Compliance with recommended pneumococcal vaccination schedule in patients treated for rheumatoid arthritis: A retrospective cohort study in the Veterans Affairs population.

INTRODUCTION: Invasive pneumococcal disease (IPD) is a leading cause of death. Rheumatoid arthritis (RA) patients are at risk of IPD due to immunosuppressant medications. Up until 2022, two pneumococcal vaccines, the 13-valent Pneumococcal conjugate vaccine (PCV13) and pneumococcal polysaccharide vaccine (PPSV23), were recommended. Despite the recommendation change to give a single 20-valent PCV vaccine (PCV20), some still require multiple vaccinations. There is a need to identify barriers to vaccine uptake. METHODS: We conducted a retrospective cohort study to assess the on-time vaccination rates for PCV13 and PPSV23 in treated RA patients between 2010 and 2018 using national Veterans Affairs data. Patients > 18 years of age diagnosed with RA and newly initiated on RA treatment were included. Pneumococcal vaccine compliance was assessed by measuring on-time receipt of PCV13 and PPSV23 vaccinations. We identified factors using multivariate logistic regression and described the occurrence of these factors using descriptive statistics. RESULTS: A total of 39,243 patients were included in the study. Most patients were white (75.8 %), male (85.4 %), on methotrexate therapy (41.4 %). The average age was 62.3 years. The proportion of patients considered vaccine compliant is 43.9 %. The primary independent risk factors for vaccine non-compliance were black/African American race (Odds Ratio [OR] 1.26, 95 % Confidence Interval [CI] 1.19-1.34) or missing/unknown race (OR 1.45, 95 % CI 1.31-1.61), missing/unknown ethnicity (OR 1.21, 1.02-1.43), never married (OR 1.10, 95 % CI 1.02-1.19) or widowed (OR 1.23, 95 % CI 1.12-1.34), diagnosed with congestive heart failure (OR 1.10, 95 % CI 1.00-1.22), or dementia (OR 1.48, 95 % CI 1.16-1.91). The proportion of patients who were non-compliant in patients who were vaccine naïve was 32.1 % and the non-compliance rate for non-naïve patients was 65.3 %. CONCLUSIONS: Providers should identify barriers to pneumococcal vaccination in RA patients to improve compliance. Efforts to increase vaccination should be tailored to specific high-risk groups.

Melatonin and risk of mortality in subjects with aneurysmal subarachnoid hemorrhage.

BACKGROUND: Delayed cerebral ischemia (DCI) is a cause of morbidity associated with aneurysmal subarachnoid hemorrhage (aSAH). Neuroinflammation contributes to the development of DCI. Melatonin is a sleep-promoting hormone known to have cerebral anti-inflammatory properties. We hypothesized that synthetic melatonin (or the selective melatonin receptor agonist ramelteon) incidentally prescribed to improve sleep may lower the incidence of DCI among hospitalized aSAH patients. METHODS: Subjects with a Hunt and Hess Grade I-III were identified from a data registry involving all aSAH patients admitted to our hospital between January 2015 and September 1, 2018. A cohort of patients who received either melatonin or ramelteon during their hospitalization was compared to a matched cohort that did not receive these drugs. The primary endpoint was incidence of DCI. Secondary outcomes included modified Rankin score (mRS) at discharge, discharge destination, and mortality at 6 weeks from discharge. The two groups were compared using univariate analysis. P < 0.05 was considered significant. RESULTS: There was no significant difference in the incidence of DCI (15.8% vs. 16.9%, p = 1), discharge mRS (mRS 0-3: 51.3% vs. 45.1%, p = 0.59), discharge disposition (Home: 43.6% vs. 44.4, p = 0.47), or mortality (0% vs. 9.2%; p = 0.074) between the melatonin/ramelteon and non-melatonin groups. CONCLUSION: The use melatonin had no effect on DCI but may improve mortality in aSAH subjects. Prospective studies using a larger cohort are warranted to validate these findings.

Markedly elevated thyroglobulin levels in the preoperative thyroidectomy patient correlates with metastatic burden.

BACKGROUND: Thyroglobulin (Tg) is a marker of tumor recurrence during thyroid cancer follow-up. While helpful in the postoperative setting, the clinical significance of preoperative Tg measurements remains unclear. The aim of the study was to determine if preoperative Tg levels are indicative of underlying malignancy or burden of metastatic disease. METHODS: A retrospective review of a prospectively collected database at an academic medical center of all thyroidectomy patients with a measured preoperative Tg level was conducted. Patients were grouped by Tg level into quartiles for initial univariate analysis, followed by multivariable analysis of variance. RESULTS: Between 2007 and 2012, 611 patients met criteria. Quartile breakdown was as follows: ≤19 ng/mL, 19.1-54 ng/mL, 54.1-151 ng/mL, and >151 ng/mL. Patients' age and gender were equivalent. Hashimoto's thyroiditis was most common in the lowest Tg group (24% versus 11%-12%, P < 0.01). While cancer was more common in the low Tg, metastatic disease was most common in the high Tg group. Specimen weight increased with increasing Tg levels (P < 0.01). Body mass index, gland weight, cancer, and Hashimoto's and metastatic disease were entered into a multivariable analysis. Only gland weight and metastatic disease correlated with Tg levels (both P < 0.001). All patients with Tg > 5000 ng/mL had metastatic disease (n = 6). CONCLUSIONS: Although preoperative Tg levels are not associated with a diagnosis of cancer, they are associated with the presence of metastatic disease. All patients with a Tg > 5000 ng/mL had significant disease burden. In patients with concern for metastatic disease, preoperative serum Tg may be a useful marker to aid decision making.

Critical analysis of artificial teeth for endodontic teaching.

The purpose of this study was to evaluate the use of artificial teeth for endodontic teaching. A questionnaire was prepared and submitted to 18 professors of Endodontics from different Brazilian universities to evaluate the following features of five cloudy resin artificial teeth: internal and external anatomy; coronal chambers regarding their size, shape and canal path; root canal regarding their size, shape and position; fulfillment of the pulp chamber and root canals by considering the texture, quantity, color, and ease of handling; resin hardness and visualization of the radiographic image. The results presented favorable opinions, in terms of internal and external anatomy, coronal pulp chambers and root canal and handling and radiographic imaging. The contents of the pulp space and hardness of the teeth were considered satisfactory. The average grade assigned to the artificial tooth quality was 8.4, in a 0-10 scale. In conclusion, the artificial teeth have potential to replace the natural teeth in endodontic teaching; however, improvements are still necessary to reach a better quality model.

Critical analysis of artificial teeth for endodontic teaching

The purpose of this study was to evaluate the use of artificial teeth for endodontic teaching. A questionnaire was prepared and submitted to 18 professors of Endodontics from different Brazilian universities to evaluate the following features of five cloudy resin artificial teeth: internal and external anatomy; coronal chambers regarding their size, shape and canal path; root canal regarding their size, shape and position; fulfillment of the pulp chamber and root canals by considering the texture, quantity, color, and ease of handling; resin hardness and visualization of the radiographic image. The results presented favorable opinions, in terms of internal and external anatomy, coronal pulp chambers and root canal and handling and radiographic imaging. The contents of the pulp space and hardness of the teeth were considered satisfactory. The average grade assigned to the artificial tooth quality was 8.4, in a 0-10 scale. In conclusion, the artificial teeth have potential to replace the natural teeth in endodontic teaching; however, improvements are still necessary to reach a better quality model.