Perspectives From the RadDiscord Annual Survey: Overview of the Top Study Tools and Evaluation of Study Time and Various Resources.

RATIONALE AND OBJECTIVES: Each year, senior radiology residents take the American Board of Radiology Qualifying (Core) exam to evaluate competency. Approximately 10% of first-time examinees will fail this exam (1). Understanding factors that contribute to success will help residency program directors and trainees prepare for future exams. RadDiscord (www.raddiscord.org), an international radiology educational community, is in the unique position to evaluate different study materials and resources. The goal of this paper is to report the results from the RadDiscord survey and analyze the factors that correlate with higher exam performance and passing. MATERIALS AND METHODS: Following the February 2021, June 2021, and June 2022 exams, RadDiscord members were provided an anonymous survey, collecting information on study resources and exam scores. The collected data were analyzed using various statistical methods. Both descriptive and inferential analyses were performed. RESULTS: A total of 318 residents responded (95% passed). Significant variability in Qualifying (Core) exam performance and perceived quality of internal didactics existed between program types. Residents who did less than 2000 practice questions performed lower on the exam. The Diagnostic Radiology In-Training (DXIT) exam was the most predictive for passing and performance. Qualifying (Core) exam performance negatively correlated with study time, though certain residents did receive some benefit from study time. CONCLUSION: Many factors correlate with passing and Qualifying (Core) exam performance. Residency programs with fewer resources should consider alternative ways to support residents beyond offering study time. Residents who complete at least 2000 practice questions are more likely to pass and DXIT results can be a useful gauge to identify exam readiness.

Near-infrared spectroscopy for kidney oxygen monitoring in a porcine model of hemorrhagic shock, hemodilution, and REBOA.

Acute kidney injury is a common complication of trauma and hemorrhagic shock. In a porcine model of hemorrhagic shock, resuscitative endovascular balloon aortic occlusion (REBOA) and hemodilution, we hypothesized that invasive kidney oxygen concentration measurements would correlate more strongly with noninvasive near infra-red spectroscopy (NIRS) oxygen saturation measurements when cutaneous sensors were placed over the kidney under ultrasound guidance compared to placement over the thigh muscle and subcutaneous tissue. Eight anesthetized swine underwent hemorrhagic shock 4 of which were resuscitated with intravenous fluids prior to the return of shed blood (Hemodilution protocol) and 4 of which underwent REBOA prior to resuscitation and return of shed blood (REBOA protocol). There was a moderate correlation between the NIRS and kidney tissue oxygen measurements (r = 0.61 p < 0.001; r = 0.67 p < 0.001; r = 0.66 p < 0.001for left kidney, right kidney, and thigh NIRS respectively). When the animals were separated by protocol, the Hemodilution group showed a weak or nonsignificant correlation between NIRS and kidney tissue oxygen measurements (r = 0.10 p < 0.001; r = 0.01 p = 0.1007; r = 0.28 p < 0.001 for left kidney, right kidney, and thigh NIRS respectively). This contrasts with the REBOA group, where left and right kidney as well as thigh NIRS were moderately correlated with kidney tissue oxygen (r = 0.71 p < 0.001; r = 0.74 p < 0.001; r = 0.70 p < 0.001; for left kidney, right kidney, and thigh NIRS respectively). There was a strong correlation between both kidney NIRS signals and thigh NIRS measurements (r = 0.85 p < 0.001; r = 0.88 p < 0.001;for left kidney vs thigh and right kidney vs thigh respectively). There was also a strong correlation between left and right kidney NIRS (r = 0.90 p < 0.001). These relationships were maintained regardless of the resuscitation protocol. These results suggest that kidney NIRS measurements were more closely related to thigh NIRS measurements than invasive kidney tissue oxygen concentration.

Longitudinal analysis of cigar use patterns among US youth and adults, 2013-2019.

BACKGROUND: Cigars are available in a range of pack quantities, which contrasts regulations requiring cigarettes to be sold in packs of 20 or greater. Smaller packages may be associated with increases in initiation while larger packs may lead consumers to smoke more. The purpose of this study was to inform pack quantity regulations by examining whether usual cigar pack quantity purchased was associated with use, initiation, and discontinuation among youth and adults for four cigar types: premium cigars, large cigars, cigarillos, and filtered cigars. METHODS: We analyzed waves 1-5 (2013-2019) of the adult and waves 2-5 (2014-2019) of the youth Population Assessment of Tobacco and Health (PATH) Study. Samples included those responding to the item on pack quantity and providing data at all waves (adults: premium cigars [N = 536], large cigars [N = 1,272], cigarillos [N = 3,504], filtered cigars [N = 1,281]; youth: premium cigars [N = 55], large cigars [N = 217], cigarillos [N = 1514], filtered cigars [N = 266]). Generalized estimating equation models examined the population-averaged effects of pack quantity on cigar use, initiation, and discontinuation. RESULTS: Adult pack quantity was positively associated with the days used per month for premium cigars (b: 0.23, 95% CI: 0.11, 0.34), large cigars (b: 0.17, 95% CI: 0.08, 0.25), cigarillos (b: 0.12, 95% CI: 0.003, 0.24), and filtered cigars (b: 0.07, 95% CI: 0.04, 0.10), and positively associated with amount smoked per day for all cigar types. Youth pack quantity was positively associated with days used per month for premium cigars (b: 0.88, 95% CI: 0.33, 1.43), large cigars (b: 0.79, 95% CI: 0.43, 1.15), and cigarillos (b: 0.17, 95% CI: 0.01, 0.34). Adult initiation was associated with pack quantity for filtered cigars (b: -2.22, 95% CI: -4.29, -0.13), as those who initiated purchased smaller pack quantities compared to those who did not initiate that wave. Pack quantity was not associated with discontinuation for adults or youth. CONCLUSIONS: Cigar use increased as usual pack quantity purchased increased across cigar types for youth and adults. Small increases in pack quantity (e.g., one additional cigar) are likely to result in consuming less than one additional day per month, though larger increases (e.g., 10 additional cigars per pack) may result in greater use.

7-Ketocholesterol Promotes Retinal Pigment Epithelium Senescence and Fibrosis of Choroidal Neovascularization via IQGAP1 Phosphorylation-Dependent Signaling.

Accumulation of 7-ketocholesterol (7KC) occurs in age-related macular degeneration (AMD) and was found previously to promote fibrosis, an untreatable cause of vision loss, partly through induction of endothelial-mesenchymal transition. To address the hypothesis that 7KC causes mesenchymal transition of retinal pigment epithelial cells (RPE), we exposed human primary RPE (hRPE) to 7KC or a control. 7KC-treated hRPE did not manifest increased mesenchymal markers, but instead maintained RPE-specific proteins and exhibited signs of senescence with increased serine phosphorylation of histone H3, serine/threonine phosphorylation of mammalian target of rapamycin (p-mTOR), p16 and p21, ß-galactosidase labeling, and reduced LaminB1, suggesting senescence. The cells also developed senescence-associated secretory phenotype (SASP) determined by increased IL-1ß, IL-6, and VEGF through mTOR-mediated NF-κB signaling, and reduced barrier integrity that was restored by the mTOR inhibitor, rapamycin. 7KC-induced p21, VEGF, and IL-1ß were inhibited by an inhibitor of protein kinase C. The kinase regulates IQGAP1 serine phosphorylation. Furthermore, after 7KC injection and laser-induced injury, mice with an IQGAP1 serine 1441-point mutation had significantly reduced fibrosis compared to littermate control mice. Our results provide evidence that age-related accumulation of 7KC in drusen mediates senescence and SASP in RPE, and IQGAP1 serine phosphorylation is important in causing fibrosis in AMD.

Dynamic Biophysical Cues Near the Tip Cell Microenvironment Provide Distinct Guidance Signals to Angiogenic Neovessels.

The formation of new vascular networks via angiogenesis is a crucial biological mechanism to balance tissue metabolic needs, yet the coordination of factors that influence the guidance of growing neovessels remain unclear. This study investigated the influence of extracellular cues within the immediate environment of sprouting tips over multiple hours and obtained quantitative relationships describing their effects on the growth trajectories of angiogenic neovessels. Three distinct microenvironmental cues-fibril tracks, ECM density, and the presence of nearby cell bodies-were extracted from 3D time series image data. The prominence of each cue was quantified along potential sprout trajectories to predict the response to multiple microenvironmental factors simultaneously. Sprout trajectories significantly correlated with the identified microenvironmental cues. Specifically, ECM density and nearby cellular bodies were the strongest predictors of the trajectories taken by neovessels (p < 0.001 and p = 0.016). Notwithstanding, direction changing trajectories, deviating from the initial neovessel orientation, were significantly correlated with fibril tracks (p = 0.003). Direction changes also occurred more frequently with strong microenvironmental cues. This provides evidence for the first time that local matrix fibril alignment influences changes in sprout trajectories but does not materially contribute to persistent sprouting. Together, our results suggest the microenvironmental cues significantly contribute to guidance of sprouting trajectories. Further, the presented methods quantitatively distinguish the influence of individual microenvironmental stimuli during guidance.

Antitachycardia pacing at the His bundle is safer than conventional right ventricular antitachycardia pacing in a canine myocardial ischemic injury model.

INTRODUCTION: Antitachycardia pacing (ATP) is used to terminate ventricular tachycardia (VT) by delivering rapid, low energy pacing to the right ventricle (RV). Unfortunately, ATP is not effective against all VT episodes and can result in adverse outcomes, such as VT acceleration and degeneration into ventricular fibrillation (VF). Improving ATP is therefore desirable. Our objective was to compare the efficacy and safety of ATP delivered at the His bundle to traditional ATP. METHODS: Six dogs were anesthetized and pacing leads were implanted in the RV and His bundle. The left anterior descending artery was occluded for 2 h to create an ischemic injury. In a study 4-7 days later, a 128-electrode sock was placed snugly around the ventricles and VT was induced using rapid pacing. ATP was delivered from either the His bundle or RV lead, then attempted at the other location if unsuccessful. Success rates and instances of VT acceleration and degeneration into VF were calculated. RESULTS: We induced 83 runs of VT and attempted ATP 128 times. RV ATP was successful in 36% of attempts; His ATP was successful in 38% of attempts. RV ATP resulted in significantly more adverse outcomes. RV and His ATP induced VT acceleration in 9% and 3% of trains, respectively, and induced degeneration into VF in 5% and 1% of trains, respectively. CONCLUSION: His bundle ATP is safer, but not significantly more effective, than RV ATP.

Micellar Encapsulation of Propofol Reduces its Adsorption on Extracorporeal Membrane Oxygenator (ECMO) Circuit.

Extracorporeal membrane oxygenation (ECMO) is a life-saving cardiopulmonary bypass device used on critically ill patients with refractory heart and lung failure. Patients supported with ECMO receive numerous drugs to treat critical illnesses and the underlying diseases. Unfortunately, most drugs prescribed to patients on ECMO lack accurate dosing information. Dosing can be variable in this patient population because the ECMO circuit components can adsorb drugs and affect drug exposure substantially. Propofol is a widely used anesthetic in ECMO patients and is known to have high adsorption rates in ECMO circuits due to its high hydrophobicity. In an attempt to reduce adsorption, we encapsulated propofol with Poloxamer 407 (Polyethylene-Polypropylene Glycol). Size and polydispersity index (PDI) were characterized using dynamic light scattering. Encapsulation efficiency was analyzed using High performance liquid chromatography. Cytocompatibility of micelles was analyzed against human macrophages and the formulation was finally injected in an ex-vivo ECMO circuit to determine the adsorption of propofol. Size and PDI of micellar propofol were 25.5 ± 0.8 nm and 0.08 ± 0.01, respectively. Encapsulation efficiency of the drug was 96.1 ± 1.3%. Micellar propofol demonstrated colloidal stability at physiological temperature for a period of 7 days, and was cytocompatible with human macrophages. Micellar propofol demonstrated a significant reduction in adsorption of propofol in the ECMO circuit at earlier time points compared to free propofol (Diprivan®). We observed 97 ± 2% recovery of the propofol from the micellar formulation after an infusion. These results demonstrate the potential of micellar propofol to reduce drug adsorption to ECMO circuit.

Serum procalcitonin level is independently associated with mechanical ventilation and case-fatality in hospitalized COVID-19-positive US veterans-A potential marker for disease severity.

The Coronavirus-19 disease (COVID-19) has claimed over 6.8 million lives since first being reported in late 2019. The virus that causes COVID-19 disease is highly contagious and spreads rapidly. To date, there are no approved prognostic tools that could predict why some patients develop severe or fatal disease outcomes. Early COVID-19 studies found an association between procalcitonin (PCT) and hospitalization or duration of mechanical ventilation and death but were limited by the cohort sizes. Therefore, this study was designed to confirm the associations of PCT with COVID-19 disease severity outcomes in a large cohort. For this retrospective data analysis study, 27,154 COVID-19-positive US veterans with post-infection PCT laboratory test data and their disease severity outcomes were accessed using the VA electronic healthcare data. Cox regression models were used to test the association between serum PCT levels and disease outcomes while controlling for demographics and relevant confounding variables. The models demonstrated increasing disease severity (ventilation and death) with increasing PCT levels. For PCT serum levels above 0.20 ng/ml, the unadjusted risk increased nearly 2.3-fold for mechanical ventilation (hazard ratio, HR, 2.26, 95%CI: 2.11-2.42) and in-hospital death (HR, 2.28, 95%CI: 2.16-2.41). Even when adjusted for demographics, diabetes, pneumonia, antibiotic use, white blood cell count, and serum C-reactive protein levels, the risks remained relatively high for mechanical ventilation (HR, 1.80, 95%CI: 1.67-1.94) and death (HR, 1.76, 95%CI: 1.66-1.87). These data suggest that higher PCT levels have independent associations with ventilation and in-hospital death in veterans with COVID-19 disease, validating previous findings. The data suggested that serum PCT level may be a promising prognostic tool for COVID-19 severity assessment and should be further evaluated in a prospective clinical trial.

The association between pulmonary artery enlargement and mortality in an Emergency Department population undergoing computed tomography pulmonary angiography.

Findings of an enlarged pulmonary artery diameter (PAd) and increased pulmonary artery to ascending aorta ratio (PA:AA) on contrast-enhanced computed tomography pulmonary angiography (CTPA) are associated with increased mortality in particular groups of patients with cardiopulmonary disease. However, the frequency and prognostic significance of these incidental findings has not been studied in unselected patients evaluated in the Emergency Department (ED). This study aims to determine the prevalence and associated prognosis of enlarged pulmonary artery measurements in an ED cohort. We measured PA and AA diameters on 990 CTPA studies performed in the ED. An enlarged PA diameter was defined as >27 mm in females and >29 mm in males, while an increased PA:AA was defined as >0.9. Poisson regression was performed to calculate prevalence ratios for relevant comorbidities, and multivariable Cox regression was performed to calculate hazard ratios (HR) for mortality of patients with enlarged pulmonary artery measurements. An enlarged PAd was observed in 27.9% of 990 patients and was more commonly observed in older patients and in patients with obesity or heart failure. Conversely, PA:AA was increased in 34.2% of subjects, and was more common in younger patients and those with peripheral vascular disease or obesity. After controlling for age, sex, and comorbidities, both enlarged PAd (HR 1.29, 95% CI 1.00-1.68, p = 0.05) and PA:AA (HR 1.70, 95% CI 1.31-2.22 p < 0.01) were independently associated with mortality. In sum, enlarged PAd and increased PA:AA are common in patients undergoing CTPAs in the ED setting and both are independently associated with mortality.

Retinopathy of prematurity protection conferred by uteroplacental insufficiency through erythropoietin signaling in an experimental Murine Model.

BACKGROUND: Recent clinical studies suggest that preeclampsia, characterized by uteroplacental insufficiency (UPI) and infant intrauterine growth restriction (IUGR), may be protective against retinopathy of prematurity (ROP) in preterm infants. Experimental models of UPI/IUGR have found an association of erythropoietin (EPO) with less severe oxygen-induced retinopathy (OIR); however, it is unclear if EPO/EPO receptor (EPOR) signaling was involved. We hypothesized that maternal UPI and resultant infant IUGR would protect against features of ROP through EPO/EPOR signaling. METHODS: We compared transgenic mice with hypoactive EPOR signaling (hWtEPOR) to littermate wild-type mice (mWtEpoR) in a novel combined model of IUGR and ROP. Thromboxane A2 (TXA2) was infused into pregnant C57Bl/6J dams to produce UPI/IUGR; postnatal pups and their foster dams were subjected to a murine OIR model. RESULTS: Following hyperoxia, hematocrits were similar between littermate wild-type (mWtEpoR) TXA2/OIR and vehicle/OIR pups. mWtEpoR TXA2/OIR had increased serum EPO, retinal EPO and VEGF, and decreased avascular retinal area (AVA) compared to vehicle/OIR pups. In comparison to the mWtEpoR TXA2/OIR pups, AVA was not reduced in hWtEPOR TXA2/OIR pups. CONCLUSION: Our findings provide biologic evidence that UPI/OIR-induced endogenous EPOR signaling confers protection against hyperoxia-induced vascular damage that may be related to pathophysiology in ROP. IMPACT: Maternal preeclampsia and infant growth restriction confer retinovascular protection against high oxygen-induced damage through endogenous erythropoietin signaling.

Self-reporting of Conflicts of Interest by Ophthalmology Researchers Compared with the Open Payments Database Industry Reports.

PURPOSE: To evaluate the completeness of conflict-of-interest self-reporting by ophthalmology researchers and to assess factors associated with self-reporting. DESIGN: Cross-sectional observational study. PARTICIPANTS: We evaluated articles published between January and June 2017 in Ophthalmology, JAMA Ophthalmology, the American Journal of Ophthalmology, and Investigative Ophthalmology and Visual Science. To assess more accurately the cases in which an author published multiple articles, we defined a unit of analysis, authorship, for which each author of each article is a unique data point. To enable comparison with the Open Payments Database (OPD), we only included United States physician authorships. METHODS: For each authorship, we defined self-reported relationships as the companies listed in the article's conflict-of-interest disclosures. Based on journal policies, we defined OPD-reported relationships as the list of companies that reported payments to the author within 36 months before submission. MAIN OUTCOME MEASURES: For each authorship, we assessed the proportion of OPD-reported relationships that were self-reported. The primary measurement was the proportion of authorships reporting none of their OPD-reported relationships. RESULTS: Of the 660 total authorships (486 unique authors), 413 authorships (63%) reported none of their OPD-reported relationships, 112 (17%) reported some of them, 9 (1%) reported all of them, and 126 (19%) had 0 relationships. The proportion of authorships reporting none of their relationships did not differ significantly between journals that required reporting of all relationships compared with journals that required reporting only of relevant relationships (adjusted percentage, 61.4% vs. 64.3%; P = 0.46). Authorships with more dollars received during the reporting period showed higher rates of self-reporting (P < 0.001). CONCLUSIONS: Even among journals that required complete reporting, self-reporting was low compared with an industry-maintained database of financial relationships. Deficiencies in reporting may undermine confidence in self-reporting and may compromise the transparency that is needed to interpret research results fairly. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found after the references.

Postoperative ileus risk after posterior thoracolumbar fusion performed with total intravenous anesthesia versus inhaled anesthesia.

OBJECTIVE: There has been an increase in the use of total intravenous anesthesia (TIVA) for intraoperative neuromonitoring during thoracolumbar posterior spinal fusion (PSF). Although prior studies have identified risk factors for postoperative ileus (PI) after PSF, to the authors' knowledge, PI rates in patients receiving inhaled anesthetic versus TIVA have not been evaluated. In this study the authors analyzed whether TIVA is associated with greater risk of PI in PSF patients. METHODS: In this retrospective single-institution cohort study, all patients undergoing PSF at the authors' tertiary academic institution from May 2014 to December 2020 were included. Patients undergoing anterior/lateral approaches or who had concurrent abdominal procedures unrelated to ileus in the same admission were excluded. PI was defined using radiographic and/or clinical diagnoses (postoperative radiographs, abdominal CT, and/or ICD-9 or -10 codes) and was confirmed via chart review. The use of TIVA or inhaled anesthetic was captured from the anesthesia record; patients were excluded if they were missing anesthesia technique data. Postoperative occurrence of PI was compared between patients who had TIVA or inhaled anesthetics while controlling for collected demographic, clinical, and surgical variables. RESULTS: Of the 2819 patients meeting inclusion criteria, 283 (10.0%) had PI (mean ± SD age 59.3 ± 15.8 years; 155 [54.8%] male). The mean patient length of stay was 7.7 ± 5.0 days, which was significantly longer than that of patients without PI (4.9 ± 3.9 days, p < 0.001). Patients with PI had more levels fused (46% of PI patients with ≥ 5 levels fused vs 25% of non-PI patients, p < 0.001) and longer operations (6.0 ± 2.2 vs 5.4 ± 1.9 hours, p < 0.001). TIVA patients were more likely than inhalation-only patients to experience PI, but this finding did not reach significance on univariate analysis (11.0% PI rate vs 8.9%, p = 0.06). After propensity matching 125 non-PI patients and 50 PI patients by age, sex, operative time, and number of levels fused, there was a significant difference in intraoperative opiate dosing between TIVA and inhalational patients (275.7 ± 187.5 intravenous morphine milligram equivalents vs 120.9 ± 155.5, p < 0.001). On multivariate analysis of PI outcome, TIVA was an independently significant predictor (OR 1.45, p = 0.02), as was anesthesia time (OR per hour increase: 1.09, p = 0.03) and ≥ 8 levels fused (OR 1.86, p = 0.01). CONCLUSIONS: In a large cohort of PSF patients, TIVA was associated with a higher rate of PI compared with inhaled anesthetic. This effect is likely due to higher intraoperative opiate use in these patients.

Real-Time Breastfeeding Documentation: Timing of Breastfeeding Initiation and Outpatient Duration.

BACKGROUND: Current breastfeeding guidelines promote initiating breastfeeding ≤1 h after birth to establish long-term breastfeeding. Previous studies dichotomized initiation to ≤1 h versus subsequent hours combined. There are limited data evaluating the effect of initiation in each subsequent hour on breastfeeding duration. Our objective was to evaluate the association between breastfeeding initiated at ≤1 h versus the subsequent 23 hours after birth and outpatient breastfeeding duration. METHODS: In this retrospective cohort study, we analyzed real-time, discretely documented electronic health record (EHR) breastfeeding data for 3315 infants born at a university center and followed to age ≥12 mo at 27 university primary care clinics. The primary outcome was breastfeeding duration. The exposure variable was hour of breastfeeding initiation within 24 h postnatally. Data were analyzed by univariable and multivariable linear regression separately for infants born by vaginal versus cesarean delivery. RESULTS: In adjusted models, initiating breastfeeding during each hour from age >1 to ≤6 h and during ages >6 to ≤24 h was not associated with decreased breastfeeding duration versus initiating breastfeeding at ≤1 h after birth for infants born via vaginal or cesarean delivery. CONCLUSIONS: Delaying breastfeeding initiation to >1 to ≤24 h after birth is not associated with decreased breastfeeding duration compared with initiating breastfeeding at ≤1 h after birth. Integration of breastfeeding measures into inpatient and outpatient EHR discrete data fields may clarify best practices that support long-term breastfeeding as a public health imperative.

A Nationwide Analysis Evaluating the Safety of Using Acellular Dermal Matrix with Tissue Expander-Based Breast Reconstruction.

Background In March 2021, the United States Food and Drug Administration (FDA) safety communication cautioned against the use of acellular dermal matrix (ADM) products in breast reconstruction and reiterated that the FDA does not approve ADM use in breast surgery. This study aims to assess the safety of ADM use in breast reconstruction. Methods Women who underwent ADM and non-ADM assisted tissue expander (TE)-based breast reconstruction were identified using the National Surgical Quality Improvement Program database (2012-2019). Trends of ADM use over time, and 30-day outcomes of surgical site infection (SSI), dehiscence, and unplanned reoperation were assessed. Results Of the 49,049 TE-based breast reconstructive cases, 42.4% were ADM assisted and 57.6% non-ADM assisted. From 2012 to 2019, the use of ADM increased from 26.1 to 55.6% (relative risk [RR] =1.10; p < 0.01). Higher rates of SSI (3.9 vs. 3.4%; p = 0.003) and reoperation (7.4 vs. 6.0%; p < 0.001) were seen in the ADM cohort. There was no significant difference seen in dehiscence rates (0.7 vs. 0.7%; p = 0.73). The most common reoperation within 30 days for the ADM group (17.6%) was removal of TE without insertion of implant (current procedural terminology: 11,971). ADM-assisted breast reconstruction was associated with increased relative risk of SSI by 10% (RR = 1.10, confidence interval [CI]: 1.01-1.21; p = 0.03) and reoperation by 15% (RR = 1.15, CI: 1.08-1.23; p < 0.001). Conclusions ADM-assisted breast reconstruction more than doubled from 2012 to 2019. There are statistically higher complication rates of SSI (0.5%) and reoperation (1.4%) with ADM use in TE-based breast reconstruction, suggesting that reconstruction without ADM is safe when comparing immediate postoperative outcomes.

Is the Activity Measure for Postacute Care "6-Clicks" Tool Associated With Discharge Destination Postacute Stroke?

Objective: To investigate the association of poststroke physical function, measured within 24 hours prior to discharge from the acute care hospital using Activity Measure for Postacute Care (AM-PAC) Inpatient "6-Clicks" scores and discharge destination (home vs facility and inpatient rehabilitation facility [IRF] vs skilled nursing facility [SNF]). Design: Retrospective cross-sectional cohort study. Setting: Acute care, University Hospital. Participants: Individuals post acute ischemic stroke, N=721, 51.3% male, mean age 63.6±16.4 years. Interventions: Not applicable. Main Outcome Measures: AM-PAC "6-Clicks" 3 domains: basic mobility, daily activity, and applied cognition. Results: AM-PAC basic mobility and daily activity were significant predictors of discharge. Those in the home discharge group had AM-PAC basic mobility mean t scale score of 48.5 compared with a score of 34.8 for individuals sent to a facility and daily activity score of 47.2 compared with 32.7 for individuals sent to a facility. The AM-PAC variables accounted for an additional 24% of the variance in the discharge destination, with basic mobility and daily activity accounting for most of the variance.The AM-PAC scores were not statistically different and were not able to discriminate between placement in an IRF vs SNF. The mean basic mobility t scale score for individuals going to an IRF was 34.9 compared with 34.6 for those going to an SNF. The daily activity score for IRF was 32.8 compared with 32.6 for SNF. The AM-PAC accounted for no additional variance in discharge destination to an IRF or SNF. Conclusions: The AM-PAC Inpatient "6-Clicks" 3 domains are able to distinguish individuals with stroke being discharged to home from postacute care (PAC) but not for differentiating between PAC facilities (IRF vs SNF) in this cohort of individuals post stroke.

Aging results in DNA damage and telomere dysfunction that is greater in endothelial versus vascular smooth muscle cells and is exacerbated in atheroprone regions.

Aging increases the risk of atherosclerotic cardiovascular disease which is associated with arterial senescence; however, the mechanisms responsible for the development of cellular senescence in endothelial cells (ECs) and vascular smooth muscle cells (VSMCs) remain elusive. Here, we study the effect of aging on arterial DNA damage and telomere dysfunction. Aging resulted in greater DNA damage in ECs than VSMCs. Further, telomere dysfunction-associated DNA damage foci (TAF: DNA damage signaling at telomeres) were elevated with aging in ECs but not VMSCs. Telomere length was modestly reduced in ECs with aging and not sufficient to induce telomere dysfunction. DNA damage and telomere dysfunction were greatest in atheroprone regions (aortic minor arch) versus non-atheroprone regions (thoracic aorta). Collectively, these data demonstrate that aging results in DNA damage and telomere dysfunction that is greater in ECs than VSMCs and elevated in atheroprone aortic regions.

Angiotensin-converting enzyme inhibitors reduce community-acquired pneumonia hospitalization and mortality.

BACKGROUND: Pneumonia is a global disorder and a common reason for prolonged hospitalization. Angiotensin-converting enzyme inhibitors (ACEi) have pleiotropic effects that support a role in modulating pneumonia, but results have been controversial. OBJECTIVES: The present study was conducted to elucidate an ACEi-induced pneumonia benefit in at-risk neurologically impaired population and to determine whether a mortality benefit exists. METHODS: A cohort study using a large health-system of 29,011 unique ACEi users and 1635 case patients 65 years of age or older without neurological disorders affecting swallowing who were admitted with community-acquired pneumonia hospitalization and followed up from January 1, 2015 to December 31, 2019 (5 years). The association between ACEi use and pneumonia hospitalization and mortality were determined after propensity score matching using Cox and logistic regression. RESULTS: The experimental cohort was 74.9 ± 7.3 years and 51% were male. ACEi users had lower odds of acquiring pneumonia versus ACEi non-users (odds ratio) 0.72 [95% Confidence Interval (CI) 0.51 to 0.99]; p = 0.048. The risk of short-term mortality (<30 days) (HR) 0.42, p < 0.001 and long-term mortality (≥30 day) (HR) 0.83, p < 0.002 was significantly lower for ACEi users compared with the ACEi non-users. CONCLUSIONS: ACEi use in patients at risk of pneumonia without neurological swallowing disorders is associated with reduction in hospitalization and lowering of short- and long-term mortality. Given the high incidence of morbidity and mortality associated with pneumonia, and the susceptibility in older populations with underlying cardiovascular or renal disease or social dependencies, our data support the prescribing of ACEi in these populations to reduce pneumonia hospitalization risk as well as short- and long-term mortality.

Orthostatic Challenge Causes Distinctive Symptomatic, Hemodynamic and Cognitive Responses in Long COVID and Myalgic Encephalomyelitis/Chronic Fatigue Syndrome.

Background: Some patients with acute COVID-19 are left with persistent, debilitating fatigue, cognitive impairment ("brain fog"), orthostatic intolerance (OI) and other symptoms ("Long COVID"). Many of the symptoms are like those of other post-infectious fatigue syndromes and may meet criteria for myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS). Common diagnostic laboratory tests are often unrevealing. Methods: We evaluated whether a simple, standardized, office-based test of OI, the 10-min NASA Lean Test (NLT), would aggravate symptoms and produce objective hemodynamic and cognitive abnormalities, the latter being evaluated by a simple smart phone-based app. Participants: People with Long COVID (N = 42), ME/CFS (N = 26) and healthy control subjects (N = 20) were studied just before, during, immediately after, 2 and 7 days following completion of the NLT. Results: The NLT provoked a worsening of symptoms in the two patient groups but not in healthy control subjects, and the severity of all symptoms was similar and significantly worse in the two patient groups than in the control subjects (p < 0.001). In the two patient groups, particularly those with Long COVID, the NLT provoked a marked and progressive narrowing in the pulse pressure. All three cognitive measures of reaction time worsened in the two patient groups immediately following the NLT, compared to the healthy control subjects, particularly in the Procedural Reaction Time (p < 0.01). Conclusions: A test of orthostatic stress easily performed in an office setting reveals different symptomatic, hemodynamic and cognitive abnormalities in people with Long COVID and ME/CFS, compared to healthy control subjects. Thus, an orthostatic challenge easily performed in an office setting, and the use of a smart phone app to assess cognition, can provide objective confirmation of the orthostatic intolerance and brain fog reported by patients with Long COVID and ME/CFS.