' knowledge, this is the first reported case of a primary cardiac mast cell tumor causing arrhythmia and pericardial effusion in a dog.

Pathways and modification of warm water flowing beneath Thwaites Ice Shelf, West Antarctica.

Thwaites Glacier is the most rapidly changing outlet of the West Antarctic Ice Sheet and adds large uncertainty to 21st century sea-level rise predictions. Here, we present the first direct observations of ocean temperature, salinity, and oxygen beneath Thwaites Ice Shelf front, collected by an autonomous underwater vehicle. On the basis of these data, pathways and modification of water flowing into the cavity are identified. Deep water underneath the central ice shelf derives from a previously underestimated eastern branch of warm water entering the cavity from Pine Island Bay. Inflow of warm and outflow of melt-enriched waters are identified in two seafloor troughs to the north. Spatial property gradients highlight a previously unknown convergence zone in one trough, where different water masses meet and mix. Our observations show warm water impinging from all sides on pinning points critical to ice-shelf stability, a scenario that may lead to unpinning and retreat.

Mutations in the alpha 2 helix of HLA-A2 affect presentation but do not inhibit binding of influenza virus matrix peptide.

Previous studies have suggested that MHC class I molecules bind and present peptides to CTL in a manner that is analogous to the presentation of peptides by class II molecules to Th. Crystallographic studies of HLA-A2 have led to the assignment of a putative peptide binding site that is bordered by two alpha helices consisting of residues 50-84 and 138-180. In this study, we have investigated whether residues in the alpha 2 helix are involved in the binding and/or presentation of a peptide to CTL. We have generated CTL to type A influenza virus by stimulation of human PBL with a synthetic peptide from the influenza A virus matrix protein (M1 residues 57-68) in the presence of rIL-2. Such HLA-A2.1-restricted influenza virus-immune CTL do not recognize infected HLA-A2.3+ targets. A2.1 and A2.3 differ by three amino acids in the alpha 2 domain: Ala vs. Thr at position 149, Val vs. Glu at position 152, and Leu vs. Trp at position 156. Site-directed mutants of the A2.1 gene that encode A2 molecules that resemble A2.3 at positions 149, 152, and 156 have been constructed, transfected into human cells, and assayed for their ability to present the M1 peptide. The results demonstrate that most, but not all, A2.1-restricted M1-peptide-specific CTL fail to recognize M1 peptide-exposed transfectants with certain single amino acid substitutions at positions 152 and 156. In contrast, M1 peptide-exposed transfectants that express A2 molecules with an Ala----Thr substitution at position 149 were recognized by all CTL tested, but they exhibited an apparent difference in the kinetics of peptide binding. These results indicate that amino acid substitutions at positions 152 and 156 of the putative peptide binding site of the A2 molecule can affect presentation without eliminating binding, and indicate that the failure to recognize complexes between the peptide and the mutant A2 molecules is due to different TCR specificities and not to the failure to bind the peptide.

The evalaution of the foot core system in individuals with plantar heel pain.

OBJECTIVE: To compare foot posture, plantar sensation, plantar fascia thickness, intrinsic foot muscle performance, and abductor hallucis morphology in individuals with and without plantar heel pain (PHP). DESIGN: Cross-Sectional. SETTING: Laboratory. PARTICIPANTS: Sixteen individuals with PHP and sixteen matched healthy participants. MAIN OUTCOME MEASURES: Static foot posture, plantar sensation, plantar fascia thickness, intrinsic foot muscle performance and abductor hallucis morphology were evaluated. Foot posture was assessed with the Foot Posture Index-6. Abductor hallucis morphology and plantar fascia thickness were measured utilizing diagnostic ultrasound. Plantar foot sensation was assessed at the head of the first metatarsal and medial longitudinal arch using Semmes-Weinstein Monofilaments. Intrinsic foot muscle performance was assessed using the intrinsic foot muscle test (IFMT). Mann-Whitney U and independent t-tests were used to examine between group differences. RESULTS: Individuals with PHP exhibited a more pronated foot posture and greater plantar fascia thickness at the proximal insertion compared to healthy controls. Plantar sensation thresholds were higher in the PHP compared to healthy controls at the head of the first metatarsal. There were no group differences in abductor hallucis morphology or IFMT performance. CONCLUSIONS: Individuals with PHP exhibited a more pronated foot posture, thicker plantar fascia, and diminished plantar tactile sensation.

Cardiac biomarkers of disordered eating as a function of diagnostic subtypes.

OBJECTIVE: The purpose of this study was to identify cardiac biomarkers of disordered eating as a function of diagnostic subtype as assessed via self-report inventory. METHOD: Mean heart rate (HR), systolic and diastolic blood pressure, mean R wave amplitude (mV), mean T wave amplitude (mV), QTc interval (sec), Tpeak-Tend interval prolongation (sec), QTc interval prolongation (sec), QRS prolongation (sec), and spectral indicators of cardiac dysfunction (LF/HF spectral ratio, HF spectral power) were assessed via electrocardiography among women with no eating disorder symptoms (n = 32), subclinical eating disorder symptoms (n = 92), anorexia nervosa (n = 7), bulimia nervosa (n = 89), binge eating disorder (BED: n = 20), and other specified feeding and eating disorders (OSFED: n = 19). RESULTS: MANOVA results showed statistically significant group differences. Follow-up tests revealed significantly decreased mean R wave amplitude among participants with self-indicated clinical (bulimia nervosa, binge eating disorder) and subclinical forms of disordered eating compared to asymptomatic controls. DISCUSSION: Results suggest decreased mean R wave amplitude is a promising cardiac biomarker of disordered eating.

Impact of Centralizing Care for Genitourinary Malignancies to High-volume Providers: A Systematic Review.

CONTEXT: The centralization of cancer care is associated with better clinical outcomes and may be a method for optimizing value-based health care systems. OBJECTIVE: To systematically review the literature regarding the impact of centralization of care on clinical outcomes for genitourinary malignancies. EVIDENCE ACQUISITION: A systematic review was conducted using Ovid and MEDLINE to identify studies between 1970 and 2018 reporting on the centralization of care for genitourinary malignancies. Prospective and retrospective studies were screened. EVIDENCE SYNTHESIS: There were no published randomized control trials (RCTs) on the centralization of care for genitourinary malignancies. Twenty-two retrospective studies met inclusion criteria. Centralization of radical cystectomy was the most studied. Care for bladder cancer, prostate cancer, penile cancer, testicular cancer, and renal cancer was reportedly associated with better morbidity and survival outcomes for patients treated at high-volume centers. However, evidence of better outcomes for centralization of care remains limited for penile, renal, and testicular cancers owing to the paucity of data and/or the lower incidence of these genitourinary malignancies. CONCLUSIONS: Care for genitourinary malignancies by high-volume providers was associated with greater utilization of cancer surgery, lower morbidity, and better survival outcomes. Centralization of care was most appropriate for complex procedures such as radical cystectomy when interpreted in the context of survival outcomes. Further research is needed to address the impact of centralizing care for all urologic malignancies with consideration of the associated costs and patient-reported measures, including quality of life and patient experience. PATIENT SUMMARY: We explored the evidence for moving major operations into larger centers. We focused on surgery for cancers of the bladder, prostate, testicle, penis, and kidney, and found that larger-volume hospitals had better survival outcomes and fewer complications when compared to smaller hospitals. The difference may be greatest for complex major surgeries such as radical cystectomy.

Comparison of Costs of Radical Cystectomy vs Trimodal Therapy for Patients With Localized Muscle-Invasive Bladder Cancer.

Importance: Earlier studies on the cost of muscle-invasive bladder cancer treatments lack granularity and are limited to 180 days. Objective: To compare the 1-year costs associated with trimodal therapy vs radical cystectomy, accounting for survival and intensity effects on total costs. Design, Setting, and Participants: This population-based cohort study used the US Surveillance, Epidemiology, and End Results-Medicare database and included 2963 patients aged 66 to 85 years who had received a diagnosis of clinical stage T2 to T4a muscle-invasive bladder cancer from January 1, 2002, through December 31, 2011. The data analysis was performed from March 5, 2018, through December 4, 2018. Main Outcomes and Measures: Total Medicare costs within 1 year of diagnosis following radical cystectomy vs trimodal therapy were compared using inverse probability of treatment-weighted propensity score models that included a 2-part estimator to account for intrinsic selection bias. Results: Of 2963 participants, 1030 (34.8%) were women, 2591 (87.4%) were white, 129 (4.4%) were African American, and 98 (3.3%) were Hispanic. Median costs were significantly higher for trimodal therapy than radical cystectomy in 90 days ($83 754 vs $68 692; median difference, $11 805; 95% CI, $7745-$15 864), 180 days ($187 162 vs $109 078; median difference, $62 370; 95% CI, $55 581-$69 160), and 365 days ($289 142 vs $148 757; median difference, $109 027; 95% CI, $98 692-$119 363), respectively. Outpatient care, radiology, medication expenses, and pathology/laboratory costs contributed largely to the higher costs associated with trimodal therapy. On inverse probability of treatment-weighted adjusted analyses, patients undergoing trimodal therapy had $136 935 (95% CI, $122 131-$152 115) higher mean costs compared with radical cystectomy 1 year after diagnosis. Conclusions and Relevance: Compared with radical cystectomy, trimodal therapy was associated with higher costs among patients with muscle-invasive bladder cancer. The differences in costs were largely attributed to medication and radiology expenses associated with trimodal therapy. Extrapolating cost figures resulted in a nationwide excess spending of $468 million for trimodal therapy compared with radical cystectomy for patients who received a diagnosis of bladder cancer in 2017.

Systematic Review of Factors Associated with the Utilization of Radical Cystectomy for Bladder Cancer.

CONTEXT: Despite established guidelines for the treatment of muscle-invasive bladder cancer, it has been reported that radical cystectomy (RC) is markedly underused, especially among patients of advanced age and those with higher comorbidity burden and lower access to care. Understanding the interactions between patient, provider, and hospital factors may inform targeted interventions to optimize RC utilization. OBJECTIVE: To systematically review the literature regarding factors associated with RC utilization. EVIDENCE ACQUISITION: A systematic search was conducted using Ovid and Medline according to Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines to identify studies between 1970 and 2017 reporting on RC utilization. Prospective and retrospective studies were included. EVIDENCE SYNTHESIS: There are no published randomized control trials on RC utilization. Variations in study quality and design precluded a formal statistical meta-analysis. RC receipt significantly depended on patient, provider, and hospital factors. Patient factors associated with lower RC use included advanced age, African American and Hispanic race/ethnicity, higher comorbidity burden, unmarried marital status, higher tumor stage and grade, and lower socioeconomic status. Provider factors associated with underutilization included lower surgeon volume and a metropolitan location. Finally, hospital factors associated with lower RC use included low hospital volume, nonacademic affiliation, and hospital location in the Midwest. CONCLUSIONS: RC is reportedly underutilized. We found that age, race, marital status, socioeconomic factors, cancer severity, comorbidity burden, surgeon volume, and facility type and location significantly determined RC receipt. Improved understanding of the varying contributions of the risk factors according to patient, provider, and hospital determinants may assist in developing targeted interventions to improve RC utilization. PATIENT SUMMARY: In this review we explored the clinical evidence for factors predicting the utilization of radical cystectomy for muscle-invasive bladder cancer. Many factors related to the patient, provider, and hospital determine whether patients receive this guideline-recommended treatment. However, there remains a lack of understanding on characterization and targeted interventions according to these levels, which may improve use.