Systematic review and meta-analysis of the etiology of heavy menstrual bleeding in 2,770 adolescent females.

BACKGROUND: Adolescent heavy menstrual bleeding(HMB), menorrhagia or abnormal uterine bleeding commonly occur in adolescent women. The differential diagnosis can be challenging. The pneumonic: PALM-COEIN (polyp, adenomyosis, leiomyoma, malignancy and hyperplasia, coagulopathy, ovulatory dysfunction, endometrial, iatrogenic, and not yet classified), is commonly used but it does not stratify as to the likelihood of a disorder. We have sought to develop a probability-based differential diagnosis for Adolescent HMB, menorrhagia or abnormal uterine bleeding. METHODS: A comprehensive literature search was conducted using PubMed, EMBASE, and SCOPUS databases. Case series describing adolescents from 10-19 years of age with HMB, menorrhagia or abnormal uterine bleeding was acceptable if: more than 10 patients were included; editorials, case reports, and secondary sources such as review articles, or book chapters were excluded. No language filter was used, but an English abstract was required. The etiology of HMB, menorrhagia or abnormal uterine bleeding, and the country of origin was extracted from articles that met inclusion criteria. Cumulative rate estimates were determined by Bayesian probability modeling. RESULTS: Seventeen full text articles were reviewed in detail; 2,770 patients were included. The most frequent causes of HMB were Ovarian Uterine Disorders (23.7%; 95% CredI 22-25.5%), Coagulation Disorders (19.4%; 95% CredI 17.8-21.1%), and Platelet Disorders (6.23%; 95% CredI 5.27-7.27%) with 45.9% (95% CredI 43.8-47.%9) of the cases of indeterminate origin. CONCLUSIONS: The leading causes of HMB in healthy adolescent females were varied. The sub-analysis identified distinct etiologies, suggesting that multiple factors must be considered in the evaluation of HMB. While PALM-COEIN (polyp, adenomyosis, leiomyoma, malignancy and hyperplasia, coagulopathy, ovulatory dysfunction, endometrial, iatrogenic, and not yet classified) provides us with a comprehensive picture of the possible causes of HMB in females, this systematic review assigns probabilities to the etiologies of HMB in adolescent females, providing physicians with a more focused and efficient pathway to diagnosis.

Law Enforcement and Patient Privacy Among Survivors of Violence: A Nationwide Mixed-Methods Study.

INTRODUCTION: During the emergent treatment of violently injured patients, law enforcement (LE) officers and health care providers frequently interact. Both have duties to protect patient health, rights, and public health, however, the balance of these duties may feel at odds. The purpose of this study is to assess hospital-based violence intervention program (HVIP) representatives' experiences with LE officers among survivors of violence and the impact of hospital policies on interactions with LE officers. MATERIALS AND METHODS: A nationwide survey was distributed to the 35 HVIPs that form the Health Alliance for Violence Intervention. Data regarding respondent affiliation, programs, and perceptions of hospital policies outlining LE activity were collected. Follow-up video interviews were open coded and qualitatively analyzed using grounded theory. RESULTS: Respondents from 32 HVIPs completed the survey (91%), and 22 interviews (63%) were conducted. Common themes from interviews were: police-patient interactions; racism, bias, and victims' treatment as suspects; and training and education. Only 39% of respondents knew that policies existed and were familiar with them. Most representatives believed their hospitals' existing policies were inadequate, ineffective, or biased. Programs that reported good working relationships with LE officers offered insight on how their programs maintain these partnerships and work with LE officers towards a common goal. CONCLUSIONS: Unclear or inadequate policies relating to LE activity may jeopardize the health and privacy of violently injured patients. Primary areas identified for improvement include clarifying and revising hospital policies, education of staff and LE officers, and improved communication between health care providers and LE officers to better protect patient rights.

Cre-mediated autoexcision of selectable marker genes in soybean, cotton, canola and maize transgenic plants.

KEY MESSAGE: Efficient selectable marker gene autoexcision in transgenic plants of soybean, cotton, canola, and maize is achieved by effective Cre recombinase expression. Selectable marker genes are often required for efficient generation of transgenic plants in plant transformation but are not desired once the transgenic events are obtained. We have developed Cre/loxP autoexcision systems to remove selectable marker genes in soybean, cotton, canola and maize. We tested a set of vectors with diverse promoters and identified promising promoters to drive cre expression for each of the four crops. We evaluated both the efficiency of generating primary transgenic events with low transgene copy numbers, and the frequency of marker-free progeny in the next generation. The best performing vectors gave no obvious decrease in the transformation frequency in each crop and generated homozygous marker-free progeny in the next generation. We found that effective expression of Cre recombinase for marker gene autoexcision can be species dependent. Among the vectors tested, the best autoexcision frequency (41%) in soybean transformation came from using the soybean RSP1 promoter for cre expression. The cre gene expressed by soybean RSP1 promoter with an Arabidopsis AtpE intron delivered the best autoexcision frequency (69%) in cotton transformation. The cre gene expressed by the embryo-specific eUSP88 promoter from Vicia faba conferred the best marker excision frequency (32%) in canola transformation. Finally, the cre gene expressed by the rice CDC45-1 promoter resulted in 44% autoexcision in maize transformation. The Cre/loxP recombinase system enables the generation of selectable marker-free transgenic plants for commercial product development in four agriculturally important crops and provides further improvement opportunities for more specific and better marker excision efficiency.

The Case for Integrating Medical-Legal Partnerships Into Trauma Care.

INTRODUCTION: Medical-legal needs are health-harming adverse social conditions with a legal remedy. Medical-legal partnerships in primary care settings have been proposed to address these needs for at-risk patients already seeking medical care. Our hypothesis is that trauma patients represent a unique population that may be more likely to have baseline medical-legal needs. METHODS: A trauma-specific medical-legal needs survey was developed. Adult trauma patients who were able to give consent and were admitted to our urban Level I hospital were surveyed. Medical-legal needs were tabulated from the surveys. Those patients in the top decile of medical-legal needs were categorized as having a High Burden of medical-legal needs. Multivariate logistic regression was used to identify those independent risk factors for having a High Burden of medical-legal needs. RESULTS: A total of 566 participants completed the survey (78.2% response rate). The mean number of medical-legal needs for our population was 2.5 (SD = 3.1). 73% of our respondents had at least one medical-legal need. The most common needs were Housing (n = 229, 40%) and Education/Employment (n = 223, 39%). Older age (aOR = 3.01, 95% CI 1.2-8.1, P = 0.02), being separated or divorced (aOR = 4.25, 95% CI 1.2-14.0, P = 0.02), self perceived poor health (aOR = 8.4, 95% CI 2.61-26.86, P < 0.001), penetrating mechanism of injury (aOR = 2.52, 95% CI 1.22-5.2, P = 0.01), and having been admitted to the hospital for a longer period of time (aOR = 5.48, 95% CI 1.55-19.4, P = 0.008) were all independently associated with a High Burden of medical-legal needs. CONCLUSIONS: Trauma patients have a high baseline burden of medical-legal needs. Medical-legal partnerships embedded in trauma teams may offer an innovative strategy to help address long-term health outcomes in a highly vulnerable population that would not otherwise have contact with the healthcare system.

Measurement of Trauma Caregiver Stress: Validation of Heart rate variability in a Real-World Surgical Setting.

BACKGROUND: Acute stress is a potentially modifiable risk-factor that contributes to errors in trauma care. Research on stress mitigation is limited by the lack of a validated objective measure of surgeon stress. We sought to validate HRV in a real-world surgical setting by comparison to the Subjective Units of Distress Score (SUDS), and correlation with self-reported peak stress moments. METHODS: Attending and resident surgeons on the trauma team at a Level I Trauma Center wore armbands to measure HRV. Stress-associated blunting of HRV was analyzed using the standard deviation of N-N intervals (SDNN) and the root mean square of successive differences . Perceived stress was measured with the SUDS at random intervals and at perceived stress peaks. SUDS and HRV metrics were compared with a mixed effect regression model. Correlation between binned SUDS quartiles and HRV was evaluated. HRV at reported peak-stress moments were compared to shift baseline values. RESULTS: Twelve participants were monitored for 340 h, producing 135 SUDS responses and 65 peak-stress time points. Regression analysis demonstrated no correlation between HRV and SUDS. With a binned approach, decreased SDNN was associated with an elevated SUDS (P = 0.03). The self-identified peak-stress moments correlated with decreases in both SDNN and root mean square of successive differences (P = 0.02; P < 0.01). CONCLUSIONS: HRV by SDNN analysis correlated with heightened perceived stress, supporting its validity as a measure. However, the wide, frequent variation of HRV tracings within subjects, the sensitivity of HRV to of analytic technique, and the impact of confounders may limit its utility as an education or research tool. LEVEL OF EVIDENCE: V Diagnostic test.

Generalized eczematous dermatitis and pruritus responsive to dupilumab in a patient with immune dysregulation, polyendocrinopathy, enteropathy, X-linked (IPEX) syndrome.

This case describes a patient with immune dysregulation, polyendocrinopathy, enteropathy, X-linked (IPEX) syndrome with diffuse eczematous dermatitis and severe, intractable pruritus. Despite a bone marrow transplant and immunosuppressive therapy, his skin findings and pruritus persisted. Off-label dupilumab provided significant improvement and almost complete clearance of the dermatitis and pruritus. This is the first known report of dupilumab being used in a patient with IPEX syndrome.

A Novel Approach to ICU Survivor Care: A Population Health Quality Improvement Project.

OBJECTIVES: Deliver a novel interdisciplinary care process for ICU survivor care and their primary family caregivers, and assess mortality, readmission rates, and economic impact compared with usual care. DESIGN: Population health quality improvement comparative study with retrospective data analysis. SETTING: A single tertiary care rural hospital with medical/surgical, neuroscience, trauma, and cardiac ICUs. PATIENTS: ICU survivors. INTERVENTIONS: Reorganization of existing post discharge health care delivery resources to form an ICU survivor clinic care process and compare this new process to post discharge usual care process. MEASUREMENTS AND MAIN RESULTS: Demographic data, Acute Physiology and Chronic Health Evaluation IV scores, and Charlson Comorbidity Index scores were extracted from the electronic health record. Additional data was extracted from the care manager database. Economic data were extracted from the Geisinger Health Plan database and analyzed by a health economist. During 13-month period analyzed, patients in the ICU survivor care had reduced mortality compared with usual care, as determined by the Kaplan-Meier method (ICU survivor care 0.89 vs usual care 0.71; log-rank p = 0.0108) and risk-adjusted stabilized inverse probability of treatment weighting (hazard ratio, 0.157; 95% CI, 0.058-0.427). Readmission for ICU survivor care versus usual care: at 30 days (10.4% vs 26.3%; stabilized inverse probability of treatment weighting hazard ratio, 0.539; 95% CI, 0.224-1.297) and at 60 days (16.7% vs 34.7%; stabilized inverse probability of treatment weighting hazard ratio, 0.525; 95% CI, 0.240-1.145). Financial data analysis indicates estimated annual cost savings to Geisinger Health Plan ranges from $247,052 to $424,846 during the time period analyzed. CONCLUSIONS: Our ICU survivor care process results in decreased mortality and a net annual cost savings to the insurer compared with usual care processes. There was no statistically significant difference in readmission rates.

Testing the efficacy of a hospital-based violence intervention programme: protocol and design.

INTRODUCTION: Hospital-based violence intervention programmes (HBVIPs) are a promising strategy to reduce trauma recidivism and promote safety among victims of violent injury. While previous studies have demonstrated cost-effectiveness and positive impact on the lives of victims, there are a number of key limitations in the study designs of this evidence base. This study seeks to address the methodological shortcomings of previous research, determine the efficacy of HBVIPs using a randomised control study design, and provide a better understanding of successful service allocation within an HBVIP. METHODS AND ANALYSIS: The current study is 1 of 12 demonstration projects being implemented around the country with the purpose of bolstering the ability to provide effective, culturally appropriate and trauma-informed services for boys and men harmed by violence. We propose a randomised control trial in which male victims of violence receive one of two interventions: treatment as usual versus enhanced services. The purpose is to determine which intervention leads to reductions in trauma recidivism over the period of 1 year from contact with the programme. Differences will also be monitored on measures of mental health, quality of life and attitudes towards violence. Analyses employed will include Kaplan-Meier analysis and Cox proportional hazards regression with death and recidivism being the outcomes of interest. ETHICS AND DISSEMINATION: Study procedures have been approved by the Institutional Review Boards of the University at Buffalo and four hospitals. Results will be submitted for publication in peer-reviewed journals.

Cell Lines as Biological Models: Practical Steps for More Reliable Research.

Research in toxicology relies on in vitro models such as cell lines. These living models are prone to change and may be described in publications with insufficient information or quality control testing. This article sets out recommendations to improve the reliability of cell-based research.

Coronary Artery Disease Association With Arterial Calcifications on Routine Hand Radiographs.

PURPOSE: Arterial calcifications in the lower extremity, chest, and cardiac vessels have been linked to coronary artery disease (CAD). However, the relation between arterial calcifications observed on routine hand and upper-extremity radiographs and atherosclerosis has not been determined. This study examined whether arterial calcifications found on hand radiographs are associated with CAD. METHODS: A record review from a single institution identified 345 patients with both hand radiographs and CAD screening with cardiac stress testing or coronary angiography. Patients with chronic kidney disease, end-stage renal disease, or incomplete hand films were excluded. We reviewed x-rays for findings of arterial calcifications. Cardiac testing results were used to establish a baseline diagnosis of CAD. We made group comparisons and employed multivariable logistic regression to evaluate the association between upper-extremity calcification and CAD. RESULTS: A total of 210 patients met inclusion criteria: 155 with CAD and 55 without it. Mean age was 72 years, body mass index was 28.8, and 54% were male. Patients had comorbidities of hypertension (91%), hyperlipidemia (87%), diabetes (39%), cerebrovascular accident (9%), and a history of tobacco use (53%). Of 155 CAD patients, 67 had arterial calcifications on hand radiographs (43%), compared with 6 of 55 without it (11%). In a multivariable model controlling for sex, hyperlipidemia, and diabetes, the presence of arterial calcifications on hand plain films indicated a 6.2-fold increased odds of CAD. CONCLUSIONS: The current data demonstrate that arterial calcifications on hand radiographs are independently associated with CAD. This may represent an opportunity to the treating physician as a point of referral or investigation for underlying or occult CAD. TYPE OF STUDY/LEVEL OF EVIDENCE: Prevalence III.

Authentication of M14 melanoma cell line proves misidentification of MDA-MB-435 breast cancer cell line.

A variety of analytical approaches have indicated that melanoma cell line UCLA-SO-M14 (M14) and breast carcinoma cell line MDA-MB-435 originate from a common donor. This indicates that at some point in the past, one of these cell lines became misidentified, meaning that it ceased to correspond to the reported donor and instead became falsely identified (through cross-contamination or other means) as a cell line from a different donor. Initial studies concluded that MDA-MB-435 was the misidentified cell line and M14 was the authentic cell line, although contradictory evidence has been published, resulting in further confusion. To address this question, we obtained early samples of the melanoma cell line (M14), a lymphoblastoid cell line from the same donor (ML14), and donor serum preserved at the originator's institution. M14 samples were cryopreserved in December 1975, before MDA-MB-435 cells were established in culture. Through a series of molecular characterizations, including short tandem repeat (STR) profiling and cytogenetic analysis, we demonstrated that later samples of M14 and MDA-MB-435 correspond to samples of M14 frozen in 1975, to the lymphoblastoid cell line ML14, and to the melanoma donor's STR profile, sex and blood type. This work demonstrates conclusively that M14 is the authentic cell line and MDA-MB-435 is misidentified. With clear provenance information and authentication testing of early samples, it is possible to resolve debates regarding the origins of problematic cell lines that are widely used in cancer research.

Reduction in Overt and Silent Stroke Recurrence Rate Following Cerebral Revascularization Surgery in Children with Sickle Cell Disease and Severe Cerebral Vasculopathy.

BACKGROUND: Children with sickle cell disease (SCD) and moyamoya may benefit from indirect cerebral revascularization surgery in addition to chronic blood transfusion therapy for infarct prevention. We sought to compare overt and silent infarct recurrence rates in children with SCD undergoing revascularization. METHODS: This was a retrospective cohort study of all children with SCD and moyamoya treated at two children's hospitals. Clinical events and imaging studies were reviewed. RESULTS: Twenty-seven children with SCD and confirmed moyamoya receiving chronic transfusion therapy were identified, of whom 12 underwent indirect cerebral revascularization. Two subjects had postoperative transient ischemic attacks and another had a subarachnoid blood collection, none of which caused permanent consequences. Two subjects had surgical wound infections. Among these 12 children, the rate of overt and silent infarct recurrence decreased from 13.4 infarcts/100 patient-years before revascularization to 0 infarcts/100 patient-years after revascularization (P = 0.0057); the postrevascularization infarct recurrence rate was also significantly lower than the overall infarct recurrence of 8.87 infarcts/100 patient-years in 15 children without cerebral revascularization (P = 0.025). CONCLUSIONS: The rate of overt and silent infarct recurrence was significantly lower following indirect cerebral revascularization. A prospective study of cerebral revascularization in children with SCD is needed.

New Approaches for Working with Children and Families Involved in Family Treatment Drug Courts: Findings from the Children Affected by Methamphetamine Program.

This is a descriptive study of the Children Affected by Methamphetamine (CAM) grant program, a federally funded effort to improve outcomes through the addition of targeted interventions for 1,940 families, including 2,596 adults and 4,245 children involved in 12 diverse Family Treatment Drug Courts (FTDCs) located across six U.S. states. The majority were children of parents with a primary methamphetamine use disorder. Findings reflect grantees' reporting on 18 performance indicators of child safety and permanency, adult recovery, and family well-being. Additional information gleaned from grantees' biannual reports provides insights about program implementation. Results, drawn from this large and complex dataset, indicate that comprehensively addressing families' needs is associated with better outcomes than those experienced by similarly situated families in grantees' communities and the nation overall. In addition to describing common program components and outcomes, this article presents important lessons learned about implementing evidence-based children's services in the FTDC context, as well as future directions for research and evaluation in this arena.

What medical-legal partnerships can do for trauma patients and trauma care.

ABSTRACT: Trauma patients are particularly vulnerable to the impact of preexisting social and legal determinants of health postinjury. Trauma patients have a wide range of legal needs, including housing, employment, debt, insurance coverage, and access to federal and state benefits. Legal support could provide vital assistance to address the social determinants of health for injured patients. Medical legal partnerships (MLPs) embed legal professionals within health care teams to improve health by addressing legal needs that affect health. Medical legal partnerships have a successful track record in oncology, human immunodeficiency virus/acquired immune deficiency syndrome, and pediatrics, but have been little used in trauma. We conducted a scoping review to describe the role of MLPs and their potential to improve health outcomes for patients with traumatic injuries. We found that MLPs use legal remedies to address a variety of social and structural conditions that could affect patient health across several patient populations, such as children with asthma and patients with cancer. Legal intervention can assist patients in obtaining stable and healthy housing, employment opportunities, debt relief, access to public benefits, and immigration assistance. Medical legal partnership structure varies across institutions. In some, MLP lawyers are employed directly by a health care institution. In others, MLPs function as partnerships between a health system and an external legal organization. Medical legal partnerships have been found to reduce hospital readmissions, increase treatment utilization by patients, decrease patient stress levels, and benefit health systems financially. This scoping review outlines the potential of MLPs to improve outcomes for injured patients. Establishing trauma-focused MLPs could be a feasible intervention for trauma centers around the country seeking to improve health outcomes and reduce disparities for injured patients.

Integration of Medical Legal Services into a Hospital-Based Violence Intervention Program: A Survey and Interview-Based Provider Needs Assessment.

BACKGROUND: Violent injury among trauma surgery patients is strongly associated with exposure to harmful social determinants of health and negative long-term health outcomes. Medical-legal partnerships in other settings successfully provide patients with legal services to address similar health-harming legal needs and may offer a promising model for the care of violently-injured patients. STUDY DESIGN: An electronic survey tool was distributed to clinicians and staff affiliated with the hospital-based violence intervention program at a single urban level one trauma center. Semi-structured follow up interviews were conducted with participants, and interviews were coded using thematic analysis and grounded theory. RESULTS: Participants reported many health-harming legal needs among their violently injured patients. The most commonly-identified needs were: health insurance denials (62.5%); difficulty accessing crime victims compensation funds (56.3%); trouble accessing official documents (50%); and problems with non-SSDI public benefits (50%). Participants reported inconsistent methods for learning about and responding to patients' health-harming legal needs. The most common barriers to addressing these needs included: lack of awareness that a lawyer could help with the issue (68.8%); prioritization of other needs (68.8%); previous negative legal experiences (62.5%); and cost (62.5%). Identified needs encompass issues traditionally-addressed by MLPs as well as more novel challenges faced by violent injury survivors. CONCLUSION: This survey and interview-based study identifies complex health-harming legal needs present among violently-injured trauma surgery patients. Medical-legal partnerships specially-designed for the setting of violent injury appear well-suited to meet these needs, potentially reducing risk of violent re-injury, long-term negative health outcomes, and healthcare system costs. LEVEL OF EVIDENCE: Level IV / Prognostic and Epidemiological.

Structural and functional characterization of triketone dioxygenase from Oryza Sativa.

The transgenic expression of rice triketone dioxygenase (TDO; also known as HIS1) can provide protection from triketone herbicides to susceptible dicot crops such as soybean. Triketones are phytotoxic inhibitors of plant hydroxyphenylpyruvate dioxygenases (HPPD). The TDO gene codes for an iron/2-oxoglutarate-dependent oxidoreductase. We obtained an X-ray crystal structure of TDO using SeMet-SAD phasing to 3.16 Å resolution. The structure reveals that TDO possesses a fold like that of Arabidopsis thaliana 2-oxoglutarate­iron-dependent oxygenase anthocyanidin synthase (ANS). Unlike ANS, this TDO structure lacks bound metals or cofactors, and we propose this is because the disordered flexible loop over the active site is sterically constrained from folding properly in the crystal lattice. A combination of mass spectrometry, nuclear magnetic resonance, and enzyme activity studies indicate that rice TDO oxidizes mesotrione in a series of steps; first producing 5-hydroxy-mesotrione and then oxy-mesotrione. Evidence suggests that 5-hydroxy-mesotrione is a much weaker inhibitor of HPPD than mesotrione, and oxy-mesotrione has virtually no inhibitory activity. Of the close homologues which have been tested, only corn and rice TDO have enzymatic activity and the ability to protect plants from mesotrione. Correlating sequence and structure has identified four amino acids necessary for TDO activity. Introducing these four amino acids imparts activity to a mesotrione-inactive TDO-like protein from sorghum, which may expand triketone herbicide resistance in new crop species.

Antiviral cellular therapy for enhancing T-cell reconstitution before or after hematopoietic stem cell transplantation (ACES): a two-arm, open label phase II interventional trial of pediatric patients with risk factor assessment.

Viral infections remain a major risk in immunocompromised pediatric patients, and virus-specific T cell (VST) therapy has been successful for treatment of refractory viral infections in prior studies. We performed a phase II multicenter study (NCT03475212) for the treatment of pediatric patients with inborn errors of immunity and/or post allogeneic hematopoietic stem cell transplant with refractory viral infections using partially-HLA matched VSTs targeting cytomegalovirus, Epstein-Barr virus, or adenovirus. Primary endpoints were feasibility, safety, and clinical responses (>1 log reduction in viremia at 28 days). Secondary endpoints were reconstitution of antiviral immunity and persistence of the infused VSTs. Suitable VST products were identified for 75 of 77 clinical queries. Clinical responses were achieved in 29 of 47 (62%) of patients post-HSCT including 73% of patients evaluable at 1-month post-infusion, meeting the primary efficacy endpoint (>52%). Secondary graft rejection occurred in one child following VST infusion as described in a companion article. Corticosteroids, graft-versus-host disease, transplant-associated thrombotic microangiopathy, and eculizumab treatment correlated with poor response, while uptrending absolute lymphocyte and CD8 T cell counts correlated with good response. This study highlights key clinical factors that impact response to VSTs and demonstrates the feasibility and efficacy of this therapy in pediatric HSCT.

Cumulative incidence of cancer after solid organ transplantation.

BACKGROUND: Solid organ transplantation recipients have elevated cancer incidence. Estimates of absolute cancer risk after transplantation can inform prevention and screening. METHODS: The Transplant Cancer Match Study links the US transplantation registry with 14 state/regional cancer registries. The authors used nonparametric competing risk methods to estimate the cumulative incidence of cancer after transplantation for 2 periods (1987-1999 and 2000-2008). For recipients from 2000 to 2008, the 5-year cumulative incidence, stratified by organ, sex, and age at transplantation, was estimated for 6 preventable or screen-detectable cancers. For comparison, the 5-year cumulative incidence was calculated for the same cancers in the general population at representative ages using Surveillance, Epidemiology, and End Results data. RESULTS: Among 164,156 recipients, 8520 incident cancers were identified. The absolute cancer risk was slightly higher for recipients during the period from 2000 to 2008 than during the period from 1987 to 1999 (5-year cumulative incidence: 4.4% vs. 4.2%; P = .006); this difference arose from the decreasing risk of competing events (5-year cumulative incidence of death, graft failure, or retransplantation: 26.6% vs. 31.9%; P < .001). From 2000 to 2008, the 5-year cumulative incidence of non-Hodgkin lymphoma was highest at extremes of age, especially in thoracic organ recipients (ages 0-34 years: range, 1.74%-3.28%; aged >50 years; range, 0.36%-2.22%). For recipients aged >50 years, the 5-year cumulative incidence was higher for colorectal cancer (range, 0.33%-1.94%) than for the general population at the recommended screening age (aged 50 years: range, 0.25%-0.33%). For recipients aged >50 years, the 5-year cumulative incidence was high for lung cancer among thoracic organ recipients (range, 1.16%-3.87%) and for kidney cancer among kidney recipients (range, 0.53%-0.84%). The 5-year cumulative incidence for prostate cancer and breast cancer was similar or lower in transplantation recipients than at the recommended ages of screening in the general population. CONCLUSIONS: Subgroups of transplantation recipients have a high absolute risk of some cancers and may benefit from targeted prevention or screening.

Timing of intracranial hypertension following severe traumatic brain injury.

BACKGROUND: We asked whether continuous intracranial pressure (ICP) monitoring data could provide objective measures of the degree and timing of intracranial hypertension (ICH) in the first week of neurotrauma critical care and whether such data could be linked to outcome. METHODS: We enrolled adult (>17 years old) patients admitted to our Level I trauma center within 6 h of severe TBI. ICP data were automatically captured and ICP 5-minute means were grouped into 12-hour time periods from admission (hour 0) to >7 days (hour 180). Means, maximum, percent time (% time), and pressure-times-time dose (PTD, mmHg h) of ICP >20 mmHg and >30 mmHg were calculated for each time period. RESULTS: From 2008 to 2010, we enrolled 191 patients. Only 2.1% had no episodes of ICH. The timing of maximum PTD20 was relatively equally distributed across the 15 time periods. Median ICP, PTD20, %time20, and %time30 were all significantly higher in the 84-180 h time period than the 0-84 h time period. Stratified by functional outcome, those with poor functional outcome had significantly more ICH in hours 84-180. Multivariate analysis revealed that, after 84 h of monitoring, every 5% increase in PTD20 was independently associated with 21% higher odds of having a poor functional outcome (adjusted odds ratio = 1.21, 95% CI 1.02-1.42, p = 0.03). CONCLUSIONS: Although early elevations in ICP occur, ICPs are the highest later in the hospital course than previously understood, and temporal patterns of ICP elevation are associated with functional outcome. Understanding this temporal nature of secondary insults has significant implications for management.

Metabolic and bariatric surgery for obesity in Prader Willi syndrome: systematic review and meta-analysis.

Obesity is the leading cause of morbidity and mortality in patients with Prader-Willi Syndrome (PWS). Our objective was to compare changes in body mass index (BMI) after metabolic and bariatric surgery (MBS) for the treatment of obesity (BMI ≥35 kg/m2) in PWS. A systematic review of MBS in PWS was performed using PubMed, Embase, and Cochrane Central, identifying 254 citations. Sixty-seven patients from 22 articles met criteria for inclusion in the meta-analysis. Patients were organized into 3 groups: laparoscopic sleeve gastrectomy (LSG), gastric bypass (GB), and biliopancreatic diversion (BPD). No mortality within 1 year was reported in any of the 3 groups after a primary MBS operation. All groups experienced a significant decrease in BMI at 1 year with a mean reduction in BMI of 14.7 kg/m2 (P < .001). The LSG groups (n = 26) showed significant change from baseline in years 1, 2, and 3 (P value at year 3 = .002) but did not show significance in years 5, 7, and 10. The GB group (n = 10) showed a significant reduction in BMI of 12.1 kg/m2 in the first 2 years (P = .001). The BPD group (n = 28) had a significant reduction in BMI through 7 years with an average reduction of 10.7 kg/m2 (P = .02) at year 7. Individuals with PWS who underwent MBS had significant BMI reduction sustained in the LSG, GB, and BPD groups for 3, 2, and 7 years, respectively. No deaths within 1 year of these primary MBS operations were reported in this study or any other publication.