Profiling of Non-Coding Regulators and Their Targets in Epicardial Fat from Patients with Coronary Artery Disease.

Epicardial fat is a continuously growing target of investigation in cardiovascular diseases due to both its anatomical proximity to the heart and coronary circulation and its unique physiology among adipose depots. Previous reports have demonstrated that epicardial fat plays key roles in coronary artery disease, but the non-coding RNA and transcriptomic alterations of epicardial fat in coronary artery disease have not been investigated thoroughly. Micro- and lncRNA microarrays followed by GO-KEGG functional enrichment analysis demonstrated sex-dependent unique mi/lncRNAs altered in human epicardial fat in comparison to subcutaneous fat in both patients with and without coronary artery disease (IRB approved). Among the 14 differentially expressed microRNAs in epicardial fat between patients with and without coronary artery disease, the hsa-miR-320 family was the most highly represented. IPW lncRNA interacted with three of these differentially expressed miRNAs. Next-generation sequencing and pathway enrichment analysis identified six unique mRNAs-miRNA pairs. Pathway enrichment identified inflammation, adipogenesis, and cardiomyocyte apoptosis as the most represented functions altered by the mi/lncRNAs and atherosclerosis and myocardial infarction among the highest cardiovascular pathologies associated with them. Overall, the epicardial fat in patients with coronary artery disease has a unique mi/lncRNA profile which is sex-dependent and has potential implications for regulating cardiac function.

Assessing Colorectal Cancer Screening Barriers in Rural Appalachia.

OBJECTIVES: The age-appropriate colorectal cancer (CRC) screening rate in the rural Appalachian area is low compared with the national rate, which may account for the overall higher incidence of CRC in this area. The purpose of this study was to explore potential barriers to CRC screening in the West Virginia Appalachian area. METHODS: A cross-sectional survey was designed to identify patient-reported barriers to CRC screening using the health belief model to assess their attitudes and behaviors. Autonomous paper-based surveys were randomly handed to individuals older than 50 years at various locations, including healthcare and nonhealthcare facilities. All of the responses were then categorized into two groups: the screened group and the unscreened group. Differences among both groups were statistically analyzed. RESULTS: There were three main areas that significantly accounted for the discrepancies between the screened and unscreened groups: perceptions of discomfort from screening tests, psychological and behavior deterrents in CRC screening and diagnosis, and limited resources for accessing care, especially transportation. In particular, psychological and behavioral deterrents in CRC screening appeared to play a role in promoting aversion to CRC screening. CONCLUSIONS: Lack of CRC screening awareness and knowledge may be responsible for fatalism regarding CRC and aversion to screening. Thus, multidisciplinary interventions that provide education about CRC screening, early intervention prognosis, and treatment options, as well as addressing systemic barriers to screening, such as assistance with scheduling, prep instructions, and transportation, can improve the screening rate in Appalachia and eventually lead to better outcomes through the early diagnosis of CRC.

Effects of Norepinephrine Infusion on Cutaneous Surface Temperatures of the Distal Extremities.

OBJECTIVES: The etiology of vasopressor-induced digital necrosis is poorly understood, but the skin changes resemble those of frostbite, and it is known from experience that patients taking vasopressors have decreased digital temperatures. We aimed to examine the effects of norepinephrine use on surface temperatures of the distal extremities because there have been no studies examining this relation. METHODS: Surface temperatures of all digits, palms, and soles were measured using an infrared thermometer in patients receiving different rates of norepinephrine infusion in the intensive care unit and compared with those not receiving any vasopressors. RESULTS: A total of 101 measurements from 41 unique individuals were obtained. Temperature gradients between the core and the fingertips were consistently more pronounced in those receiving norepinephrine compared with those not receiving norepinephrine and increased with increasing rates of norepinephrine infusion, except with high-dose norepinephrine. Temperature gradients were more pronounced in the toes. CONCLUSIONS: Norepinephrine use was associated with greater core-to-fingertip temperature gradients and were more pronounced in the toes compared with the fingers.

Comparison of Geriatric Trauma Outcomes When Admitted to a Medical or Surgical Service After a Fall.

BACKGROUND: Blunt trauma in the geriatric population is fraught with poor outcomes, with injury severity and comorbidities impacting morbidity and mortality. METHODS: We retrospectively reviewed 2172 patients aged ≥65 y who fell, requiring hospital admission between January 2012 and December 2016. There were 403 patients in the surgical arm (SA) and 1769 patients in the medical arm (MA). Ground-level falls were the only mechanism of injury included. We excluded all ICU admissions and deaths within 24 h. RESULTS: There were 5 deaths (1.24%) in the SA and 16 deaths (0.90%) in the MA (P = 0.57). The mean trauma injury severity score survival probability prediction in the SA was 96.9% versus 97.1% in the MA. MA patients had more comorbidities overall than SA patients. There was no difference in mortality between the SA and MA groups in multiple logistic regression models that accounted for trauma injury severity scores (TRISS) and comorbidities. Unadjusted hospital length of stay was 1 d shorter (median; 95% CI -1.4 to -0.6) in the SA and 0.5 d shorter (median; 95% CI -0.8 to -0.1) when adjusted for TRISS and comorbidities using multiple quantile regression. Finally, patients in the SA were 2.1 (95% CI 1.7 to 2.6) times more likely to be discharged home compared with patients in the MA, and this remained significant (OR 1.9; 95% CI 1.5 to 2.5) with simultaneous adjustment for TRISS and comorbidities using multiple logistic regression. CONCLUSIONS: Geriatric blunt trauma patients admitted to surgical services after mechanical falls have no difference in survival, a shorter median length of stay, and increased likelihood of being discharged home compared with patients admitted to medical services.

Outcomes After Open Reduction With Internal Fixation of Mandible Fractures.

INTRODUCTION/HYPOTHESIS: Mandible fractures contribute substantially to morbidity after blunt trauma. Controversy exists surrounding the appropriate timing of surgical intervention and benefit from routine postreduction imaging. METHODS: The authors retrospectively reviewed 146 patients who sustained traumatic mandible fractures at a level 2 trauma center over a 5-year period, between January 2012 and December 2016. The authors excluded all patients who did not undergo surgery, underwent operative closed reduction only, sustained other significant maxillofacial injuries, penetrating mechanisms, and other major injuries based on injury severity scores (ISS) over 15. There were 51 patients meeting inclusion criteria. The authors reviewed admission face computed tomography (CT) scans and Panorex x-rays. Patients were divided into early (<72 hours) and late (>72 hours) open reduction with internal fixation (ORIF) groups. The authors reviewed demographics, mechanism of injury, postreduction imaging, and ISS. All statistical analyses were performed using Stata 15. RESULTS: There were 39 males (76%) and 12 females (24%) in the authors' study, with a mean age of 32 years. Twenty-eight patients (55%) underwent early ORIF and 23 patients (45%) underwent late ORIF, with no mortalities. There was no statistically significant difference in ISS between the 2 groups (P = 0.081). Preoperative face CT scans were performed in 49 patients (96%) and Panorex in 2 patients (4%). Eight patients (16%) had both modalities, with CT face identifying fractures in 5 patients not seen on Panorex, resulting in a change in operative approach. Postreduction imaging was obtained in 33 patients (65%), of whom 26 were Panorex X-rays. These demonstrated adequate reduction in 31 patients (94%) and did not change management in any instance. Complications occurred in 19 patients (37%), of whom there were 11 with uncontrolled pain after 1 week, 6 abscesses, 5 nonunions/malunions, 2 hardware extrusions, and 1 incisional dehiscence. A positive urine drug screen predicted uncontrolled pain (P < 0.05). There was no statistically significant difference in complications between the 2 groups. CONCLUSION: The authors' data suggest that CT scans of the face are superior to panoramic radiographs in traumatic mandible fracture evaluation, with no apparent benefit from routine postreduction imaging in detecting complications. Open reduction with internal fixation remains an effective treatment with favorable outcomes, and operative delays > 72 hours do not appear to increase complication rates.

The Tri-State Experience. Outcome Analysis of Patients with Triple Negative Breast Cancer Treated at Marshall University.

Breast cancer is the most frequently diagnosed malignancy in women in the United States. It is the second most common malignancy to cause death, with approximately 39,000 women dying of breast cancer in the United States in 2013. Triple negative breast cancer is defined as the absence of estrogen, progesterone and human epidermal growth factor receptor 2 receptors. It has been associated with a higher incidence in African American women, a younger age and a more advanced stage at diagnosis, and an inferior overall survival. To recognize the differences of our West Virginia community population when compared to the national average, we conducted a retrospective review of all patients diagnosed with breast cancer from 2000-2012.

Recognizing Guttate Psoriasis and Initiating Appropriate Treatment.

Guttate psoriasis is a less common form of psoriasis. It manifests with numerous small, teardrop shaped, scaly plaques on the trunk and extremities. The etiology includes both environmental and genetic factors. It commonly arises 3-4 weeks following a beta hemolytic streptococcal infection. In some cases, it may be misdiagnosed as an allergy to the antibiotics being used to treat the streptococcal infection. The treatment of guttate psoriasis can vary by severity, but the mainstay treatment includes photo therapy and topical steroids. This case report presents the etiology, clinical findings and current treatment options of guttate psoriasis. It also discusses importance of differentiating guttate psoriasis from an antibiotic allergy. The confusion between the two can often delay and make treatment more difficult.

Features on Computed Tomography That Correlate With Acute Appendicitis.

Background: The purpose of this study is to investigate the relevant findings in adult patients admitted to Cabell Huntington Hospital who were diagnosed with acute appendicitis. Methods: Patients who had the postoperative diagnosis of acute appendicitis and a preoperative computed tomography (CT) scan from January 2011 through December 2016 were included in this retrospective chart review. Results: There were 592 patients. A thick, edematous appendix was the most common CT finding in acute appendicitis. The average diameter was 12.6 mm. The wall thickness correlated to the diameter of the appendix (P < 0.001). For comparison, we reviewed the CT scans of 50 trauma patients who had normal abdominal CT scans. The average diameter of a normal appendix was 4.9 mm (SD 1.139) with a range of 4-7 mm. Interestingly, the admission white blood cell count (P = 0.0372) as well as the thickness of the appendix (P < 0.0001) were strongly associated with increased length of stay. Conclusions: An appendiceal diameter greater than 9 mm should be considered abnormal and associated with acute appendicitis. Appendiceal size, white blood cell count, and age correlate with length of stay. Early antibiotics and early surgical intervention may decrease length of stay.

Outcomes of primary percutaneous intervention of the unprotected left main coronary artery stenosis in myocardial infarction.

OBJECTIVE: The aim of our study was to examine the 30-day and 1-year survival rate for patients undergoing percutaneous coronary artery intervention (PCI) of unprotected left main (ULM) stenosis by the presence (acute myocardial infarction [AMI] group) or absence (non-AMI group) of AMI at the time of hospital admission. METHODS: We retrospectively reviewed 64 patients undergoing PCI of ULM stenosis at our regional heart institute between 2000 and 2008. Patients had no history of coronary artery bypass grafting. RESULTS: Thirty-six men and 28 women underwent PCI for ULM stenosis. Overall Kaplan-Meier survival at 30 days and 1 year was 71.5% and 57.8%, respectively. Thirty-three patients (51.6%) presented with AMI. Those with AMI had lower survival at both 30 days (59.2 vs 83.9%; P = 0.04) and 1 year (45.2 vs 70.2%; P = 0.04) compared with those without AMI. Compared with a lesion involving only the ostial/mid LM, diffuse disease (N = 11) was associated with an increased mortality at 1 year (hazard ratio 0.27; 95% confidence interval 0.09-0.79). A stent size >3 mm was associated with lower mortality at 1 year (hazard ratio 0.42; 95% confidence interval 0.19-0.93). CONCLUSIONS: We found that AMI at presentation was significantly associated with higher mortality in patients undergoing ULM stenting. LM lesion location and stent size were both significantly associated with mortality. ULM stenting is an option in patients who are unable to undergo coronary artery bypass grafting, but patients should understand the overall high risk of mortality, particularly if they present with AMI.

Quality improvement in an anticoagulation clinic: development of a new treatment protocol.

We sought to improve patient outcomes and efficiency in our anticoagulation clinic through development of a new protocol for managing heart valve patients with subtherapeutic international normalized ratio (INR) tests. The new protocol standardized use of 1 anticoagulation agent while warfarin was retitrated, timelines for INR retesting, and target INR levels depending on the type of valve implanted. The new protocol provided significant improvements in patient care; however, outcomes for clinic operating efficiency were mixed.

Impact of MRSA polymerase chain reaction (PCR) wound swabs on antibiotic de-escalation in skin and soft tissue infections.

Methicillin-resistant strains of S. aureus (MRSA) polymerase chain reaction (PCR) testing is a laboratory test that allows for rapid detection of MRSA and is available to use in skin infections via wound swab. There are limited data demonstrating the utility of MRSA PCR wound swabs on clinical outcomes in skin and soft tissue infections. This retrospective, single-center study included 652 patients to determine if the use of a MRSA PCR wound swab in skin infections results in a more rapid de-escalation in antibiotics. Patients with a MRSA PCR negative wound swab demonstrated a 1.0 (-1.5 to -0.53) day reduction of anti-MRSA antibiotic usage compared to those in the control group who did not have a MRSA PCR available (wound culture data only) (P < 0.001, unadjusted). The results of this study demonstrate that MRSA PCR wound swab assays have the potential to play a significant role in antibiotic de-escalation in the setting of skin and soft tissue infections.

Post-ablative hypothyroidism.

OBJECTIVE: To determine the incidence of hypothyroidism following radioactive iodine (RAI) treatment for hyperthyroidism and to study the relationship between pretreatment RAI uptake and treatment dose and the subsequent development of hypothyroidism. METHODS: Retrospective chart review of patients treated with RAI for hyperthyroidism between 1995 and 2000. 180 charts were reviewed; 41 met the inclusion criteria. Data were collected regarding the cause of hyperthyroidism, initial RAI uptake, initial dose of RAI, number of RAI treatments, and post treatment thyroid status. RESULTS: Patients in toxic nodular goiter group had significantly lower 24-hour RAI-123 uptake as compared to those with Graves' disease. However patients with Graves' disease received significantly lower RAI dose in comparison to those with toxic nodular goiters. Cure rates following RAI administration were similar in both groups. 70% of patients with Graves' disease developed post-ablative hypothyroidism as compared to 42% in toxic nodular goiter group (p = 0.086). There was no relationship between the dose of RAI or pretreatment RAI uptake and the likelihood of developing hypothyroidism. CONCLUSION: We found that, within our study population, post-ablative hypothyroidism tended to be more prevalent in patients with Graves' disease as compared to those with toxic nodular goiter. However cure rates following RAI administration were similar in both groups. We also found that neither the magnitude of the administered RAI dose nor the pre-treatment RAI uptake predicted the development of subsequent hypothyroidism.

Dual role for angiotensin-converting enzyme 2 in Severe Acute Respiratory Syndrome Coronavirus 2 infection and cardiac fat.

Angiotensin-converting enzyme 2 (ACE2) has been an increasingly prevalent target for investigation since its discovery 20 years ago. The finding that it serves a counterregulatory function within the traditional renin-angiotensin system, implicating it in cardiometabolic health, has increased its clinical relevance. Focus on ACE2's role in cardiometabolic health has largely centered on its apparent functions in the context of obesity. Interest in ACE2 has become even greater with the discovery that it serves as the cell receptor for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), opening up numerous mechanisms for deleterious effects of infection. The proliferation of ACE2 within the literature coupled with its dual role in SARS-CoV-2 infection and obesity necessitates review of the current understanding of ACE2's physiological, pathophysiological, and potential therapeutic functions. This review highlights the roles of ACE2 in cardiac dysfunction and obesity, with focus on epicardial adipose tissue, to reconcile the data in the context of SARS-CoV-2 infection.

Benzodiazepine Overuse in Elders: Defining the Problem and Potential Solutions.

Objective To determine the prevalence of benzodiazepine use in adults aged 65 and older at two West Virginia academic medical centers as phase one of a benzodiazepine deprescribing strategy.  Design Cross-sectional Setting Two academic hospitals in West Virginia with 107,504 hospitalized adults age 65 and older from the years 2010 to 2018 with information on admission medication use.  Measurements Use of benzodiazepines based on presence on the admission medication list. Demographics, select co-morbidities, and laboratory tests were also recorded.  Results The prevalence of benzodiazepine use was 13.5% and use remained relatively constant with increasing age over 65, even in those over age 89.  Conclusion Efforts aimed at assessing the true need for benzodiazepine use and deprescribing need to be employed, particularly with advancing age.

Relationship between dietary sodium and sugar intake: A cross-sectional study of the National Health and Nutrition Examination Survey 2001-2016.

Dietary sodium intake and cardiovascular outcomes have a reported J-shaped curve relationship. This study analyzes the relationship between dietary sodium and sugar intake as a potential mechanism to explain this association. The authors examined cross-sectional data from the National Health and Nutrition Examination Survey (NHANES) 2001-2016 where dietary sodium, carbohydrate, fat, cholesterol, and sugar intakes were assessed by 24-hour dietary recall and were standardized to a total daily intake of 2000 calories. Sodium intake was categorized into sodium quintiles (SQ) as follows: SQ1(0.06-2.6 g/d); SQ2(2.6-3.0 g/d); SQ3(3.0-3.4 g/d); SQ4(3.4-4.0 g/d); and SQ5(4.0-29.3 g/d). Simple and multivariate linear regression using SQ3 as reference were used to assess associations between daily sodium intake and the other nutrients. Our results showed that among 38 722 participants that met our study criteria, the mean age was 43.6 years (SD 16.8 years) and sex was equally distributed (48.8% male vs 51.2% female). Sugar intake went down across increasing SQs and was significantly higher in SQ1 (141.2 g/d) and SQ2 (118.6 g/d) and significantly lower in SQ4 (97.9 g/d) and SQ5 (85.6 g/d) compared to SQ3 (108.6 g/d; all P < .01). These same trends remained unchanged and significant in the fully adjusted multivariate model. In conclusion, NHANES study participants reporting low sodium intake on 24-hour dietary recall have a higher consumption of sugar. The negative impact of low sodium diet on cardiovascular health may be explained at least partially by the associated high sugar intake.

Antibiotic Prescriptions for Upper Respiratory Infections in a Pediatric Office Versus an Urgent Care Center.

It is estimated that as many as 10 million unnecessary antibiotic prescriptions are written each year for children. Children are more likely to receive antibiotics for an upper respiratory infection in an urgent care center compared with the primary care office. However, no study has examined the antibiotic prescribing practices of the same physicians in these settings. This retrospective chart review evaluated pediatricians' antibiotic prescribing practices for patients with symptoms of an upper respiratory tract infection in the office setting and an urgent care setting. There was no difference in the total antibiotic prescribing rate by pediatricians in their primary care office versus an urgent care setting. Pediatricians who were high antibiotic prescribers in the office setting were also high prescribers in the urgent care. The highest prescribing physicians prescribed the appropriate recommended antibiotics for a particular diagnosis the lowest percentage of the time. Efforts to promote antimicrobial stewardship should be directed toward the individual physician and not toward the location where the patients are being evaluated.

Testing educational strategies for Shaken Baby Syndrome.

UNLABELLED: Shaken Baby Syndrome (SBS) occurs from the violent shaking of an infant, which may lead to brain damage or death. The goal of this study was to assess educational methods used to teach new mothers about SBS. METHODS: Forty six parents at a community hospital were selected and randomly divided into three groups. Group 1 received a short lesson about SBS. Group 2 received the lesson and watched a locally developed SBS video. Group 3 received the lesson and watched a true dramatization of SBS created by a national organization. Pre and post surveys were administered. RESULTS: Study groups were similar in regard to age, marital status, socioeconomic status and education. Group 1 parents showed no differences in scoring. Group 2 parents showed a significant increase in defining SBS and what to do for persistent infant crying. Group 3 parents scored significantly higher in defining SBS. CONCLUSION: Both video presentations improved scoring on understanding SBS but only the local video presentation increased scores in the management of persistent infant crying.

Effect of removing outliers on statistical inference: implications to interpretation of experimental data in medical research.

BACKGROUND: Data editing with elimination of "outliers" is commonly performed in the biomedical sciences. The effects of this type of data editing could influence study results, and with the vast and expanding amount of research in medicine, these effects would be magnified. METHODS AND RESULTS: We first performed an anonymous survey of medical school faculty at institutions across the United States and found that indeed some form of outlier exclusion was performed by a large percentage of the respondents to the survey. We next performed Monte Carlo simulations of excluding high and low values from samplings from the same normal distribution. We found that removal of one pair of "outliers", specifically removal of the high and low values of the two samplings, respectively, had measurable effects on the type I error as the sample size was increased into the thousands. We developed an adjustment to the t score that accounts for the anticipated alteration of the type I error (tadj=tobs-2(log(n)^0.5/n^0.5)), and propose that this be used when outliers are eliminated prior to parametric analysis. CONCLUSION: Data editing with elimination of outliers that includes removal of high and low values from two samples, respectively, can have significant effects on the occurrence of type 1 error. This type of data editing could have profound effects in high volume research fields, particularly in medicine, and we recommend an adjustment to the t score be used to reduce the potential for error.

Factors Associated with Functional Decline in Elderly Female Breast Cancer Patients in Appalachia.

Background Functional status has been previously shown in the elderly cancer population to predict both mortality as well as treatment tolerance. The goal of this study was to determine if there are certain subsets of the elderly breast cancer population that are at higher risk of experiencing functional decline following treatment. Methods Patient charts from the Edwards Comprehensive Cancer Center in Huntington, West Virginia, from January 2006 - January 2016 were reviewed. Relevant inclusion criteria included patients of 65 years of age and older with a new diagnosis of Stage 0-III breast cancer. Functional decline was defined as an increase of at least one point in Eastern Cooperative Oncology Group (ECOG) scores within one year of diagnosis. ECOG performance status was subjectively determined by the physician. Fisher's exact test and Pearson's Chi-squared test were initially utilized to assess potential factors associated with functional decline such as pretreatment ECOG score, age at diagnosis, stage, hormone receptor status, type of surgery received, whether radiation therapy, chemotherapy, or hormonal therapy was received, medical comorbidities, body mass index (BMI), complaints of weakness at diagnosis, and ambulatory status. Factors that were found to be significant were further assessed via multivariate logistic regressions. Results Three-hundred and fourteen patients were identified as meeting inclusion criteria. At one-year follow-up, 45 patients (14.3% of the cohort) had documented functional decline. On initial analysis, factors associated with functional decline included Stage III disease (p=0.002) and complaints of weakness at diagnosis (p=0.004). Following multivariate analysis, Stage III disease (p = 0.02), complaints of weakness at diagnosis (p = 0.04), and bilateral mastectomy (p = 0.03) were significantly associated with functional decline. Conclusion Patients who were diagnosed with Stage III breast cancer, had complaints of weakness at time of diagnosis, or had bilateral mastectomies were more likely to have a decline in functional status at one-year follow-up. Awareness of factors associated with functional decline in the elderly Appalachian population with Stage 0-III breast cancer will be useful during discussions regarding patient expectations, treatment, and goals of care. Elderly breast cancer patients for whom bilateral prophylactic mastectomies are not indicated may be better served by lumpectomy alone (based on patient age, hormone receptor status, and tumor size), lumpectomy followed by radiation therapy, or unilateral mastectomy to maximize the likelihood of functional preservation following treatment.