Evaluation of an Association Between Enoxaparin Dose per Estimated Blood Volume and Clinically Relevant Bleeding in Low-Weight Trauma Patients.

BACKGROUND: The optimal dosing for enoxaparin venous thromboembolism (VTE) prophylaxis in low-weight trauma patients is unknown. Estimated blood volume (EBV) has shown promise as a dose modifier. OBJECTIVE: To characterize the association of enoxaparin dose per EBV with the prevalence of VTE and bleeding in low-weight trauma patients. METHODS: This was a retrospective study of trauma patients admitted over a 4-year period. Included patients were adults weighing <60 kg who received a minimum of 3 consecutive doses of enoxaparin. The primary endpoint was a comparison of enoxaparin dose per EBV in patients experiencing bleeding and VTE. Secondary endpoints included comparisons of dose per body mass index (BMI) and total body weight (TBW) and the ability of dose per EBV to predict clinical endpoints. Subgroup analyses for patients weighing <50 kg were performed for all endpoints. RESULTS: A total of 189 patients were included. Statistical comparisons for VTE were not performed because of low prevalence. The dose of enoxaparin per EBV was not statistically different between patients who did and did not bleed in all analyses. Doses per BMI and TBW were also not statistically different between the groups. In patients weighing <50 kg, numerically higher doses per EBV, BMI, and TBW were noted in patients that bled versus those that did not. Enoxaparin dose per EBV was not a statistically significant predictor of bleeding in logistic regression models. CONCLUSION AND RELEVANCE: No significant associations between enoxaparin dose per EBV, BMI, or TBW and bleeding were noted in the study. Future analyses of EBV and other dose modifiers should consider inclusion of patients weighing <50 kg.

A Retrospective Cohort Analysis of Analgosedation Requirements in COVID-19 Compared to Non-COVID-19 Extracorporeal Membrane Oxygenation Patients.

BACKGROUND: Reports have described increased sedation requirements in patients with acute respiratory distress syndrome (ARDS) while on extracorporeal membrane oxygenation (ECMO) and for intubated COVID-19 patients. Thus, the objective of this study was to assess the analgosedation requirements of COVID-19 patients receiving ECMO compared to non-COVID-19 ECMO patients. METHODS: This retrospective, observational cohort study included adult patients with ARDS requiring venovenous or venopulmonary arterial ECMO admitted to a single intensive care unit from January 2017 to December 2021. Patients were categorized as COVID-19 ECMO or non-COVID-19 ECMO. The primary outcome was median daily dosing of parenteral analgosedative medications. Pertinent secondary outcomes included incidence of extubation or tracheostomy and change in sedation following tracheostomy or addition of oral agents. RESULTS: A total of 109 patients were evaluated; 63 COVID-19 ECMO patients and 46 non-COVID ECMO patients. The primary outcome was statistically higher in the COVID-19 compared to non-COVID-19 patients for propofol (4131.0 mg vs 2704.8 mg, P < .001), dexmedetomidine (1581.4 mcg vs 1081.3 mcg, P = .016), and parenteral morphine equivalents ([PME], 209.3 mg vs 154.1 mg, P = .027), but only propofol remained significant after adjustment for weight (31.1 mcg/kg/day vs 37.7 mcg/kg/day, P = .014). COVID-19 was significantly associated with increased propofol and PME requirements after adjustment for confounders on linear regression analysis. COVID-19 patients had more days with non-zero dose for propofol (8 days vs 7 days), dexmedetomidine (13 days vs 8.5 days), and PME (17 days vs 8.5 days). The only interventions that were associated with reductions in propofol dose were tracheostomy and antipsychotics. CONCLUSIONS: COVID-19 patients on ECMO had significantly longer durations and higher doses of propofol, dexmedetomidine, and parenteral opioids over the first 28 days of cannulation. The only interventions that were associated with statistical reductions in propofol were antipsychotics and tracheostomy.

Impact of veteran-led peer mentorship on posttraumatic stress disorder.

Peer mentorship shows promise as a strategy to support veteran mental health. A community-academic partnership involving a veteran-led nonprofit organization and institutions of higher education evaluated a collaboratively developed peer mentor intervention. We assessed posttraumatic stress disorder (PTSD), postdeployment experiences, social functioning, and psychological strengths at baseline, midpoint, and 12-week discharge using the PTSD Checklist for DSM-5 (PCL-5), Deployment Risk and Resilience Inventory-2, Social Adaptation Self-evaluation Scale, and Values in Action Survey. Brief weekly check-in surveys reinforced mentor contact and assessed retention. The sample included 307 veterans who were served by 17 veteran peer mentors. Mixed-effects linear models found a modest effect for PTSD symptom change, with a mean PCL-5 score reduction of 4.04 points, 95% CI [-6.44, -1.64], d = 0.44. More symptomatic veterans showed a larger effect, with average reductions of 9.03 points, 95% CI [-12.11, -5.95], d = 0.77. There were no significant findings for other outcome variables. Compared to younger veterans, those aged 32-57 years were less likely to drop out by 6 weeks, aORs = 0.32-0.26. Week-by-week hazard of drop-out was lower with mentors ≥ 35 years old, aHR = 0.62, 95% CI [0.37, 1.05]. Unadjusted survival differed by mentor military branch, p = .028, but the small mentor sample reduced interpretability. Like many community research efforts, this study lacked a control group, limiting the inferences that can be drawn. Continued study of veteran peer mentorship is important as this modality is often viewed as more tolerable than therapy.

Comparison of Outcomes in Patients Requiring Mechanical Circulatory Support Who Received Cangrelor in Addition to Anticoagulation Versus Anticoagulation Alone.

OBJECTIVES: To evaluate the safety of cangrelor administered concurrently with heparin or bivalirudin in patients on mechanical circulatory support. DESIGN: A single-center, retrospective cohort study of adult patients consecutively admitted between January 2016 and October 2020. SETTING: A tertiary medical center. PARTICIPANTS: Adult patients admitted to the cardiovascular intensive care unit put on mechanical circulatory support for acute myocardial infarction (AMI) or non-AMI indications. Patients who received cangrelor underwent percutaneous coronary intervention with stenting during the index event or within the last year. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The primary outcome was the incidence of major bleeding, defined by the Extracorporeal Life Support Organization criteria, in patients with mechanical circulatory support receiving cangrelor plus anticoagulation with heparin or bivalirudin with or without aspirin versus patients who did not receive cangrelor. Sixty-eight patients were included in the study. Twenty-nine patients received cangrelor, and 39 did not. Cangrelor was not associated with an increase in major bleeding; however, the CI was wide (adjusted hazard ratio 1.93, 95% CI 0.61-6.11; p = 0.262). CONCLUSIONS: Patients receiving cangrelor did not appear to be at higher risk of major bleeding compared to patients not receiving cangrelor. Larger trials should be conducted to better evaluate the safety of cangrelor in patients with mechanical circulatory support.

Effectiveness of Body Mass Index-Based Prophylactic Enoxaparin Dosing in Bariatric Surgery Patients.

INTRODUCTION: Enoxaparin is administered for venous thromboembolic (VTE) prophylaxis in bariatric surgery patients. There is concern whether body mass index (BMI)-based enoxaparin dosing consistently achieves prophylactic targets in patients with severe obesity. METHODS: This retrospective study included patients who underwent bariatric surgery at an academic medical center from Jan 2015-May 2021 and had an anti-Xa level drawn 2.5-6 h after ≥3 doses of BMI-based prophylactic enoxaparin. The primary outcome was the percentage of patients who achieved a target anti-Xa level. Secondary outcomes were prevalence of venous thromboembolic and bleeding events within 30 d post-operatively. RESULTS: Overall, 137 patients were included. Mean BMI was 59.1 ± 10.4 kg/m2, mean age was 43.9 ± 13.3 y and 110 patients (80.3%) were female. Target anti-Xa levels were achieved in 116 patients (84.7%); 14 (10.2%) were above target and 7 (5.1%) were below target. Patients with above target anti-Xa levels were significantly shorter in height than those within target range (167.1 versus 159.8 cm, P = 0.003). Five patients (3.6%) had a bleeding event; no thromboembolisms occurred. Anti-Xa levels correlated more strongly with enoxaparin dose per unit estimated blood volume (EBV) than dose per unit BMI (Rho = 0.54 versus Rho = 0.33). CONCLUSIONS: Target range anti-Xa levels were achieved in 85% of patients using BMI-based enoxaparin dosing. Patients with above target anti-Xa levels were significantly shorter by nearly 3 inches, suggesting an increased risk of overdosing enoxaparin in shorter, obese patients. An EBV-based dosing regimen may better account for patient height and is supported by a greater correlation with anti-Xa levels with dosing based on EBV than BMI.

Splice switching an oncogenic ratio of SmgGDS isoforms as a strategy to diminish malignancy.

The chaperone protein SmgGDS promotes cell-cycle progression and tumorigenesis in human breast and nonsmall cell lung cancer. Splice variants of SmgGDS, named SmgGDS-607 and SmgGDS-558, facilitate the activation of oncogenic members of the Ras and Rho families of small GTPases through membrane trafficking via regulation of the prenylation pathway. SmgGDS-607 interacts with newly synthesized preprenylated small GTPases, while SmgGDS-558 interacts with prenylated small GTPases. We determined that cancer cells have a high ratio of SmgGDS-607:SmgGDS-558 (607:558 ratio), and this elevated ratio is associated with reduced survival of breast cancer patients. These discoveries suggest that targeting SmgGDS splicing to lower the 607:558 ratio may be an effective strategy to inhibit the malignant phenotype generated by small GTPases. Here we report the development of a splice-switching oligonucleotide, named SSO Ex5, that lowers the 607:558 ratio by altering exon 5 inclusion in SmgGDS pre-mRNA (messenger RNA). Our results indicate that SSO Ex5 suppresses the prenylation of multiple small GTPases in the Ras, Rho, and Rab families and inhibits ERK activity, resulting in endoplasmic reticulum (ER) stress, the unfolded protein response, and ultimately apoptotic cell death in breast and lung cancer cell lines. Furthermore, intraperitoneal (i.p.) delivery of SSO Ex5 in MMTV-PyMT mice redirects SmgGDS splicing in the mammary gland and slows tumorigenesis in this aggressive model of breast cancer. Taken together, our results suggest that the high 607:558 ratio is required for optimal small GTPase prenylation, and validate this innovative approach of targeting SmgGDS splicing to diminish malignancy in breast and lung cancer.

Low patient engagement is associated with reduced health-related quality of life in adults with cyclic vomiting syndrome.

INTRODUCTION: Patient engagement, adaptation and self-management play a critical role in improving Health Related Quality of Life (HRQOL) and reducing health care utilization in chronic disorders. There is no data on the level of patient engagement in patients with cyclic vomiting syndrome (CVS); we thus sought to determine their level of engagement and its association with clinical covariates. METHODS: The Patient Activation Measure (PAM-13), a validated tool that measures the degree of patient engagement in their health was administered prospectively to patients with CVS. Data on demographics, health care utilization, and HRQOL (using the NIH PROMIS 10) were obtained. Patients were stratified into low engagement (PAM 1 & 2) and high engagement (PAM 3 & 4). The Fisher's exact test and Wilcoxon rank-sum tests were used to identifying significant differences between the groups. RESULTS: Of 96 patients, 45% of patients had low levels of patient engagement. On multivariate analysis, low patient engagement was significantly associated with an increased number of CVS hospitalizations in the past year (aOR 1.26 [1.07, 1.54] p = .010), lower mental HRQOL scores (aOR 0.88 [0.78, 0.97] p = .022), current tobacco use (aOR 4.85 [1.24, 22.74] p = .031), and patients who were newly established in a specialized CVS clinic (aOR 44.40 [5.38, 70.02] p = .002). CONCLUSION: Almost half of CVS patients demonstrate poor patient engagement, which is associated with poor outcomes. Identifying these patients and treatment in a specialized CVS center can potentially improve HRQOL, reduce health care utilization and improve overall healthcare outcomes.

Heparin Monitoring with an Anti-Xa Protocol Compared to Activated Clotting Time in Patients on Temporary Mechanical Circulatory Support.

BACKGROUND: Temporary mechanical circulatory support (tMCS) devices are used for patients with severe cardiac or respiratory failure; however, these patients are at high risk for clotting and bleeding. The best method to monitor heparin in these patients has not been established. OBJECTIVE: To determine the risks for bleeding and clotting while monitoring heparin with either anti-Xa or activated clotting time (ACT) in tMCS patients. METHODS: A retrospective cohort study was conducted on tMCS patients who received heparin adjusted according to an anti-Xa or ACT protocol. The primary outcome was incidence of major bleeding. Pertinent secondary outcomes were individual components of the primary outcome, clotting events, and time to therapeutic range. RESULTS: There were 103 patients included in the study: 53 in the ACT group and 50 in the anti-Xa group. Overall, there were 30 (56.6%) patients with major bleeding in the ACT group, compared with 16 (32%) patients in the anti-Xa group (P = 0.017). An anti-Xa-based protocol was associated with a decreased hazard of major bleeding (hazard ratio = 0.388 [0.215-0.701]; P = 0.002) in the univariate analysis. In the multivariable analysis, an anti-Xa protocol remained associated with a significantly lower hazard of bleeding. Findings were similar when broken down into more discrete subgroups of the entire cohort, extracorporeal membrane oxygenation life support (ECMO), and non-ECMO groups. CONCLUSION AND RELEVANCE: Anti-Xa monitoring was associated with a lower hazard of bleeding during tMCS compared to an ACT-based protocol. Further studies should evaluate if anti-Xa monitoring should be preferentially used in tMCS.

Extending INR testing intervals in warfarin patients at a multi-center anticoagulation clinic.

Warfarin has been used as an anticoagulant by millions of patients due to its effectiveness, availability, and low cost. Evidence on the safe extension of international normalized ratio (INR) testing frequency remains an area of interest, especially during the recent COVID-19 pandemic. The purpose of this study is to safely extend INR testing intervals in patients throughout a multisite, system-wide anticoagulation clinic. Updates were made to the pharmacist's collaborative practice agreement (CPA) and nurse protocol to optimize practice and allow INR testing interval extension up to a maximum of 8-weeks. The primary outcome was the change in duration between INR tests (INR testing interval) measured before and after providing staff education on clinic updates. The mean duration between INR tests (SD) was 23.69 days (11.29) in the pre-intervention period and 25.58 days (13.91) in the post-intervention period. During the COVID-19 pandemic (post2), intervals were extended further to 27.81 days (14.96), demonstrating a statistically significant increase in INR testing interval from pre-intervention to post-intervention and to post2 (p < 0.001 and p < 0.001, respectively). A secondary outcome indicated the mean time in therapeutic range (SD) showed no significant difference in pre-intervention 70.11% (25.95) versus post-intervention of 69.76% (25.69) with a difference of - 0.35% (29.93) (p = 0.956) or versus the post2 of 68.82% (27.20) with a difference of - 1.29% (33.20) (p = 0.120). This study showed that changes to the CPA and protocol allowed for a significant increase in INR testing interval while simultaneously maintaining a mean time in therapeutic range > 60% for the clinic population.

Utility of Epinephrine Levels in Determining Adrenal Vein Cannulation During Adrenal Venous Sampling for Primary Aldosteronism.

OBJECTIVE: In patients with primary aldosteronism, adrenal venous sampling (AVS) is performed to determine the presence of unilateral or bilateral adrenal disease. During AVS, verification of catheter positioning within the left adrenal vein (AV) and the right AV by comparison of AV and inferior vena cava (IVC) cortisol levels can be variable. The objective of this study was to determine the utility of AV epinephrine levels in assessing successful AV cannulation. METHODS: This was a single institution, retrospective review of patients who underwent AVS with cosyntropin stimulation for primary aldosteronism between 2009 and 2018. Successful cannulation of the AV was defined by an AV/IVC cortisol ratio selectivity index (SI) ≥3:1. Epinephrine thresholds to predict catheter placement in the AV were determined using logistic regression. The calculated epinephrine thresholds were compared with previously published thresholds. RESULTS: AVS was performed on 101 consecutive patients and, based on the SI, successful cannulation of the left AV and right AV occurred in 98 (97%) and 91(90%) patients, respectively. The calculated optimal epinephrine threshold to predict AV cannulation was 364 pg/mL (sensitivity, 92.1%; specificity, 94.6%) and the calculated optimal AV/IVC epinephrine ratio threshold was 27.4, (sensitivity, 92.1%; specificity, 91.3%). Among the 14 patients with failed AV cannulation, 3 patients would have been considered to have successful AVS using AV epinephrine levels >364 pg/mL and AV/IVC epinephrine ratio >27.4 thresholds. CONCLUSION: Obtaining 2 right AV samples routinely as well as AV and IVC epinephrine levels during AVS could prevent unnecessary repeat AVS in patients with failed AV cannulation based on cortisol-based SI <3:1.

The effect of socioeconomic factors on patient outcomes in cardiac surgery.

OBJECTIVES: Healthcare delivery is heterogenous; the reasons for this are numerous and complex. Patient-specific factors including geography, income, insurance status, age, and gender have been shown to bias surgical outcomes. Utilizing a prospectively collected all-payer database, we aim to evaluate the influence of socioeconomic factors on mortality and length of stay (LOS) after common cardiac surgical procedures. METHODS: We utilized the National Inpatient Sample, Healthcare Cost and Utilization Project, Agency for Healthcare Research and Quality for the year 2019. We included patients undergoing coronary artery bypass grafting (CABG), aortic valve replacement (AVR), transcatheter aortic valve replacement (TAVR), and combined AVR/CABG using the 10th revision of the International Classification of Diseases procedure codes. AVR and CABG were combined into a separate cohort as this was felt to represent a different pathology than isolated valvular or coronary arterial disease. Baseline demographics were summarized. Multivariable regression was performed within each procedure group to model the odds of in-hospital mortality and hospital LOS with age, sex, insurance, zip-code median household income, and location as predictors. RESULTS: Baseline patient characteristics including gender, income, geography, and payer status were similar between CABG, AVR, and AVR/CABG. TAVR patients had a higher proportion of female sex and Medicare as the primary payer, with an overall greater age. Multivariable Cox proportional hazards regression found that higher income was strongly associated with decreased LOS following AVR and CABG, and moderately associated in TAVR and AVR/CABG. Private insurance was associated with a decreased LOS in patients undergoing CABG, AVR, TAVR, and AVR/CABG. Female sex and increased age were associated with increased odds of mortality in TAVR, CABG, and AVR/CABG. Private insurance was associated with a decreased odds of mortality in patients undergoing AVR. CONCLUSIONS: These findings reveal significant disparities in patient outcomes after routine cardiac operations that are associated with socioeconomic status. Patients who did not have private insurance or had lower incomes were found to be at risk for increased LOS. Women were at a higher risk of mortality for several operations, a finding which has been previously described elsewhere. Private insurance conveyed a decreased odds of mortality in patients undergoing AVR. This data set serves to highlight differences in healthcare outcomes based on a variety of socioeconomic, geographic, and other inherent factors. Additional research is needed to identify the mechanisms behind these disparities with the goal of providing equitable care to all patients.

Non-parametric recurrent events analysis with BART and an application to the hospital admissions of patients with diabetes.

Much of survival analysis is concerned with absorbing events, i.e., subjects can only experience a single event such as mortality. This article is focused on non-absorbing or recurrent events, i.e., subjects are capable of experiencing multiple events. Recurrent events have been studied by many; however, most rely on the restrictive assumptions of linearity and proportionality. We propose a new method for analyzing recurrent events with Bayesian Additive Regression Trees (BART) avoiding such restrictive assumptions. We explore this new method via a motivating example of hospital admissions for diabetes patients and simulated data sets.

Pediatric Feeding Disorder: A Nationwide Prevalence Study.

OBJECTIVE: To assess the prevalence of pediatric feeding disorder (PFD) in US children. STUDY DESIGN: We conducted a retrospective cohort study of Medicaid Databases from Arizona (2009-2017) and Wisconsin (2005-2014) (public insurance databases) and The Truven Health Analytics MarketScan Commercial Claims and Encounters Database (2009-2015) (a nationwide private insurance database). Diagnoses and procedures were identified from inpatient and outpatient claims using the International Classification of Diseases (ICD)-9 and ICD-10 diagnostic codes and ICD and Current Procedural Terminology-4 procedure codes. Children with PFD were identified by presence of 1 or more PFD diagnosis and absence of any eating disorder diagnoses within a calendar year. RESULTS: We identified 126 002 and 367 256 children 5 years of age or younger with PFD with public and private insurance, respectively. Over a 5-year period (2009-2014) the prevalences of PFD in children with public insurance in Arizona and Wisconsin were 32.91 (95% CI, 32.61-33.20) and 34.73 (95% CI, 34.37-35.09) children per 1000 child-years, respectively. Similarly, the prevalence of PFD in private insurance carriers was 21.07 (95% CI, 21.00-21.14) children per 1000 child-years. The prevalence trends showed a significant linear increase in children within both insurance cohorts. In 2014, the annual prevalence of PFD was 1 in 23, 1 in 24, and 1 in 37 in children under 5 years in the publicly insured cohorts in Wisconsin, Arizona, and the privately insured cohort, respectively. CONCLUSIONS: The prevalence of feeding disorders in the US rivals that of commonly diagnosed conditions such as eating disorders and autism.

Abnormal hearing patterns are not associated with endothelium-dependent vasodilation and carotid intima-media thickness: The Framingham Heart Study.

INTRODUCTION: Prior data suggest associations between hearing loss, cardiovascular (CV) risk factors, and CV disease. Whether specific hearing loss patterns, including a strial pattern associated with inner ear vascular disease, are associated with systemic endothelial dysfunction and carotid intima-media thickness (IMT) remains unclear. METHODS: We evaluated participants without prevalent CVD in the Framingham Offspring Study who underwent formal audiogram testing and brachial and carotid artery ultrasounds. Audiograms were categorized as normal or as belonging to one of four abnormal patterns: cochlear-conductive, low-sloping, sensorineural, or strial. Endothelial function as measured by brachial artery flow-mediated dilation (FMDmm and FMD%). Internal and common intima-media thicknesses (icIMT and ccIMT, respectively) were compared between audiogram patterns. RESULTS: We studied 1672 participants (mean age 59 years, 57.6% women). The prevalence of each hearing pattern was as follows: 43.7% normal; 20.3% cochlear-conductive; 20.3% sensorineural; 7.7% low-sloping; and 8.0% strial. Strial pattern hearing loss was nearly twice as prevalent (p = 0.001) in those in the highest quartile of ccIMT and nearly 50% higher in those in the highest icIMT quartile (p = 0.04). There were no statistically significant differences between the prevalence of the strial pattern comparing the lowest quartiles of FMDmm and FMD% with the upper three quartiles. Age- and sex-adjusted linear regression models did not show significant associations between the vascular measures and hearing patterns. CONCLUSION: Abnormal hearing patterns were not significantly associated with impaired brachial FMD and increased carotid IMT after adjusting for age and sex effects, which may reflect age and sex-related distributional differences based on hearing loss pattern.

Solid organ donor-recipient race-matching: analysis of the United Network for Organ Sharing database.

Donor ethnicity is a prognosticator in organ transplant. However, the impact of donor/recipient race-matching is unclear. We hypothesized that there would be increased survival in donor-recipient race-matched organ recipients because of genetic and physiologic similarities. The UNOS database from 1999 to 2018 was queried for all solid organ transplantations including heart, lung, liver, kidney, and pancreas transplants. Data were sorted by donor and recipient race into matched and unmatched categories for Caucasian, African American, and Hispanic transplant recipients. After controlling for potential confounders via inverse propensity of treatment weighting, post-transplant patient and graft survival were compared between race-matched and -unmatched donor groups for each organ. Race-matched Caucasian recipients experienced 1-3% improvement in mortality across most time points in lung, liver, and pancreas transplants, while Hispanics did not benefit. Matched African American recipients experienced 4-6% improvement in patient and graft survival in liver transplant but had 7-9% worse survival rates at 5 years in lung and pancreas transplants. Race-matching does not influence patient outcomes enough to factor into organ transplant offers. African American liver transplant recipients benefited the most. Matching was detrimental to African American lung and pancreas transplant recipients indicating there may be other factors influencing the outcomes of these transplants.

Seasonal trends in donor heart availability: an analysis of the UNOS database.

Despite the widespread belief that donor organ availability varies around holidays and seasons, there is little empirical data supporting this long-held belief. Variations in donor heart availability may be of interest to patients and clinicians. The UNOS/OPTN registry was queried for all heart donations from October 1987 through March 2017. Daily heart donation rates were modeled nationally using Poisson regression including splines for year and day of the year. Seasonality was assessed using a likelihood ratio test for the spine terms for day of the year. The holiday effect was assessed using conditional logistic regression. Seasonal plots suggest a significant, although modest, increase in organ availability during the summer months, except for region 1. The regions with the highest amplitude were region 7 (peak: June 21, amplitude: 16.63%) and region 6 (peak: July 5, amplitude: 11.29%). There was no significant difference in the odds of heart donation when comparing holidays vs. non-holidays using national data (odds ratio [95% CI]: 1.01 [0.98, 1.03], P = 0.560) or any regional subsets. There was no observable correlation between donor heart availability and holidays. However, a significant seasonality effect was observed with higher donation rates occurring during warmer months.

Patterns of Cannabis Use in Patients With Cyclic Vomiting Syndrome.

BACKGROUND & AIMS: Some patients with cyclic vomiting syndrome (CVS) use cannabis to relieve stress and for its antiemetic properties. However, chronic cannabis use has been associated paradoxically with cannabinoid hyperemesis syndrome (CHS) and some patients with CVS are thought to have CHS. We sought to characterize patterns of cannabis use by patients with CVS and identify those who could be reclassified as having CHS. METHODS: We performed a cross-sectional study of 140 patients with CVS (72% female; mean age, 37 ± 13 y) seen at a specialized clinic. Patients were screened for cannabis use with the cannabis use disorder identification test. Patients were classified as regular (use ≥4 times/wk) or occasional users (<4 times/wk). RESULTS: Forty-one percent of patients were current cannabis users, with 21% reporting regular use. Regular users were more likely to be male and to report an anxiety diagnosis, and smoked cannabis with higher tetrahydrocannabinol content and for a longer duration. Most users reported that cannabis helped control CVS symptoms. Among all cannabis users, 50 of 57 (88%) reported that they had abstained for longer than 1 month, but only 1 user reported resolution of CVS episodes during the abstinence period. This patient subsequently resumed using cannabis but remains free of symptoms. CONCLUSIONS: Cannabis is used commonly among patients with CVS-patients report relief of symptoms with use. We found 21% of patients with CVS to be regular users, but only 1 met the Rome IV criteria for CHS. Longitudinal studies are needed to determine the relationships among cannabis use, hyperemesis, and mood symptoms.

Racial and Ethnic Variation Associated With Human Papillomavirus Genotype in Anal Dysplasia.

BACKGROUND: Human Papillomavirus (HPV) is known to cause dysplasia and cancer. In cervical disease, there are documented differences in prevalence of HPV genotypes among racial/ethnic groups. Little is known about prevalence of HPV genotypes in anal dysplasia. This study aimed to evaluate association between HPV genotypes and race/ethnicity in a racially heterogenous population with anal dysplasia. METHODS: This was a single-institution retrospective review of patients treated for anal dysplasia between 2008 and 2019. HPV genotype, obtained via anal swab testing, was recorded as HPV 16, HPV 18, or other non-16/18 high-risk (HR) HPV genotypes. Univariate and multivariate logistic regression analyses were used to evaluate the association between patient factors and HPV genotype. RESULTS: Of 517 patients meeting inclusion criteria, 46.8% identified as White, 37.1% as Black, 13.2% as Hispanic, and 2.9% as other/unknown. Race/ethnicity (P = 0.016) and sex (P < 0.001) were significantly associated with differences in prevalence of HPV genotypes. Black (odds ratio 1.56, 95% confidence interval 1.00-2.44) and male (odds ratio 2.35, 95% confidence interval 1.42-3.92) patients were significantly more likely to have non-16/18 HR HPV genotypes. CONCLUSIONS: In a racially and socioeconomically diverse cohort of patients with anal dysplasia, Black race and male sex were associated with increased likelihood of infection with a non-16/18 HR HPV genotype. Many of these genotypes are not covered by currently available vaccines. Further study is warranted to evaluate anal HPV genotypes in a larger cohort, as this may have important implications in HPV vaccination and anal dysplasia screening efforts.

Comparison of overall survival in gallbladder carcinoma at academic versus community cancer centers: An analysis of the National Cancer Data Base.

BACKGROUND AND OBJECTIVES: Gallbladder carcinoma (GBC) has a poor prognosis. Studies demonstrated that teaching facilities may provide a lower risk of mortality in patients undergoing pancreatic and colon resection vs nonteaching facilities. We hypothesized that survival rates are higher in academic cancer centers (ACCs) vs community cancer centers (CCCs). METHODS: Patients with all stages of GBC were identified from the National Cancer Database (2007-2012). Propensity score matching adjusted for selection bias. Descriptive statistics were calculated for all variables. Overall survival (OS) was compared by facility type (ACC vs CCC) and case volume (low vs high) via multivariable Cox proportional hazards regression. RESULTS: A total of 7967 patients met the inclusion criteria. Following propensity matching, 2801 patients were analyzed from each facility type. Median OS following surgery was higher for ACC (20.99 months, 95% confidence interval [CI], 19.61-22.64, P = .002) than CCC (17.68 months, 95% CI, 16.46-19.25). Following Cox modeling, GBC treatment at ACCs was a protective factor for OS (adjusted hazard ratio 0.876, 95% CI, 0.801-0.958, P = .004). DISCUSSION: GBC treatment at ACCs is an independent predictor of OS. High volume ACCs are associated with improved OS compared with low volume ACCs. The site of care and case volume in ACCs may contribute to improved survival outcomes.

Trends in the use of therapeutic plasma exchange in multiple myeloma.

INTRODUCTION: Therapeutic plasma exchange (TPE) is traditionally performed for hyperviscosity, neuropathy and to mitigate renal injury in the setting of high clonal free light chain burden in patients with multiple myeloma (MM) with unknown clinical benefit. MATERIALS AND METHODS: Retrospective study of adults ≥18 years with MM who received TPE in the in-patient setting in the United States from 1993 to 2015. We examined the temporal trends of TPE utilization in MM hospitalizations, hospital charges, in-hospital mortality, and length of hospitalization and the predictors of in-hospital mortality and length of hospitalizations. RESULTS: The number of MM-hospitalizations for TPE in adults increased significantly from 1993 to 2015 (1% in 1993-1999 to 2.1% in 2008-2015 of all MM discharges, P for trend <.0001). About 70% of TPE recipients had acute kidney injury (AKI). The median hospital charges increased 5-fold during the time period ($ 24 407 to $ 113 496; P for trend <.0001). In-hospital mortality decreased (17.5% (SE 2.66) in 1993-1997 to 8.7% (1.39) in 2007 to 2013) P for trend <.005) while the length of stay remained unchanged (11.2 days vs 11.9 days, P for trend 0.17). On adjusted analysis, significant predictors of in-hospital mortality among MM TPE recipients include, Charlson Comorbidity Index (CCI) (3 vs 2 adjusted odds ratio, aOR 2.16, 95% CI 1.26-3.71; P = .005), year (continuous) (aOR 0.93, 95% CI 0.90-0.96; P < .001) and race (other vs white; aOR 0.44, 95% CI 0.25-0.78; P = 0.004). CONCLUSIONS: There has been a substantial increase in the use and associated cost of TPE in hospitalized MM patients.