Utility of Methicillin-Resistant Staphylococcus aureus Nasal PCR Testing in Pediatric Patients With Suspected Respiratory Infections.

Observational studies in adults suggest nasal methicillin-resistant Staphylococcus aureus (MRSA) swabs have a high negative predictive value (NPV) for ruling out MRSA pneumonia, however, pediatric data are limited. This retrospective study of 505 pediatric patients found a 99.8% NPV among children with suspected respiratory infections.

Reported changes in romantic and sexual behavior among college and graduate students during COVID-19.

Objective: To understand changes in romantic and sexual behavior among college and graduate students in North Carolina during COVID-19. Participants: Participants were between 18-30 years old and enrolled in a two- or four-year college or graduate program in North Carolina (n = 926). Methods: A cross-sectional web-based survey was administered to college and graduate students to assess romantic and sexual behavioral changes during COVID-19. Results: Participants continued to engage in in-person sexual intercourse during COVID-19 and reported an increase in online and virtual dating. Although the majority of participants reported following COVID-19 guidelines, they did not frequently use risk mitigation strategies such as declining kissing or sex due to COVID-19 concerns, inquiring about recent COVID-19 tests, or having sexual contact without kissing. Conclusion: Study findings suggest a need for colleges and universities to help students manage COVID-19 prevention in intimate relationships.

Evaluation of phenobarbital dosing strategies for hospitalized patients with alcohol withdrawal syndrome.

OBJECTIVE: Alcohol remains the fourth­leading preventable cause of death in the U.S. The objective of this study was to compare the incidence of phenobarbital (PHB)-resistant withdrawal and determine risk factors for PHB-resistant alcohol withdrawal syndrome (AWS). METHODS: This retrospective cohort study included adults admitted to an academic center with AWS who received PHB as part of an institution-specific treatment protocol. The primary outcome was incidence of AWS resistant to initial protocolized PHB load across two cohorts (standard-dose, 10 mg/kg vs. low-dose, 6 mg/kg). RESULTS: Among 176 included patients, there was no difference in the incidence of PHB-resistant AWS based on initial PHB load [low-dose load, 21 (18.3%) vs. standard-dose load, 12 (19.7%), p = 0.82]. There were also no differences in observed PHB-related ADEs between the groups. Total benzodiazepine dose received (mg) in the 24 h prior to initial PHB load was the only risk factor significantly associated with AWS resistant to initial protocolized PHB load [adjusted OR 1.79 (95% CI 1.24, 2.60)]. PHB-resistant withdrawal occurred in 33 (18.8%) patients with a median cumulative PHB dose of approximately 20 mg/kg during hospitalization. CONCLUSION(S): There were no differences in the incidence of PHB-resistant AWS or PHB-related ADEs based on initial PHB loading dose.

Cryocompression to Reduce Peripheral Neuropathy in Gynecologic Cancer: A Randomized Controlled Trial.

OBJECTIVE: To investigate the efficacy of cryocompression therapy to prevent chemotherapy-induced peripheral neuropathy. METHODS: This single-institution, randomized, self-controlled trial of cryocompression enrolled gynecologic cancer patients planned for five to six cycles neurotoxic chemotherapy. Exclusion criteria were prior neurotoxic chemotherapy or baseline peripheral neuropathy. Participants were randomized to cryocompression on dominant versus non-dominant hand and foot (treatment), with no intervention on the opposite side (control). Compression socks and gloves and ice bags were applied 15 minutes before, during, and 15 minutes after infusion. Primary outcome measures included the PNQ (Patient Neurotoxicity Questionnaire) and the Semmes-Weinstein monofilament test; secondary outcomes included the FACT/GOG-NTX (Functional Assessment of Cancer Therapy/Gynecologic Oncology Group - Neurotoxicity) and patient acceptability and tolerability. Sixty patients completing the study were necessary to detect a 70% reduction in the odds of PNQ grade C or higher peripheral sensory neuropathy with 80% power. RESULTS: Ninety-one patients were enrolled from January 2021 to October 2022; 69 were eligible for final analysis. Of the 91 patients, 64.8% were White, 30.8% were Black, and 1.1% were Hispanic or Latina. With successive cycles, more patients had sensory PNQ grade C or higher neuropathy on the control side compared with the cryocompression side. Cryocompression decreased the odds of sensory neuropathy (PNQ grade C or higher) by 46% at final visit (odds ratio 0.54, 95% CI 0.31-0.94; P =.03). There was no difference in tactile sensitivity based on the monofilament test between sides at the final visit. At the final visit, average FACT/GOG-NTX-11 (Functional Assessment of Cancer Therapy/Gynecologic Oncology Group - Neurotoxicity 11 Item Version) scores were significantly lower on the cryocompression than the control side (estimate -0.97, 95% CI -1.89 to -0.06; P =.04), as were FACT/GOG-NTX-4 (Functional Assessment of Cancer Therapy/Gynecologic Oncology Group - Neurotoxicity 4 Item Version) scores (estimate -0.35, 95% CI -0.64 to -0.05; P =.02). More than 85% of patients assessed the intervention as acceptable and tolerable. CONCLUSIONS: Cryocompression therapy reduces subjective chemotherapy-induced peripheral sensory neuropathy in patients who are receiving paclitaxel or cisplatin for gynecologic cancer. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov , NCT04563130.

Gender and Language in Letters of Recommendation for Obstetrics and Gynecology Fellowship Applications.

OBJECTIVE: To delineate the use of gender-biased language in letters of recommendation for Obstetrics and Gynecology fellowships and its impact on applicants. DESIGN: Fellowship letters of recommendation from 4 Obstetrics and Gynecology specialties at a single institution in 2020 were included. PRIMARY OUTCOME: frequency of agentic and communal language in letters of recommendation using Linguistics Inquiry Word Count software. SECONDARY OUTCOMES: letter of recommendation length and language utilization by author gender and applicant success measured by interviews and match success. Marginal models were fit to determine if language varied by applicant and writer gender and subspecialty. Modified Poisson regression models were used to determine associations between language and interview receipt. SETTING: Single academic institution (Duke University); 2020 OB/GYN fellowship application cycle. PARTICIPANTS: A total of 1216 letters of recommendation submitted by 326 unique applicants for OB/GYN subspecialty fellowships at our institution. RESULTS: Rates of gender-biased language were low (Agentic:1.3%; communal: 0.8%). Agentic term use did not vary by applicant or author gender (p = 0.78 and 0.16) Male authors utilized 19% fewer communal terms than females (p < 0.001). Each 0.25% increase in agentic language was associated with an 18% reduction in the probability of interview invitation at our institution (p = 0.004). Percentage of agentic or communal language was not associated with successful matching into any subspecialty. CONCLUSIONS: No differences in agentic vs communal language based on applicant gender were found in this cohort, though female letter writers wrote longer letters with more communal terms. Increasing agentic terms negatively impacted interview invitation but did not affect successful matching.

Preemptive immune globulin therapy in sensitized lung transplant recipients.

BACKGROUND: Sensitized lung transplant recipients are at increased risk of developing donor-specific antibodies, which have been associated with acute and chronic rejection. Perioperative intravenous immune globulin has been used in sensitized individuals to down-regulate antibody production. METHODS: We compared patients with a pre-transplant calculated panel reactive antibody ≥25% who did not receive preemptive immune globulin therapy to a historical control that received preemptive immune globulin therapy. Our cohort included 59 patients, 17 patients did not receive immune globulin therapy and 42 patients received therapy. RESULTS: Donor specific antibody development was numerically higher in the non-immune globulin group compared to the immune globulin group (58.8% vs 33.3%, respectively, odds ratio 2.80, 95% confidence interval [0.77, 10.79], p = 0.13). Median time to antibody development was 9 days (Q1, Q3: 7, 19) and 28 days (Q1, Q3: 7, 58) in the non-immune globulin and immune globulin groups, respectively. There was no significant difference between groups in the incidence of primary graft dysfunction at 72 h post-transplant or acute cellular rejection, antibody-mediated rejection, and chronic lung allograft dysfunction at 12 months. CONCLUSION: These findings are hypothesis generating and emphasize the need for larger, randomized studies to determine association of immune globulin therapy with clinical outcomes.

Geographic variation in the rate and route of hysterectomy for benign disease in the USA: A retrospective cross-sectional study.

OBJECTIVES: To describe population rate of hysterectomy for benign disease in the USA, including geographic variation across states and Hospital Service Areas (HSAs; areas defined by common patient flows to healthcare facilities). DESIGN: Cross-sectional study. SETTING: Four US states including 322 HSAs. POPULATION: A total of 316 052 cases of hysterectomy from 2012 to 2016. METHODS: We compiled annual hysterectomy cases, merged female populations, and adjusted for reported rates of previous hysterectomy. We assessed small-area variation and created multi-level Poisson regression models. MAIN OUTCOME MEASURES: Prior-hysterectomy-adjusted population rates of hysterectomy for benign disease. RESULTS: The annual population rate of hysterectomy for benign disease was 49 per 10 000 hysterectomy-eligible residents, declining slightly over time, mostly among reproductive-age populations. Rates peaked among residents ages 40-49 years, and declined with increasing age, apart from an increase with universal coverage at age 65 years. We found large differences in age-standardised population rates of hysterectomy across states (range 42.2-69.0), and HSAs (range: overall 12.9-106.3; 25th-75th percentile 44.0-64.9). Among the non-elderly population, those with government-sponsored insurance had greater variation than those with private insurance (coefficient of variation 0.61 versus 0.32). Proportions of minimally invasive procedures were similar across states (71.0-74.8%) but varied greatly across HSAs (27-96%). In regression models, HSA population characteristics explained 31.8% of observed variation in annual rates. Higher local proportions of government-sponsored insurance and non-White race were associated with lower population rates. CONCLUSIONS: We found substantial variation in rate and route of hysterectomy for benign disease in the USA. Local population characteristics explained less than one-third of observed variation.

Propofol-Associated Hypertriglyceridemia in Adults With Acute Respiratory Distress Syndrome on Extracorporeal Membrane Oxygenation.

The incidence and risk factors for propofol-associated hypertriglyceridemia (HTG) in patients receiving extracorporeal membrane oxygenation (ECMO) have not been evaluated. The purpose of this study was to determine the incidence and risk factors for propofol-associated HTG in patients with acute respiratory distress syndrome (ARDS) on ECMO. This retrospective, cohort study included 167 adults admitted to a medical intensive care unit (ICU) from July 1, 2013 to September 1, 2021, who received 24 hours of concurrent propofol and ECMO therapy. The primary outcome was the incidence of propofol-associated HTG. Secondary outcomes included HTG risk factors, time to development and resolution of HTG, and incidence of pancreatitis. HTG occurred in 58 (34.7%) patients. Patients with HTG had longer durations of ECMO (19 vs. 13 days, p < 0.001), longer ICU length of stay (26.5 vs. 23 days, p = 0.002), and higher in-hospital mortality (51.7 vs. 34.9%, p = 0.047). Baseline sequential organ failure assessment score was associated with an increased risk of developing HTG (hazard ratio [HR] = 1.19, 95% confidence interval [CI] = 1.09-1.30; p < 0.001). Propofol-associated HTG occurred in one-third of patients receiving ECMO for ARDS. Higher baseline illness severity and ECMO duration were associated with an increased risk of propofol-associated HTG.

Validation of a sonographic checklist for the detection of histologic placenta accreta spectrum.

BACKGROUND: To standardize research terminology and to reduce unanticipated placenta accreta spectrum, the European Working Group for Abnormally Invasive Placenta developed a consensus checklist for reporting suspected placenta accreta spectrum observed during an antenatal ultrasound. The diagnostic accuracy of the European Working Group for Abnormally Invasive Placenta checklist has not been assessed. OBJECTIVE: This study aimed to test the performance of the European Working Group for Abnormally Invasive Placenta sonographic checklist in predicting histologic placenta accreta spectrum. STUDY DESIGN: This was a multisite, blinded, retrospective review of transabdominal ultrasound studies performed between 26 to 32 weeks' gestation for subjects with histologic placenta accreta spectrum between 2016 and 2020. We matched a control cohort of subjects without histologic placenta accreta spectrum in a 1:1 ratio. To reduce reader bias, we matched the control cohort for known risk factors including previa, number of previous cesarean deliveries, previous dilation and curettage, in vitro fertilization, and clinical factors affecting image quality including multiple gestation, body mass index, and gestational age at the ultrasound. Nine sonologists from 5 referral centers, blinded to the histologic outcomes, interpreted the randomized ultrasound studies using the European Working Group for Abnormally Invasive Placenta checklist. The primary outcome was the sensitivity and specificity of the checklist to predict placenta accreta spectrum. Two separate sensitivity analyses were performed. First, we excluded subjects with mild disease (ie, only assessed subjects with histologic increta and percreta). Second, we excluded interpretations from the 2 most junior sonologists. RESULTS: A total of 78 subjects were included (39 placenta accreta spectrum, 39 matched control). Clinical risk factors and image quality markers were statistically similar between the cohorts. The checklist sensitivity (95% confidence interval) was 76.6% (63.4-90.6) and the specificity (95% confidence interval) was 92.0% (63.4-99.9) with a positive and negative likelihood ratio of 9.6 and 0.3, respectively. When we excluded subjects with mild placenta accreta spectrum disease, the sensitivity (95% confidence interval) increased to 84.7% (73.6-96.4) and the specificity was unchanged at 92.0% (83.2-99.9). Sensitivity and specificity were unchanged when the interpretations from the 2 most junior sonologists were excluded. CONCLUSION: The 2016 European Working Group for Abnormally Invasive Placenta checklist for interpreting placenta accreta spectrum has a reasonable performance in detecting histologic placenta accreta spectrum and excluding cases without placenta accreta spectum.

Standard Restrictions vs Expedited Activity After Pelvic Organ Prolapse Surgery: A Randomized Clinical Trial.

Importance: Restrictions on postoperative activity following pelvic organ prolapse (POP) surgery are not evidence based. Nonetheless, many pelvic surgeons place lifting and activity restrictions on patients following surgery. Objective: To evaluate whether expedited activity results in noninferior anatomic and symptomatic outcomes compared with standard activity restrictions after POP surgery. Design, Setting, and Participants: This randomized noninferiority clinical trial included patients undergoing vaginal or laparoscopic apical reconstructive surgery for POP between July 1, 2020, and October 31, 2021, at a single academic tertiary referral center in Durham, North Carolina. Anatomic outcomes were assessed by masked examiners, and subjective outcomes were assessed via validated surveys, both completed at 3 months postoperatively. Patients meeting minimum physical activity criteria with at least stage II bothersome POP were eligible. A total of 218 patients were approached, of whom 123 were randomly assigned and 107 had complete outcome data and were included in the analysis. Interventions: Patients were randomly assigned to receive standard restrictions vs expedited postoperative activity instructions. Main Outcomes and Measures: The anatomic coprimary outcome was maximum anatomic POP support loss (SLmax), which is the most distal point of pelvic organ support loss according to the Pelvic Organ Prolapse Quantification System (noninferiority margin, 1.0 cm). The symptomatic coprimary outcome was the Pelvic Organ Prolapse Distress Inventory (POPDI) symptom score (noninferiority margin, 34.3 points). Differences between outcomes were assessed using linear regression models controlling for baseline SLmax and POPDI, respectively. Results: Of 123 participants randomized, 107 had complete 3-month outcome data and were included in the analysis. Mean (SD) age was 62.8 (10.1) years. At 3 months, mean (SD) SLmax was -1.7 (1.4) cm in the expedited group and -1.5 (1.4) cm in the standard group (P = .44). After adjusting for baseline SLmax, the mean maximum support loss was 0.18 cm higher within the vaginal canal in the expedited group (95% CI, -0.68 to 0.33 cm). The coprimary outcome of POPDI score was a mean (SD) 23.7 (41.8) points in the expedited group vs 25.7 (39.3) points in the standard group (P = .80). After adjusting for baseline scores, mean POPDI scores were 5.79 points lower in the expedited group (95% CI, -20.41 to 8.84). Conclusions and Relevance: The findings demonstrate that expedited activity after prolapse surgery results in noninferior anatomic and symptomatic prolapse outcomes. It is reasonable to instruct patients undergoing minimally invasive prolapse surgery to resume physical activities ad lib postoperatively. Trial Registration: ClinicalTrials.gov Identifier: NCT04329715.

Patient and Surgery Characteristics of Inpatient Hysterectomies Among Transgender Individuals.

Purpose: The purpose of this study is to estimate population-based rates of inpatient hysterectomy and accompanying bilateral salpingo-oophorectomy by indication and evaluate surgical patient characteristics by indication, year, patient age, and hospital location. Methods: We used 2016 and 2017 cross-sectional data from the Nationwide Inpatient Sample to estimate the hysterectomy rate for individuals aged 18-54 years with a primary indication for gender-affirming care (GAC) compared to other indications. Outcome measures were population-based rates for inpatient hysterectomy and bilateral salpingo-oophorectomy by indication. Results: The population-based rate of inpatient hysterectomy for GAC per 100,000 was 0.05 (95% confidence interval [CI] = 0.02-0.09) in 2016 and 0.09 (95% CI = 0.03-0.15) in 2017. For comparison, the rates per 100,000 for fibroids were 85.76 in 2016 and 73.25 in 2017. Rates of bilateral salpingo-oophorectomy in the setting of hysterectomy were higher in the GAC group (86.4%) than in comparison groups (22.7%-44.1% for all other benign indications, 77.4% for cancer) across all age ranges. A higher rate of hysterectomies performed for GAC was done laparoscopically or robotically (63.6%) than other indications, and none was done vaginally, as opposed to comparison groups (0.7%-9.8%). Conclusion: The population-based rate for GAC was higher in 2017 compared to 2016 and low compared to other hysterectomy indications. Rates of concomitant bilateral salpingo-oophorectomy were more prevalent for GAC than for other indications at similar ages. The patients in the GAC group tended to be younger, insured, and most procedures occurred in the Northeast (45.5%) and West (36.4%).

Exploratory analysis of mesenteric-portal axis CT radiomic features for survival prediction of patients with pancreatic ductal adenocarcinoma.

OBJECTIVE: To develop and evaluate task-based radiomic features extracted from the mesenteric-portal axis for prediction of survival and response to neoadjuvant therapy in patients with pancreatic ductal adenocarcinoma (PDAC). METHODS: Consecutive patients with PDAC who underwent surgery after neoadjuvant therapy from two academic hospitals between December 2012 and June 2018 were retrospectively included. Two radiologists performed a volumetric segmentation of PDAC and mesenteric-portal axis (MPA) using a segmentation software on CT scans before (CTtp0) and after (CTtp1) neoadjuvant therapy. Segmentation masks were resampled into uniform 0.625-mm voxels to develop task-based morphologic features (n = 57). These features aimed to assess MPA shape, MPA narrowing, changes in shape and diameter between CTtp0 and CTtp1, and length of MPA segment affected by the tumor. A Kaplan-Meier curve was generated to estimate the survival function. To identify reliable radiomic features associated with survival, a Cox proportional hazards model was used. Features with an ICC ≥ 0.80 were used as candidate variables, with clinical features included a priori. RESULTS: In total, 107 patients (60 men) were included. The median survival time was 895 days (95% CI: 717, 1061). Three task-based shape radiomic features (Eccentricity mean tp0, Area minimum value tp1, and Ratio 2 minor tp1) were selected. The model showed an integrated AUC of 0.72 for prediction of survival. The hazard ratio for the Area minimum value tp1 feature was 1.78 (p = 0.02) and 0.48 for the Ratio 2 minor tp1 feature (p = 0.002). CONCLUSION: Preliminary results suggest that task-based shape radiomic features can predict survival in PDAC patients. KEY POINTS: • In a retrospective study of 107 patients who underwent neoadjuvant therapy followed by surgery for PDAC, task-based shape radiomic features were extracted and analyzed from the mesenteric-portal axis. • A Cox proportional hazards model that included three selected radiomic features plus clinical information showed an integrated AUC of 0.72 for prediction of survival, and a better fit compared to the model with only clinical information.

Contraceptive Access and Use Among Undergraduate and Graduate Students During COVID-19: Online Survey Study.

BACKGROUND: The COVID-19 pandemic led to widespread college campus closures in the months of March to June 2020, endangering students' access to on-campus health resources, including reproductive health services. OBJECTIVE: To assess contraceptive access and use among undergraduate and graduate students in North Carolina during the COVID-19 pandemic. METHODS: We conducted a cross-sectional web-based survey of undergraduate and graduate students enrolled at degree-granting institutions in North Carolina. Participants were recruited using targeted Instagram advertisements. The survey queried several aspects of participants' sexual behavior, including sex drive, level of sexual experience, number of sexual partners, digital sexual experience, dating patterns, and types of contraception used. Participants were asked to compare many of these behaviors before and after the pandemic. The survey also assessed several sociodemographic factors that we hypothesized would be associated with contraceptive use based on prior data, including educational background, sexual orientation and gender minority status (ie, lesbian, gay, bisexual, transgender, queer), health insurance status, race, ethnicity, degree of sensation seeking, religiosity, and desire to become pregnant. RESULTS: Over 10 days, 2035 Instagram users began our survey, of whom 1002 met eligibility criteria. Of these 1002 eligible participants, 934 completed the survey, for a 93% completion rate. Our respondents were mostly female (665/934, 71%), cisgender (877/934, 94%), heterosexual (592/934, 64%), white (695/934 75%), not Hispanic (835/934, 89%), and enrolled at a 4-year college (618/934, 66%). Over 95% (895/934) of respondents reported that they maintained access to their preferred contraception during the COVID-19 pandemic. In a multivariable analysis, participants who were enrolled in a 4-year college or graduate program were less likely to lose contraceptive access when compared to participants enrolled in a 2-year college (risk ratio [RR] 0.34, 95% CI 0.16-0.71); in addition, when compared to cisgender participants, nonbinary and transgender participants were more likely to lose contraceptive access (RR 2.43, 95% CI 1.01-5.87). Respondents reported that they were more interested in using telehealth to access contraception during the pandemic. The contraceptive methods most commonly used by our participants were, in order, condoms (331/934, 35.4%), oral contraception (303/934, 32.4%), and long-acting reversible contraception (LARC; 221/934, 23.7%). The rate of LARC use among our participants was higher than the national average for this age group (14%). Emergency contraception was uncommonly used (25/934, 2.7%). CONCLUSIONS: Undergraduate and graduate students in North Carolina overwhelmingly reported that they maintained access to their preferred contraceptive methods during the COVID-19 pandemic and through changing patterns of health care access, including telehealth. Gender nonbinary and transgender students and 2-year college students may have been at greater risk of losing access to contraception during the first year of the COVID-19 pandemic.

Utility of a risk assessment model in predicting 30†day unplanned hospital readmission in adult patients receiving outpatient parenteral antimicrobial therapy.

Objectives: Outpatient parenteral antimicrobial therapy (OPAT) is associated with high hospital readmission rates. A 30 day unplanned readmission risk prediction model for OPAT patients has been developed in the UK. Given significant differences in patient mix and methods of OPAT delivery, we explored the model for its utility in Duke University Health System (DUHS) patients receiving OPAT. Methods: We analysed OPAT episodes of adult patients from two hospitals between 1 July 2019 and 1 February 2020. The discriminative ability of the model to predict 30 day unplanned all-cause and OPAT-related admission was examined. An updated model was created by logistic regression with the UK risk factors and additional risk factors, OPAT delivery in a skilled nursing facility, vancomycin use and IV drug abuse. Results: Compared with patients of the UK cohort, our study patients were of higher acuity, treated for more invasive infections, and received OPAT through different modes. The 30 day unplanned readmission rate in our cohort was 20% (94/470), with 59.5% (56/94) of those being OPAT-related. The original model was unable to discriminate for all-cause readmission with a C-statistic of 0.52 (95% CI 0.46-0.59) and for OPAT-related readmission with a C-statistic of 0.55 (95% CI 0.47-0.64). The updated model with additional risk factors did not have improved performance, with a C-statistic of 0.55 (95% CI 0.49-0.62). Conclusions: The UK 30 day unplanned hospital readmission model performed poorly in predicting readmission for the OPAT population at a US academic medical centre.

Direct-to-consumer fertility testing: utilization and perceived utility among fertility patients and reproductive endocrinologists.

RESEARCH QUESTION: What is the utilization of direct-to-consumer fertility tests (DTCFT) among fertility patients? How does the perceived utility of DTCFT differ between patients and reproductive endocrinologists (REI)? DESIGN: Infertility patients visiting the Duke Fertility Center between December 2020 and December 2021 were sent an electronic invitation to participate in a patient survey. Members of the Society of Reproductive Endocrinology and Infertility were also sent e-mail invitations to participate in the REI survey. DTCFT were defined as tests not ordered by a physician or performed at a physician's office, including calendar methods of ovulation prediction, urinary ovulation prediction kits, basal body temperature (BBT) monitoring, hormone analysis, ovarian reserve testing and semen analysis. Patients and REI were asked how likely they were to recommend a given DTCFT, on a 0-10 Likert scale. RESULTS: In total, 425 patients (response rate 50.5%) and 178 REI (response rate 21.4%) completed the surveys. Patients reported the utilization of calendar methods of ovulation prediction (83.8%), urinary ovulation prediction (78.8%), BBT monitoring (30.8%), hormone analysis (15.3%), semen analysis (10.1%) and ovarian reserve testing (9.2%). REI rated the utility of all DTCFT significantly lower than patients did (average discordance -4.2, P < 0.001), except for urinary ovulation prediction, which REI gave a significantly higher score (discordance +1.0, P < 0.001). Prior pregnancy was significantly associated with home ovulation prediction utilization among patients (adjusted odds ratio 3.21, 95% confidence interval 1.2-9.83). CONCLUSIONS: Methods of ovulation prediction are commonly used by fertility patients. Significant discordance exists in the perceived utility of DTCFT between patients and REI. Patient education and guidelines are needed to better inform individuals considering DTCFT.

Prospective Observational Study of N-terminal Pro-Brain Natriuretic Peptide Levels in Obese and Nonobese Women during Pregnancy.

OBJECTIVE: N-terminal pro-brain natriuretic peptide (NT-proBNP), a marker of ventricular dysfunction, varies by body mass index (BMI) outside of pregnancy. This study aimed to determine whether obesity affects NT-proBNP levels in pregnancy. STUDY DESIGN: This was a prospective observational study of healthy pregnant people in the third trimester (3TM) and postpartum (PP). Patients were excluded if they had significant medical comorbidities or if their fetuses had anomalies, growth restriction or aneuploidy. NT-proBNP was measured at 28 weeks (3TM), predelivery (PD), 1 to 2 days PP (immediate postpartum [IPP]), and 4 to 6 weeks PP (delayed postpartum [DPP]). LogNT-proBNP levels were analyzed using linear mixed effects models, including BMI < or ≥30, time, and time-by-BMI interactions. RESULTS: Fifty-five people (28 [51%] with BMI ≥ 30 and 27 [49%] with BMI < 30) were enrolled. A greater proportion of obese than nonobese subjects developed hypertensive disorders of pregnancy (50 vs. 15%, p = 0.010) and obese patients had higher systolic blood pressures at all time points (p < 0.05). NT-proBNP levels (median [interquartile range] in pg/mL) were 18 (6-28) versus 26 (17-48) at 3TM, 16 (3-38) versus 43 (21-60) at PD, 58 (20-102) versus 63 (38-155) at IPP, and 33 (27-56) versus 23 (8-42) at DPP for obese compared with nonobese patients. In linear mixed effects models, logNT-proBNP was lower in obese patients at 3TM (ß = -0.89 [95% confidence interval, CI: -1.51, -0.26]) and PD (ß = -1.05 [95% CI: -1.72, -0.38]). The logNT-proBNP trends over time differed by BMI category, with higher values in obese patients at both PP time points compared with the 3TM (IPP ß = 1.24 [95% CI: 0.75, 1.73]; DPP ß = 1.08 [95% CI: 0.52, 1.63]), but only IPP for nonobese patients (ß = 0.87 [95% CI: 0.36, 1.38]). CONCLUSION: Obese patients had lower NT-proBNP levels than nonobese patients during pregnancy but not PP. The prolonged PP elevation in NT-proBNP in obese patients suggests that their PP cardiac recovery may be more prolonged. KEY POINTS: · NT-proBNP levels are lower in obese than nonobese patients during pregnancy.. · Levels remain elevated in obese, but not nonobese, patients up to 4 to 6 weeks' postpartum.. · A lower threshold for concern regarding NT-proBNP levels may be needed in obese pregnant people..

Markers of ovarian reserve as predictors of future fertility.

OBJECTIVE: To determine the association between ovarian reserve biomarkers and future fertility among late reproductive-age women. DESIGN: Cohort study of participants enrolled in Time to Conceive (TTC), a time-to-pregnancy cohort study of the ovarian reserve biomarkers. SETTING: Community. PATIENT(S): Women aged 30-44 years without a history of infertility who provided a blood sample at enrollment in TTC and who agreed to future follow-up. INTERVENTION(S): Not applicable. MAIN OUTCOME MEASURE(S): The primary outcomes were probability of achieving a live birth >3 years after enrollment in TTC, diagnosis of infertility at any time, and time-to-pregnancy in future pregnancy attempts. RESULT(S): Women with diminished ovarian reserve, defined as those with an antimüllerian hormone (AMH) level <0.7 ng/mL or follicle-stimulating hormone (FSH) level ≥10 mIU/mL, did not have low risk of future live birth (relative risk [RR], 1.32; 95% confidence interval [CI], 0.95-1.83 and RR, 1.28; 95% CI, 0.97-1.70, respectively) compared with women with normal ovarian reserve after adjusting for age at blood draw, race, obesity, use of hormonal contraception, and year of enrollment in original study. Among women in the cohort that attempted to conceive, there was not a significant association between diminished ovarian reserve, as measured by AMH or FSH, and risk of future infertility (RR, 0.65; 95% CI, 0.21-2.07 and RR,1.69; 95% CI, 0.86-3.31, respectively). Similarly, there was no association between AMH and FSH levels and future fecundability (fecundability ratio, 0.97; 95% CI, 0.59, 1.60; and fecundability ration, 0.86; 95% CI, 0.55-1.36, respectively). CONCLUSION: Diminished ovarian reserve is not associated with reduced future reproductive capacity. Given the lack of association, women should be cautioned regarding use biomarkers of ovarian reserve as predictors of their future reproductive capacity.

Comparison of Open-Access, Trough-Only Online Calculators Versus Trapezoidal Method for Calculation of Vancomycin Area Under the Curve (AUC).

BACKGROUND: Vancomycin area-under-the-curve (AUC) monitoring is associated with reduced nephrotoxicity but may increase cost and workload for personnel compared to trough monitoring. OBJECTIVE: The purpose of this study was to compare the accuracy of vancomycin AUC calculated by open-access, online, trough-only calculators to AUCs calculated by the trapezoidal method (TM) using peak and trough concentrations. METHODS: This retrospective, multi-center study included adults ≥18 years old with stable renal function who received vancomycin with steady-state peak and trough concentrations. Areas under the curve calculated by TM were compared to AUCs calculated by 3 online calculators using trough-only options for calculation: ClinCalc, VancoVanco, and VancoPK. The primary outcome was actual difference in AUC between TM and the online calculators. Secondary outcomes were percent difference in AUC and clinical alignment in dose adjustments between methods. RESULTS: Seventy patients were included for analysis. There was a statistically significant difference in AUC between TM and ClinCalc (median actual difference: -52, P < 0.001) and VancoVanco (median actual difference: 95, P < 0.001), whereas there was no significant difference between TM and VancoPK (median actual difference: -0.8, P = 0.827). Discordant dose adjustments were indicated when comparing ClinCalc, VancoVanco, and VancoPK to TM in 28%, 36%, and 12% of cases, respectively. CONCLUSION: The AUC calculator most closely aligned with TM was VancoPK, whereas other included calculators were statistically different. Owing to the cost and complexity of obtaining multiple levels, our findings support using a single steady-state trough using VancoPK as an alternative to TM for calculation of vancomycin AUC.

Improving well-being for individuals with persistent pain after surgery for breast cancer, lobular carcinoma in situ, or ductal carcinoma in situ: A randomized clinical trial.

>276,000 Americans will be diagnosed with invasive breast cancer, lobular carcinoma in situ, or ductal carcinoma in situ this year and most will undergo breast surgery as part of their care. Although prognosis is excellent, many patients experience persistent post-surgical pain (PSP), which has no satisfactory pharmacological treatment. The causal contributions of pain-associated psychological factors (e.g., catastrophic thoughts about pain, psychological flexibility, self-efficacy) to the continuing burden of PSP have not yet been determined and may be opportune intervention targets. The randomized trial described here will compare the benefits of three manualized behavioral interventions for individuals with PSP. Participants will receive either: 1) self-guided health education (SGHE); 2) interventionist-guided health education (IGHE); or 3) interventionist-guided pain coping skills training with elements of acceptance and commitment therapy that specially target catastrophic thoughts about pain, self-efficacy, and psychological flexibility (CST-PSP). Participants will prospectively complete validated assessments of primary outcomes (PSP severity and interference) at baseline (pre-intervention) and 3-, 6-, and 12-months later. Validated measures of emotional distress and cancer-specific distress will be assessed as secondary outcomes. To test their roles as drivers of PSP, catastrophic thoughts about pain, self-efficacy, and psychological flexibility, will be assessed and statistically analyzed as mediators of hypothesized beneficial effects. The interventions' impacts on pain sensitivity and central sensitization will be investigated to test these physiological pathways as proximal drivers of PSP. To better characterize the patient experience, additional validated measures will be explored for associations with PSP, along with demographic and clinical factors. Trial registration: https://clinicaltrials.gov/ct2/show/NCT04225585, registered January 13, 2020.

Clinical and imaging predictors of the natural course of bland portal vein thrombus in cirrhotic patients.

BACKGROUND: Portal vein thrombus (PVT) in cirrhotic patients is associated with worsening portal hypertension, leads to increased complexity of necessary interventions such as transjugular liver portosystemic shunt or liver transplantation, and is associated with worse outcomes after liver transplantation. Additionally, there are no established consensus guidelines for management of bland PVT in cirrhotic patients, which currently exists on a spectrum and is patient and provider dependent. PURPOSE: The aim of this study was to determine whether there are associations between key clinical and imaging variables and bland PVT burden over time. MATERIAL AND METHODS: This exploratory, retrospective, single-center study included patients who underwent two or more multiphase CT or MRI examinations between 1/1/2013 and 12/31/2019 and had a diagnosis of PVT. Three readers independently evaluated all index and follow-up examinations for PVT burden using a proposed 8-point scale and the established Yerdel score. Key clinical factors were collected from the electronic medical record. The PVT burden over time and the association of this burden with key clinical and imaging variables were assessed using logistic regression models. RESULTS: 138 patients with cirrhosis and bland PVT were included in the analyses. Median age was 60 years (interquartile range 55-67; 90 men) and median follow-up time was 19.6 months. At baseline, the mean score was 2.31 (± 1.44) and at the final follow-up examination, the mean score was 2.52 (± 1.99). Baseline occlusion level was the only statistically significant association with worsening PVT burden in all four vascular territories (p-value < 0.0001). Anticoagulation status did not have a statistically significant association with change in thrombus burden in any vascular territory or cumulative thrombus burden across all territories (p-value 0.11-0.43). CONCLUSION: In conclusion, our study shows that in cirrhotic patients with bland PVT, the thrombus burden did not change significantly over time and baseline thrombus burden is the only clinical factor significantly associated with increasing burden over time.