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OBJECTIVES: Aneurysmal subarachnoid hemorrhage (aSAH) is an emergent neurosurgical condition associated with high morbidity and mortality. The prognostic significance of baseline frailty status in aSAH patients has not been previously evaluated in a large, nationally representative sample. MATERIALS AND METHODS: Clinical outcomes data from the National Inpatient Sample from 2010-2018 were compared among sub-cohorts stratifying admissions by increasing frailty thresholds [(assessed using the 11-point modified frailty index (mFI-11)]. The previously validated NIS-SAH Severity Score (NIS-SSS) and NIS-SAH Outcome Measure (NIS-SOM) were utilized. Complex samples multivariable logistic regression and receiver operating characteristic (ROC) curve analyses were performed to assess adjusted associations and discrimination of frailty for endpoints. RESULTS: Among 64,102 aSAH hospitalizations (mean age 55.4 years), 20.4% of admissions were classified as robust (mFI=0), 43.4% as pre-frail (mFI = 1), 24.9% as frail (mFI = 2), and 11.2% as severely frail (mFI ≥ 3). Following multivariable analysis adjusting for age and aSAH severity, increasing frailty was independently associated with NIS-SOM (OR = 1.15, 95% CI 1.09-1.21; p < 0.001), extended length of hospital stay (eLOS) (OR = 1.08, 1.02-1.13; p = 0.008), neurological complications (OR = 1.08, 1.03-1.13; p < 0.001), and medical complications (OR = 1.14, 1.08-1.21; p < 0.001). Based on ROC curve analysis, frailty achieved an AUC of 0.59 (0.58-0.60) and 0.54 (0.53-0.55) for NIS-SOM and eLOS, respectively. Age and NIS-SSS demonstrated significantly greater discrimination for NIS-SOM [AUC 0.69 (0.68-0.70) and 0.79 (0.78-0.80), respectively), while NIS-SSS achieved significantly greater discrimination for eLOS [(AUC 0.74 (0.73-0.75)] in comparison to both age and frailty. CONCLUSIONS: This national database evaluation of frailty in aSAH patients demonstrates an independent association between increasing frailty and poor functional outcome. Age and aSAH severity, however, may be more robust prognostic factors.
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Fragilidade , Hemorragia Subaracnóidea , Fragilidade/complicações , Fragilidade/diagnóstico , Fragilidade/epidemiologia , Hospitalização , Humanos , Pacientes Internados , Tempo de Internação , Pessoa de Meia-Idade , Estudos Retrospectivos , Hemorragia Subaracnóidea/complicações , Hemorragia Subaracnóidea/diagnóstico , Hemorragia Subaracnóidea/terapia , Resultado do TratamentoRESUMO
BACKGROUND: Defining clinical phenotypes provides opportunities for new diagnostics and may provide insights into early intervention and disease prevention. There is increasing evidence that patient-derived health data may contain information that complements traditional methods of clinical phenotyping. The utility of these data for defining meaningful phenotypic groups is of great interest because social media and online resources make it possible to query large cohorts of patients with health conditions. METHODS: We evaluated the degree to which patient-reported categorical data is useful for discovering subclinical phenotypes and evaluated its utility for discovering new measures of disease severity, treatment response and genetic architecture. Specifically, we examined the responses of 1961 patients with inflammatory bowel disease to questionnaires in search of sub-phenotypes. We applied machine learning methods to identify novel subtypes of Crohn's disease and studied their associations with drug responses. RESULTS: Using the patients' self-reported information, we identified two subpopulations of Crohn's disease; these subpopulations differ in disease severity, associations with smoking, and genetic transmission patterns. We also identified distinct features of drug response for the two Crohn's disease subtypes. These subtypes show a trend towards differential genotype signatures. CONCLUSION: Our findings suggest that patient-defined data can have unplanned utility for defining disease subtypes and may be useful for guiding treatment approaches.
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Doença de Crohn , Doenças Inflamatórias Intestinais , Doença de Crohn/diagnóstico , Doença de Crohn/tratamento farmacológico , Doença de Crohn/genética , Genótipo , Humanos , Fenótipo , Inquéritos e QuestionáriosRESUMO
BACKGROUND AND PURPOSE: While patients with angiogram-negative subarachnoid hemorrhages (ANSAH) have better prognoses than those with aneurysmal SAH, frailty's impact on outcomes in ANSAH is unclear. We previously showed that the modified frailty index (mFI-11) is associated with poor outcomes following ANSAH. Here, we compared the mFI-5, mFI-11, Charlson Comorbidity Index (CCI), and temporalis thickness (TMT) to determine which index was the best predictor of ANSAH outcomes and mortality rates. METHODS: In this retrospective cohort analysis between 2014 and 2018, patients with non-traumatic, angiogram negative SAH (ANSAH) were identified. The admission mFI-5, mFI-11, CCI, and TMT were calculated for each patient. Primary outcomes were mortality rate, discharge location, and prolonged length of stay (PLOS; LOS >85th percentile). Multivariate logistic regression and receiver operating characteristic (ROC) curves were used to evaluate frailty as predictors of primary endpoints. RESULTS: We included 75 patients with a mean age of 55.4 ± 1.5 years. There were 4 patient deaths (5.3%), 53 patients (70.7%) discharged home, and 11 patients (14.7%) with PLOS. On ROC analysis, the mFI-5 had the highest discriminatory value for mortality (AUC = 0.97) while the mFI-11 was most discriminatory for discharge home (AUC = 0.85) and PLOS (AUC = 0.78). On multivariate analysis, the only independent predictor of mortality was the mFI-11 (OR = 0.46; 95%CI: 1.45-14.23; p = 0.009) while the mFI-5 was the best predictor of discharge home (OR = 0.21; 95% CI: 0.08-0.61; p = 0.004). On multivariate analysis, the only independent predictor of PLOS was the Hunt and Hess score (OR = 2.63; 95%CI: 1.38-5.00; p = 0.003). The CCI and TMT were inferior to either mFI for predicting primary endpoints. CONCLUSIONS: Increasing frailty is associated with poorer outcomes and higher mortality following ANSAH. The mFI-5 and mFI-11 were found to be superior predictors of discharge home and mortality rate. While larger prospective study is needed, frailty, as measured by mFI-11 and -5, should be considered when evaluating ANSAH prognosis.
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Fragilidade , Hemorragia Subaracnóidea , Angiografia , Fragilidade/diagnóstico , Humanos , Pacientes Internados , Tempo de Internação , Pessoa de Meia-Idade , Alta do Paciente , Complicações Pós-Operatórias , Estudos Retrospectivos , Hemorragia Subaracnóidea/diagnóstico por imagem , Hemorragia Subaracnóidea/terapiaRESUMO
The ecological community of microorganisms in/on humans, termed the microbiome, is vital for sustaining homeostasis. While culture-independent techniques have revealed the role of the gut microbiome in human health and disease, the role of the cutaneous microbiome in wound healing is less defined. Skin commensals are essential in the maintenance of the epithelial barrier function, regulation of the host immune system, and protection from invading pathogenic microorganisms. In this review, we summarize the literature derived from pre-clinical and clinical studies on how changes in the microbiome of various acute and chronic skin wounds impact wound healing tissue regeneration. Furthermore, we review the mechanistic insights garnered from model wound healing systems. Finally, in the face of growing concern about antibiotic-resistance, we will discuss alternative strategies for the treatment of infected wounds to improve wound healing and outcomes. Taken together, it has become apparent that commensals, symbionts, and pathogens on human skin have an intimate role in the inflammatory response that highlights several potential strategies to treat infected, non-healing wounds. Despite these promising results, there are some contradictory and controversial findings from existing studies and more research is needed to define the role of the human skin microbiome in acute and chronic wound healing.
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Microbiota , Pele/microbiologia , Cicatrização , Infecção dos Ferimentos , Animais , Anti-Infecciosos/uso terapêutico , Humanos , Microbiota/efeitos dos fármacos , Probióticos/uso terapêutico , Cicatrização/efeitos dos fármacos , Infecção dos Ferimentos/tratamento farmacológico , Infecção dos Ferimentos/microbiologia , Infecção dos Ferimentos/terapiaRESUMO
PURPOSE: Erythrocytosis is the most common dose limiting adverse effect of testosterone therapy but the mechanisms of testosterone mediated erythropoiesis remain unclear. In this study we examine risk factors for erythrocytosis associated with testosterone therapy. MATERIALS AND METHODS: A retrospective review was performed of 179 hypogonadal men on testosterone therapy at a single andrology clinic. Demographic data, testosterone therapy formulation and duration of treatment, and 5α-reductase inhibitor use were assessed. Serum dihydrotestosterone, total testosterone, free testosterone, follicle-stimulating hormone, luteinizing hormone, hematocrit and lipid levels were extracted, and changes during treatment were determined. Spearman's rank correlation was used to identify relationships between change in hematocrit and study variables. RESULTS: Of 179 patients 49 (27%) experienced a 10% or greater change in hematocrit and erythrocytosis (hematocrit 50% or greater) developed in 36 (20.1%) at a median followup of 7 months. Topical gels were used by 41.3% of patients, injectable testosterone by 52.5% and subcutaneous pellets by 6.1%. More men who experienced a change in hematocrit of 10% or greater used injectable testosterone than men with a change in hematocrit of less than 10% (65% vs 48%, p=0.035), and were less likely to be on a 5α-reductase inhibitor (2% vs 15%, p=0.017). Men with a change in hematocrit of 10% or greater had higher posttreatment dihydrotestosterone levels (605.0 vs 436.0 ng/dl, p=0.017) and lower luteinizing hormone and follicle-stimulating hormone levels than men with a change in hematocrit of less than 10%. Spearman's rank correlations yielded relationships between change in hematocrit and posttreatment dihydrotestosterone ρ=0.258, p=0.001) and total testosterone (ρ=0.171, p=0.023). CONCLUSIONS: Dihydrotestosterone may have a role in testosterone therapy related erythrocytosis and monitoring dihydrotestosterone levels during testosterone therapy should be considered. In men in whom erythrocytosis develops, 5α-reductase inhibitors may be therapeutic.
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Di-Hidrotestosterona/sangue , Terapia de Reposição Hormonal/efeitos adversos , Policitemia/sangue , Policitemia/induzido quimicamente , Testosterona/efeitos adversos , Adulto , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de RiscoRESUMO
Toxoplasma gondii modifies its host cell to suppress its ability to become activated in response to IFN-γ and TNF-α and to develop intracellular antimicrobial effectors, including NO. Mechanisms used by T. gondii to modulate activation of its infected host cell likely underlie its ability to hijack monocytes and dendritic cells during infection to disseminate to the brain and CNS where it converts to bradyzoites contained in tissue cysts to establish persistent infection. To identify T. gondii genes important for resistance to the effects of host cell activation, we developed an in vitro murine macrophage infection and activation model to identify parasite insertional mutants that have a fitness defect in infected macrophages following activation but normal invasion and replication in naive macrophages. We identified 14 independent T. gondii insertional mutants out of >8000 screened that share a defect in their ability to survive macrophage activation due to macrophage production of reactive nitrogen intermediates (RNIs). These mutants have been designated counter-immune mutants. We successfully used one of these mutants to identify a T. gondii cytoplasmic and conoid-associated protein important for parasite resistance to macrophage RNIs. Deletion of the entire gene or just the region encoding the protein in wild-type parasites recapitulated the RNI-resistance defect in the counter-immune mutant, confirming the role of the protein in resistance to macrophage RNIs.
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Proteínas de Protozoários/isolamento & purificação , Toxoplasma/fisiologia , Regiões 5' não Traduzidas/genética , Processamento Alternativo , Animais , Citosol/química , Deleção de Genes , Genes de Protozoários , Ativação de Macrófagos , Macrófagos/parasitologia , Camundongos , Camundongos Endogâmicos C57BL , Mutagênese Insercional , Doadores de Óxido Nítrico/farmacologia , Organelas/química , Isoformas de Proteínas/química , Isoformas de Proteínas/fisiologia , Proteínas de Protozoários/química , Proteínas de Protozoários/genética , Proteínas de Protozoários/fisiologia , Espécies Reativas de Nitrogênio/metabolismo , Homologia de Sequência de Aminoácidos , Toxoplasma/efeitos dos fármacos , Toxoplasma/genética , Toxoplasma/ultraestruturaRESUMO
Frailty is an emerging concept in clinical practice used to predict outcomes and dictate treatment algorithms. Frail patients, especially older adults, are at higher risk for adverse outcomes. Aneurysmal subarachnoid hemorrhage (aSAH) is a neurosurgical emergency associated with high morbidity and mortality rates that have previously been shown to correlate with frailty. However, the relationship between treatment selection and post-treatment outcomes in frail aSAH patients is not established. We conducted a meta-analysis of the relevant literature in accordance with PRISMA guidelines. We searched PubMed, Embase, Web of Science, and Google Scholar using "Subarachnoid hemorrhage AND frailty" and "subarachnoid hemorrhage AND frail" as search terms. Data on cohort age, frailty measurements, clinical grading systems, and post-treatment outcomes were extracted. Of 74 studies identified, four studies were included, with a total of 64,668 patients. Percent frailty was 30.4% under a random-effects model in all aSAH patients (p < 0.001). Overall mortality rate of aSAH patients was 11.7% when using a random-effects model (p < 0.001). There was no significant difference in mortality rate between frail and non-frail aSAH patients, but this analysis only included two studies and should be interpreted cautiously. Age and clinical grading, rather than frailty, independently predicted outcomes and mortality in aSAH patients.
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BACKGROUND: Increasing evidence supports the effectiveness of venous sinus stenting (VSS) with favorable outcomes, safety, and expenses compared with shunting for idiopathic intracranial hypertension. Yet, no evidence is available regarding optimal postoperative recovery, which has increasing importance with the burdens on health care imposed by the coronavirus disease 2019 pandemic. We examined adverse events and costs after VSS and propose an optimal recovery pathway to maximize patient safety and reduce stress on health care resources. METHODS: A retrospective review was undertaken of elective VSS operations performed from May 2008 to August 2021 at a single institution. Primary data included hospital length of stay, intensive care unit (ICU) length of stay, adverse events, need for ICU interventions, and hospital costs. RESULTS: Fifty-three patients (98.1% female) met the inclusion criteria. Of these patients, 51 (96.2%) were discharged on postoperative day (POD) 1 and 2 patients were discharged on POD 2. Both patients discharged on POD 2 remained because of groin hematomas from femoral artery access. There were no major complications or care that required an ICU. Eight patients (15.1%) were lateralized to other ICUs or remained in a postanesthesia care unit because the neurosciences ICU was above capacity. Total estimated cost for initial recovery day in a neurosciences ICU room was $2361 versus $882 for a neurosurgery/neurology ward room. In our cohort, ward convalescence would save an estimated $79,866 for bed placement alone and increase ICU bed availability. CONCLUSIONS: Our findings reaffirm the safety of VSS. These patients should recover on a neurosurgery/neurology ward, which would save health care costs and increase ICU bed availability.
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COVID-19 , Pseudotumor Cerebral , Humanos , Feminino , Masculino , Pseudotumor Cerebral/cirurgia , Procedimentos Neurocirúrgicos/efeitos adversos , Unidades de Terapia Intensiva , Atenção à Saúde , Estudos RetrospectivosRESUMO
BACKGROUND: Few studies have evaluated frailty in the setting of aneurysmal subarachnoid hemorrhage (aSAH) using large-scale data. The risk analysis index (RAI) may be implemented at the bedside or assessed retrospectively, differentiating it from other indices used in administrative registry-based research. METHODS: Adult aSAH hospitalizations were identified in the National Inpatient Sample (NIS) from 2015 to 2019. Complex samples statistical methods were performed to evaluate the comparative effect size and discriminative ability of the RAI, the modified frailty index (mFI), and the Hospital Frailty Risk Score (HFRS). Poor functional outcome was determined by the NIS-SAH Outcome Measure (NIS-SOM), shown to have high concordance with modified Rankin Scale scores > 2. RESULTS: 42,300 aSAH hospitalizations were identified in the NIS during the study period. By both ordinal [adjusted odds ratio (aOR) 3.20, 95% confidence interval (CI) 3.05, 3.36, p < 0.001] and categorical stratification [frail aOR 3.59, 95% CI 3.39, 3.80, p < 0.001; severely frail aOR 6.67, 95% CI 5.78, 7.69, p < 0.001], the RAI achieved the largest effect sizes for NIS-SOM in comparison with the mFI and HFRS. Discrimination of the RAI for NIS-SOM in high-grade aSAH was significantly greater than that of the HFRS (c-statistic 0.651 vs. 0.615). The mFI demonstrated the lowest discrimination in both high-grade and normal-grade patients. A combined Hunt and Hess-RAI model (c-statistic 0.837, 95% CI 0.828, 0.845) for NIS-SOM achieved significantly greater discrimination than both the combined models for mFI and HFRS (p < 0.001). CONCLUSION: The RAI was robustly associated with poor functional outcomes in aSAH independent of established risk factors.
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Fragilidade , Hemorragia Subaracnóidea , Adulto , Humanos , Hemorragia Subaracnóidea/complicações , Hemorragia Subaracnóidea/epidemiologia , Hemorragia Subaracnóidea/terapia , Estudos Retrospectivos , Fragilidade/diagnóstico , Fragilidade/epidemiologia , Resultado do Tratamento , Medição de RiscoRESUMO
BACKGROUND: Heparin induced thrombocytopenia Type II (HIT-II) is a dangerous thromboembolic complication of heparin therapy. The current literature on incidence and outcomes of HIT-II in aneurysmal subarachnoid hemorrhage (aSAH) patients remains sparse. OBJECTIVE: We report our institution's incidence and outcomes of HIT-II in aSAH patients. METHODS: We performed a retrospective cohort study at an academic medical center between June 2014 and July 2018. All patients had aSAH confirmed by digital subtraction angiography. Diagnosis of HIT-II was determined by positive results on both heparin PF4-platelet antibody ELISA (anti-PF4) and serotonin release assay (SRA). RESULTS: 204 patients met inclusion criteria. Seven patients (7/204, 3.5%) underwent laboratory testing, three of whom met clinical criteria. HIT-II incidence was confirmed in two of these seven patients (2/204, 0.98%), who had high BMI and T4 scores. CONCLUSION: Our institution's report of HIT-II incidence in aSAH patients is lower than previously reported in this population and more closely parallels HIT-II incidence in the general and surgical ICU setting. Widely-accepted American College of Chest Physicians (ACCP) clinical diagnostic criteria in conjunction with anti-PF4 and SRA testing is the gold standard of clinical diagnosis of HIT-II in aSAH patients.
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Hemorragia Subaracnóidea , Trombocitopenia , Trombose , Humanos , Hemorragia Subaracnóidea/diagnóstico por imagem , Hemorragia Subaracnóidea/tratamento farmacológico , Estudos Retrospectivos , Trombocitopenia/induzido quimicamente , Heparina/efeitos adversos , Anticoagulantes/efeitos adversosRESUMO
INTRODUCTION: Acute kidney injury (AKI) is associated with poor outcome in aneurysmal subarachnoid hemorrhage patients (aSAH). Frailty has recently been demonstrated to correlate with elevated mortality and morbidity; its impact on predicting AKI and mortality in aSAH patients has not been investigated. OBJECTIVE: Evaluating risk factors and predictors for AKI in aSAH patients. METHODS: aSAH patients from a single-center's prospectively maintained database were retrospectively evaluated for development of AKI within 14 days of admission. Baseline demographic and clinical characteristics were collected. The effect of frailty and other risk factors were evaluated. RESULTS: Of 213 aSAH patients, 53 (33.1%) were frail and 12 (5.6%) developed AKI. Admission serum creatinine (sCr) and peak sCr within 48â h were higher in frail patients. AKI patients showed a trend towards higher frailty. Mortality was significantly higher in AKI than non-AKI aSAH patients. Frailty was a poor predictor of AKI when controlling for Hunt and Hess (HH) grade or age. HH grade ≥ 4 strongly predicted AKI when controlling for frailty. CONCLUSION: AKI in aSAH patients carries a poor prognosis. The HH grade appears to have superior utility as a predictor of AKI in aSAH patients than mFI.
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Injúria Renal Aguda , Fragilidade , Hemorragia Subaracnóidea , Humanos , Hemorragia Subaracnóidea/etiologia , Estudos Retrospectivos , Fragilidade/complicações , Fatores de Risco , Injúria Renal Aguda/complicaçõesRESUMO
PURPOSE OF REVIEW: This review looks at the literature on varicocele repair and its effect on assisted reproductive techniques. The effects of varicocele correction on improved sperm production have been well documented with semen analysis data. What remain to be elucidated are the causes of the varicocele effect and how correction of the resultant pathophysiology may affect the outcomes of modern assisted reproductive technology. RECENT FINDINGS: Basic science research shows us that varicoceles exert deleterious effects on Leydig cells, Sertoli cells, and germ cells via very different mechanisms. The effects of varicocele correction on the reproductive potential of sperm are less well understood. Clinical research has shown improved semen parameters, DNA integrity, and assisted reproductive technology outcomes after varicocele repair. SUMMARY: Varicocele correction presents a possible method to optimize a couples' reproductive potential or decrease the need for complex assisted reproductive technology.
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Fertilidade , Infertilidade Masculina/prevenção & controle , Técnicas de Reprodução Assistida , Testículo/cirurgia , Procedimentos Cirúrgicos Urológicos Masculinos , Varicocele/cirurgia , Animais , Dano ao DNA , Humanos , Infertilidade Masculina/etiologia , Infertilidade Masculina/patologia , Infertilidade Masculina/fisiopatologia , Masculino , Análise do Sêmen , Espermatogênese , Espermatozoides/patologia , Testículo/patologia , Testículo/fisiopatologia , Resultado do Tratamento , Procedimentos Cirúrgicos Urológicos Masculinos/efeitos adversos , Varicocele/complicações , Varicocele/patologia , Varicocele/fisiopatologiaRESUMO
A substantial proportion of the adult United States population with type 2 diabetes (T2D) are undiagnosed, calling into question the comprehensiveness of current screening practices, which primarily rely on age, family history, and body mass index (BMI). We hypothesized that a polygenic score (PGS) may serve as a complementary tool to identify high-risk individuals. The T2D polygenic score maintained predictive utility after adjusting for family history and combining genetics with family history led to even more improved disease risk prediction. We observed that the PGS was meaningfully related to age of onset with implications for screening practices: there was a linear and statistically significant relationship between the PGS and T2D onset (-1.3 years per standard deviation of the PGS). Evaluation of U.S. Preventive Task Force and a simplified version of American Diabetes Association screening guidelines showed that addition of a screening criterion for those above the 90th percentile of the PGS provided a small increase the sensitivity of the screening algorithm. Among T2D-negative individuals, the T2D PGS was associated with prediabetes, where each standard deviation increase of the PGS was associated with a 23% increase in the odds of prediabetes diagnosis. Additionally, each standard deviation increase in the PGS corresponded to a 43% increase in the odds of incident T2D at one-year follow-up. Using complications and forms of clinical intervention (i.e., lifestyle modification, metformin treatment, or insulin treatment) as proxies for advanced illness we also found statistically significant associations between the T2D PGS and insulin treatment and diabetic neuropathy. Importantly, we were able to replicate many findings in a Hispanic/Latino cohort from our database, highlighting the value of the T2D PGS as a clinical tool for individuals with ancestry other than European. In this group, the T2D PGS provided additional disease risk information beyond that offered by traditional screening methodologies. The T2D PGS also had predictive value for the age of onset and for prediabetes among T2D-negative Hispanic/Latino participants. These findings strengthen the notion that a T2D PGS could play a role in the clinical setting across multiple ancestries, potentially improving T2D screening practices, risk stratification, and disease management.
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Background: Intra-arterial administration of chemotherapy with or without osmotic blood-brain barrier disruption enhances delivery of therapeutic agents to brain tumors. The aim of this study is to evaluate the safety of these procedures. Methods: Retrospectively collected data from a prospective database of consecutive patients with primary and metastatic brain tumors who received intra-arterial chemotherapy without osmotic blood-brain barrier disruption (IA) or intra-arterial chemotherapy with osmotic blood-brain barrier disruption (IA/OBBBD) at Oregon Health and Science University (OHSU) between December 1997 and November 2018 is reported. Chemotherapy-related complications are detailed per Common Terminology Criteria for Adverse Events (CTCAE) guidelines. Procedure-related complications are grouped as major and minor. Results: 4939 procedures (1102 IA; 3837 IA/OBBBD) were performed on 436 patients with various pathologies (primary central nervous system lymphoma [26.4%], glioblastoma [18.1%], and oligodendroglioma [14.7%]). Major procedure-related complications (IA: 12, 1%; IA/OBBBD: 27, 0.7%; P = .292) occurred in 39 procedures including 3 arterial dissections requiring intervention, 21 symptomatic strokes, 3 myocardial infarctions, 6 cervical cord injuries, and 6 deaths within 3 days. Minor procedure-related complications occurred in 330 procedures (IA: 41, 3.7%; IA/OBBBD: 289, 7.5%; P = .001). Chemotherapy-related complications with a CTCAE attribution and grade higher than 3 was seen in 359 (82.3%) patients. Conclusions: We provide safety and tolerability data from the largest cohort of consecutive patients who received IA or IA/OBBBD. Our data demonstrate that IA or IA/OBBBD safely enhance drug delivery to brain tumors and brain around the tumor.
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OBJECTIVES: We present the first review and meta-analysis of the association between adult stature and age at menarche over a broad range of human societies. We then outline possible biological explanations for observed empirical associations. METHODS: We analyzed the association between adult stature and age at menarche in 141 samples from published reports, including 35 samples for which the within-sample association was also reported. RESULTS: Overall and in small-scale societies, later age at menarche is associated with shorter adult stature. However, both between and within samples from industrialized societies, later age at menarche is associated with taller adult stature. CONCLUSIONS: The pattern of associations between adult stature and age at menarche may be explicable as a norm of reaction that evolved according to predictions of life history theory. However, nonadaptive explanations are also plausible, especially for the positive association observed in industrialized societies.
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Envelhecimento , Estatura , Menarca , Adaptação Fisiológica , Adolescente , Adulto , Criança , Feminino , HumanosRESUMO
INTRODUCTION: Penile cancer is rare, often presenting in later stages. We sought to determine if factors potentially related to access to care were associated with worse outcomes. METHODS: We performed a retrospective review of all patients with the diagnosis of penile cancer over a 14 year period at the only tertiary referral center in the state. We collected data on multiple factors potentially associated with access to care. RESULTS: Fifty-five patients with penile cancer were identified. The average age was 57 years. Of the 55 patients, 23 patients (42%) had private insurance carriers, 16 (29%) had Medicare/Medicaid, 13 (24%) had no insurance, one had VA benefits, and no data was available on two patients. Typically, 4% of patients seen at our institution are uninsured. Pathologic tumor stage distribution was Tis (n = 9), Ta (1), T1 (15), T2 (16), and T3 (4). Nodal disease was present in 11, four of whom (38%) were uninsured, and metastatic disease was present in three. Of the 55 patients, eight admitted to greater than two alcoholic drinks per day three, of whom 38% presented with advanced disease. School district graduation rate was also calculated and similar among all groups. Univariate and multivariate modeling revealed no factors associated with delay to care. CONCLUSIONS: Patients presenting to a referral center in the southeastern United States with penile cancer more commonly lack health insurance. Additionally, patients who are heavy alcohol users or are uninsured present with advanced disease. These factors contribute to poorer prognosis in these patients.
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Diagnóstico Tardio , Acessibilidade aos Serviços de Saúde , Neoplasias Penianas/patologia , Fatores Socioeconômicos , Consumo de Bebidas Alcoólicas , Humanos , Seguro Saúde , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Índice de Gravidade de Doença , Estados UnidosRESUMO
BACKGROUND: Previous studies have found that age at menarche is associated with stature, primarily via leg length. However, the effects appear to vary by population and/or time period. Improving socioeconomic conditions might amplify the association. AIM: To test whether the association between early menarche and reduced stature in industrialized countries is mediated by leg length. To further test whether these effects are modified by years of education, as a proxy for socioeconomic conditions. SUBJECTS AND METHODS: The study used data on from 3174 21-40 year-old women who participated in the third National Health and Nutrition Survey of the US (NHANES III). The anthropometric measurements employed were stature, sitting height and upper leg length. Leg length, lower leg length and ratio of sitting height to leg length were calculated. RESULTS: Earlier menarche was associated with shorter stature, by ~ 3.9 mm per year of advancement, all of which was attributable to shorter leg length. Almost two-thirds of the effect was in the lower (distal) leg. Years of education did not significantly modify effects of pubertal timing on stature or body proportions. CONCLUSION: Socioeconomic conditions might not explain variable associations between linear body proportions and pubertal timing.
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Envelhecimento/fisiologia , Antropometria , Menarca/fisiologia , Inquéritos Nutricionais , Adulto , Estatura/fisiologia , Escolaridade , Feminino , Humanos , Modelos Lineares , Estados Unidos/epidemiologia , Adulto JovemRESUMO
OBJECTIVE: In this systematic review, preoperative educational interventions for patients undergoing neurosurgical treatment are identified and their impact on patient knowledge acquisition and satisfaction is assessed. METHODS: The review was conducted in accordance with the PRISMA guidelines and used PubMed, Google Scholar, and MEDLINE databases. Studies evaluating before and after cohort or control group comparison were identified between 2007 and 2019 and were independently scored and evaluated by 3 authors. RESULTS: Eighty-one articles were assessed for eligibility and 15 met the inclusion criteria. Patient educational interventions were text-based (2 studies), multimedia/video-based (3), mobile/tablet-based (5), or used virtual reality (2) or three-dimensional printing (3). Interventions were disease-specific for cerebrovascular lesions (5), degenerative spine disease (2), concussion/traumatic brain injury (2), movement disorders (1), brain tumor (1), adolescent epilepsy (1), and other cranial/spinal elective procedures (3). Eleven studies (n = 18-175) documented patient knowledge acquisition using self-reported knowledge questionnaires (5) or more objective assessments based on true/false or multiple-choice questions (6). Most studies (10/11) reported statistically significant increases in patient knowledge after implementation of the intervention. Ten studies (n = 14-600) documented patient satisfaction using validated satisfaction surveys (2), Likert scale surveys (6), or other questionnaires (2). Although all studies reported increases in patient satisfaction after the intervention, only 4 were statistically significant. CONCLUSIONS: Patient educational interventions using various modalities are broadly applicable within neurosurgery and ubiquitously enhance patient knowledge and satisfaction. Interventions should be implemented when possible.
Assuntos
Conhecimentos, Atitudes e Prática em Saúde , Multimídia , Procedimentos Neurocirúrgicos , Educação de Pacientes como Assunto/métodos , Satisfação do Paciente , Cuidados Pré-Operatórios , Recursos Audiovisuais , Humanos , Realidade VirtualRESUMO
Although hyperglycemia is associated with worse outcomes after aneurysmal subarachnoid hemorrhage (aSAH), there is no consensus on the optimal glucose control metric, acceptable in-hospital glucose ranges, or suitable insulin regimens in this population. In this single-center retrospective cohort study of aSAH patients, admission glucose, and hospital glucose mean (MHG), minimum (MinG), maximum (MaxG), and variability were compared. Primary endpoints (mortality, complications, and vasospasm) were assessed using multivariate logistic regressions. Of the 217 patients included, complications occurred in 83 (38.2%), 124 (57.1%) had vasospasm, and 41 (18.9%) died. MHG was independently associated with (p < 0.001) mortality, MaxG (p = 0.017) with complications, and lower MinG (p = 0.015) with vasospasm. Patients with MHG ≥ 140 mg/dL had 10 × increased odds of death [odds ratio (OR) = 10.3; 95% CI 4.6-21.5; p < 0.0001] while those with MinG ≤ 90 mg/dL had nearly 2× increased odds of vasospasm (OR = 1.8; 95% CI 1.01-3.21; p = 0.0422). While inpatient insulin was associated with increased complications and provided no mortality benefit, among those with MHG ≥ 140 mg/dL insulin therapy resulted in lower mortality (OR = 0.3; 95% CI 0.1-0.9; p = 0.0358), but no increased complication risk. While elevated MHG and MaxG are highly associated with poorer outcomes after aSAH, lower MinG is associated with increased vasospasm risk. Future trials should consider initiating insulin therapy based on MHG rather than other hyperglycemia measures.
Assuntos
Hiperglicemia/metabolismo , Hemorragia Subaracnóidea/complicações , Feminino , Índice Glicêmico , Humanos , Hiperglicemia/etiologia , Hiperglicemia/mortalidade , Masculino , Pessoa de Meia-Idade , Razão de Chances , Estudos Retrospectivos , Hemorragia Subaracnóidea/mortalidade , Resultado do Tratamento , Vasoespasmo Intracraniano/etiologia , Vasoespasmo Intracraniano/metabolismo , Vasoespasmo Intracraniano/mortalidadeRESUMO
Intersexual conflicts over mating can engender antagonistic coevolution of strategies, such as coercion by males and selective resistance by females. Orangutans are exceptional among mammals for their high levels of forced copulation. This has typically been viewed as an alternative mating tactic used by the competitively disadvantaged unflanged male morph, with little understanding of how female strategies may have shaped and responded to this behaviour. Here, we show that male morph is not by itself a good predictor of mating dynamics in wild Bornean orangutans but that female conception risk mediated the occurrence and quality of male-female interactions. Near ovulation, females mated cooperatively only with prime flanged males who they encountered at higher rates. When conception risk was low, willingness to associate and mate with non-prime males increased. Our results support the hypothesis that, together with concealed ovulation, facultative association is a mechanism of female choice in a species in which females can rarely avoid coercive mating attempts. Female resistance, which reduced copulation time, may provide an additional mechanism for mate selection. However, coercive factors were also important as prime males were frequently aggressive to females and females used mating strategies consistent with infanticide avoidance.