Affiliated Clinics Research Articles

Influence of embryo culture medium (G5 and HTF) on pregnancy and perinatal outcome after IVF: a multicenter RCT.

Does embryo culture medium influence pregnancy and perinatal outcome in IVF? Embryo culture media used in IVF affect treatment efficacy and the birthweight of newborns. A wide variety of culture media for human preimplantation embryos in IVF/ICSI treatments currently exists. It is unknown which medium is best in terms of clinical outcomes. Furthermore, it has been suggested that the culture medium used for the in vitro culture of embryos affects birthweight, but this has never been demonstrated by large randomized trials. We conducted a multicenter, double-blind RCT comparing the use of HTF and G5 embryo culture media in IVF. Between July 2010 and May 2012, 836 couples (419 in the HTF group and 417 in the G5 group) were included. The allocated medium (1:1 allocation) was used in all treatment cycles a couple received within 1 year after randomization, including possible transfers with frozen-thawed embryos. The primary outcome was live birth rate. Couples that were scheduled for an IVF or an ICSI treatment at one of the six participating centers in the Netherlands or their affiliated clinics. The live birth rate was higher, albeit nonsignificantly, in couples assigned to G5 than in couples assigned to HTF (44.1% (184/417) versus 37.9% (159/419); RR: 1.2; 95% confidence interval (CI): 0.99-1.37; P = 0.08). Number of utilizable embryos per cycle (2.8 ± 2.3 versus 2.3 ± 1.8; P < 0.001), implantation rate after fresh embryo transfer (20.2 versus 15.3%; P < 0.001) and clinical pregnancy rate (47.7 versus 40.1%; RR: 1.2; 95% CI: 1.02-1.39; P = 0.03) were significantly higher for couples assigned to G5 compared with those assigned to HTF. Of the 383 live born children in this trial, birthweight data from 380 children (300 singletons (G5: 163, HTF: 137) and 80 twin children (G5: 38, HTF: 42)) were retrieved. Birthweight was significantly lower in the G5 group compared with the HTF group, with a mean difference of 158 g (95% CI: 42-275 g; P = 0.008). More singletons were born preterm in the G5 group (8.6% (14/163) versus 2.2% (3/137), but singleton birthweight adjusted for gestational age and gender (z-score) was also lower in the G5 than in the HTF group (-0.13 ± 0.08 versus 0.17 ± 0.08; P = 0.008). This study was powered to detect a 10% difference in live births while a smaller difference could still be clinically relevant. The effect of other culture media on perinatal outcome remains to be determined. Embryo culture media used in IVF affect not only treatment efficacy but also perinatal outcome. This suggests that the millions of human embryos that are cultured in vitro each year are sensitive to their environment. These findings should lead to increased awareness, mechanistic studies and legislative adaptations to protect IVF offspring during the first few days of their existence. This project was partly funded by The NutsOhra foundation (Grant 1203-061) and March of Dimes (Grant 6-FY13-153). The authors declare no conflict of interest. NTR1979 (Netherlands Trial Registry). 1 September 2009. 18 July 2010.

"There were more decisions and more options than just yes or no": Evaluating a decision aid for advanced cancer patients and their family caregivers.

Few decision aids are available for patients with a serious illness who face many treatment and end-of-life decisions. We evaluated the Looking Ahead: Choices for Medical Care When You're Seriously Ill® patient decision aid (PtDA), one component of an early palliative care clinical trial. Our participants included individuals with advanced cancer and their caregivers who had participated in the ENABLE (Educate, Nurture, Advise, Before Life Ends) early palliative care telehealth randomized controlled trial (RCT) conducted in a National Cancer Institute-designated cancer center, a U.S. Department of Veterans Affairs medical center, and affiliated outreach clinics in rural New England. ENABLE included six weekly patient and three weekly family caregiver structured sessions. Participants watched the Looking Ahead PtDA prior to session 3, which covered content on decision making and advance care planning. Nurse coaches employed semistructured interviews to obtain feedback from consecutive patient and caregiver participants approximately one week after viewing the Looking Ahead PtDA program (booklet and DVD). Between April 1, 2011, and October 31, 2012, 57 patients (mean age = 64), 42% of whom had lung and 23% gastrointestinal cancer, and 20 caregivers (mean age = 59), 80% of whom were spouses, completed the PtDA evaluation. Participants reported a high degree of satisfaction with the PtDA format, as well as with its length and clarity. They found the format of using patient interviews "validating." The key themes were: (1) "the earlier the better" to view the PtDA; (2) feeling empowered, aware of different options, and an urgency to participate in advance care planning. The Looking Ahead PtDA was well received and helped patients with a serious illness realize the importance of prospective decision making in guiding their treatment pathways. We found that this PtDA can help seriously ill patients prior to the end of life to understand and discuss future healthcare decision making. However, systems to routinely provide PtDAs to seriously ill patients are yet not well developed.

Family Caregiver Depressive Symptom and Grief Outcomes From the ENABLE III Randomized Controlled Trial

ContextLittle is known about whether early palliative care (EPC) support for family caregivers (CGs) impacts depressive symptoms and grief after care recipients die. ObjectivesTo assess after-death CG depressive symptom and grief scores for early compared to delayed group CGs. MethodsWe conducted a randomized controlled trial (10/2010–9/2013) of an EPC telehealth intervention for CGs (n = 123) initiated at the time of care recipients' advanced cancer diagnosis (early group) or 12 weeks later (delayed group) in a rural comprehensive cancer center, affiliated clinics, and a Veterans Administration medical center. The ENABLE [Educate, Nurture, Advise, Before Life Ends] CG intervention consisted of three weekly sessions, monthly follow-up, and a bereavement call. CGs completed the Center for Epidemiological Study–Depression (CES-D) scale and the Prigerson Inventory of Complicated Grief-Short Form (PG13) 8–12 weeks after care recipients' deaths. Crude and covariate-adjusted between-group differences were estimated and tested using general linear models. ResultsFor care recipients who died (n = 70), 44 CGs (early: n = 19; delayed: n = 25) completed after-death questionnaires. Mean depressive symptom scores (CES-D) for the early group was 14.6 (SD = 10.7) and for the delayed group was 17.6 (SD = 11.8). Mean complicated grief scores (PG13) for the early group was 22.7 (SD = 4.9) and for the delayed group was 24.9 (SD = 6.9). Adjusted between-group differences were not statistically significant (CES-D: d = 0.07, P = 0.88; PG13: d = −0.21, P = 0.51). ConclusionCGs' depressive symptom and complicated grief scores 8–12 weeks after care recipients' deaths were not statistically different based on the timing of EPC support. The impact of timing of CG EPC interventions on CGs bereavement outcomes requires further investigation.

Sac Size and Fetal Heart Rate as Predictor of Miscarriage in Patients Undergoing Infertility Treatment [18G

INTRODUCTION: Pregnancies achieved by assisted reproductive technology (ART) are associated with a spontaneous miscarriage (SAB) rate as high as a 10–25% even after documentation of fetal cardiac activity. Our objective was to determine which ultrasound parameters are relevant in predicting miscarriage after documentation of fetal viability following ART. METHODS: A retrospective chart review was performed at Wayne State University and its affiliated infertility clinic to assess factors such as such fetal heart rate (FHR), sac size (SAC), and crown rump length (CRL). All 104 ART cycles between 2008 and 2011 resulting in singleton clinical pregnancy were analyzed. The four visits following a positive pregnancy test were analyzed for FHR, SAC and CRL. RESULTS: The relationship between the minimum (min) values of FHR, SAC, and CRL recorded at each visit between 6 and 9 weeks gestation and SAB were examined using Pearson/Spearman correlations, logistic regressions, and receiver-operating characteristic (ROC) curves. FHR_min, SAC_min, and CRL_min were positively correlated with each other (P<.05) and each was negatively correlated with SAB (P<.05). Regression analyses revealed that maternal age and CRL_min were not significant predictors for SAB unlike FHR_min and SAC_min. With one unit increase in FHR_min and SAC_min, the odds of SAB were reduced by 4% and 22%, respectively. CONCLUSION: FHR and SAC can be useful in predicting miscarriage after ART. There is a decrease in miscarriage rates as minimum FHR and minimum sac size increase. Further studies need to be conducted to determine which other parameters can predict a decrease risk of SAB.

The Effect of Curanderismo on Chronic Non-malignant Pain: A Case Report

This case study describes the effects of the use of curanderismo, an indigenous healing modality combining techniques in massage, sound, and aromatherapy, on a patient with chronic pain. Despite being a commonly used health practice in certain populations, little is reported in the medical literature about the use of curanderismo. Case report as part of a larger randomized trial of curanderismo for chronic pain. Setting was a community-based hospital affiliated primary care clinic. An adult patient with chronic, opioid dependent back pain following an injury, and subsequent spinal fusion was treated. Intervention was the patient received 33 curanderismo treatment sessions over 10 months in addition to ongoing conventional treatment at a community-based chronic pain management clinic. Main outcomes measures were self-reported assessments of pain, functional ability, mood, insomnia, and narcotic usage. Secondary outcome measure was qualitative interview. Although there was no change in quantitative self-reported pain measures, the patient reported improved function, mood, and sleep as well as decreased narcotic usage. Curanderismo, in addition to conventional pain management, improved patient reported symptoms and functional ability, led to healthy lifestyle changes, and decreased narcotic usage. Controlled studies are needed to confirm the benefit of curanderismo as safe, non-interventional, and cost-effective adjunct for chronic pain management.

Remote Ambulatory Management of Veterans with Obstructive Sleep Apnea.

Despite significant medical sequelae of obstructive sleep apnea (OSA), the condition remains undiagnosed and untreated in many affected individuals. We explored the feasibility of a comprehensive, telemedicine-based OSA management pathway in a community-based Veteran cohort. This prospective, parallel-group randomized pilot study assessed feasibility of a telemedicine-based pathway for OSA evaluation and management in comparison to a more traditional, in-person care model. The study included 60 Veterans at the Philadelphia Veterans Affairs Medical Center and two affiliated community-based outpatient clinics. Telemedicine pathway feasibility, acceptability, and outcomes were assessed through a variety of quantitative (Functional Outcomes of Sleep Questionnaire, dropout rates, positive airway pressure [PAP] adherence rates, participant satisfaction ratings) and qualitative (verbal feedback) metrics. There was no significant difference in functional outcome changes, patient satisfaction, dropout rates, or objectively measured PAP adherence between groups after 3 months of treatment. Telemedicine participants showed greater improvement in mental health scores, and their feedback was overwhelmingly positive. Our pilot study suggests that telemedicine-based management of OSA patients is feasible in terms of patient functional outcomes and overall satisfaction with care. Future studies should include larger populations to further elucidate these findings while assessing provider- and patient-related cost effectiveness.

Telehealth by an Interprofessional Team in Patients With CKD: ARandomized Controlled Trial.

Telehealth and interprofessional case management are newer strategies of care within chronic disease management. We investigated whether an interprofessional team using telehealth was a feasible care delivery strategy and whether this strategy could affect health outcomes in patients with chronic kidney disease (CKD). Randomized clinical trial. Minneapolis Veterans Affairs Health Care System (VAHCS), St. Cloud VAHCS, and affiliated clinics March 2012 to November 2013 in patients with CKD (estimated glomerular filtration rate< 60mL/min/1.73m(2)). Patients were randomly assigned to receive an intervention (n=451) consisting of care by an interprofessional team (nephrologist, nurse practitioner, nurses, clinical pharmacy specialist, psychologist, social worker, and dietician) using a telehealth device (touch screen computer with peripherals) or to usual care (n=150). The primary end point was a composite of death, hospitalization, emergency department visits, or admission to skilled nursing facilities, compared to usual care. Baseline characteristics of the overall study group: mean age, 75.1±8.1 (SD) years; men, 98.5%; white, 97.3%; and mean estimated glomerular filtration rate, 37±9mL/min/1.73m(2). Telehealth and interprofessional care were successfully implemented with meaningful engagement with the care system. One year after randomization, 208 (46.2%) patients in the intervention group versus 70 (46.7%) in the usual-care group had the primary composite outcome (HR, 0.98; 95% CI, 0.75-1.29; P=0.9). There was no difference between groups for any component of the primary outcome: all-cause mortality (HR, 1.46; 95% CI, 0.42-5.11), hospitalization (HR, 1.15; 95% CI, 0.80-1.63), emergency department visits (HR, 0.92; 95% CI, 0.68-1.24), or nursing home admission (HR, 3.07; 95% CI, 0.71-13.24). Older population, mostly men, potentially underpowered/wide CIs. Telehealth by an interprofessional team is a feasible care delivery strategy in patients with CKD. There was no statistically significant evidence of superiority of this intervention on health outcomes compared to usual care.

Psychometric properties of the positive mental health instrument among people with mental disorders: a cross-sectional study.

BackgroundThe Positive Mental Health (PMH) instrument was developed and validated to assess the level of PMH and its six dimensions in a multi-ethnic general population sample. This cross-sectional study examines the psychometric properties of the instrument for assessing the level of PMH among help-seeking patients with mental disorders.MethodsThe PMH instrument was tested among 360 out-patients with schizophrenia, depression or anxiety spectrum disorders, seeking treatment at a tertiary psychiatric hospital and its affiliated clinics in Singapore. All participants completed the PMH instrument along with measures of life satisfaction, mental and overall health and happiness. Reliability (internal consistency), construct (Exploratory Structural Equation Modeling (ESEM)) and criterion (convergent and divergent) validity of the PMH instrument were tested in this population. Items were also tested for item response theory and differential item functioning (IRT-DIF).ResultsESEM on the PMH instrument showed good fit with the model reflecting six factors (general coping, personal growth and autonomy, spirituality, interpersonal skills, emotional support, and global affect). Internal consistency was high (Cronbach’s alpha >0.85) for the instrument and its six subscales. The PMH instrument fulfilled expected correlations with related constructs and demonstrated adequate item discrimination and difficulty estimates; however, significant DIF was noted for few items for age, gender and ethnicity groups.ConclusionsThe PMH instrument is a reliable and valid instrument for measuring PMH dimensions in patients with mental disorders. Further studies in larger samples are needed to assess the impact of DIF on PMH scores. The implications for the shift in focus from just the negative aspects of mental disorders to including positive components in the assessment of patients with mental disorders are immense, and can be applied in routine mental health practice and policy making.

Initial serum thyroid peroxidase antibodies and long-term outcomes in SREAT.

To quantify clinical outcome in patients with steroid-responsive encephalopathy and associated autoimmune thyroiditis (SREAT) after the acute phase and explore potential associations of initial serum thyroid peroxidase antibody titers (TPO-Abs) with outcome. Retrospective chart review of patients diagnosed with SREAT between 01/2005 and 05/2014 in a tertiary care center and followed in an affiliated autoimmune outpatient clinic. Outcome was quantified using the extended Glasgow Outcome Scale (GOS-E). We calculated Pearson's correlation coefficients to quantify associations with clinical outcome at follow-up. Among 134 patients with encephalopathy of unknown etiology, we identified 13 patients diagnosed with SREAT. In two patients, the diagnosis was revised at subsequent hospitalization (NMDA-R encephalitis and adult-onset Still's disease). The median follow-up time was 11 months, and the median GOS-E was 6 (range 3-8). Higher serum TPO-Ab-titers correlated with more favorable outcomes (Pearson coefficient 0.65, P = 0.03). A correlation between TPO-Ab-titers and outcome has not been reported previously and challenges the notion of a mere bystander role of TPO-Abs in SREAT.

On the occasion of the 80th anniversary of the Department of Otorhinolaryngology, Dagestan State Medical Academy of the Russian Ministry of Health and the 130th birthday anniversary of professor V.A. Chudnosovetov, the founder and the first head of the Department and the affiliated clinic

On the occasion of the 80th anniversary of the Department of Otorhinolaryngology, Dagestan State Medical Academy of the Russian Ministry of Health and the 130th birthday anniversary of professor V.A. Chudnosovetov, the founder and the first head of the Department and the affiliated clinic

Family caregiver grief and depression outcomes from the ENABLE III randomized controlled trial.

48 Background: Little is known whether early palliative care (PC) support for family caregivers (FCGs) impacts grief and depression after care recipients die. We conducted a randomized controlled trial (RCT) of a nurse-led, phone-based concurrent PC intervention for FCGs delivered at the time of care recipients’ advanced cancer diagnosis (early group) or 12 weeks later (delayed group). We hypothesized that grief and depression scores would be lower for early compared to delayed group FCGs. Methods: Early vs. delayed RCT (10/2010-9/2013) of 123 FCGs of community dwelling persons with advanced cancer in a rural, New Hampshire NCI-designated comprehensive cancer center and affiliated outreach clinics and a Vermont VA medical center receiving a multicomponent intervention (ENABLE [Educate, Nurture, Advise, Before Life Ends]) consisting of 3 weekly sessions, monthly follow-up, and a bereavement call. FCGs of persons dying during the study period completed the Center for Epidemiological Study-Depression scale (CESD) and the Prigerson Inventory of Complicated Grief-Short Form (PG13) 8-12 weeks after care recipients’ deaths. Generalized estimating equations were used to compute group means, standard deviations, and between-group effect size differences. Results: For care recipients who died (n = 70), 44 FCGs (early: n = 19; delayed: n = 25) completed after-death questionnaires. Mean depression scores (CESD) for the early group was 14.6 (SD = 10.7) and for the delayed group was 17.6 (SD = 11.8). Mean grief scores (PG13) for the early group was 22.7 (SD = 4.9) and for the delayed group was 24.9 (SD = 6.9). Between-group effect size differences were not statistically significant (CESD: d = -.27, p = .38; PG13: d = -.36, p = .24). Conclusions: Though statistically insignificant, the magnitude of the observed between-group differences for depression was small and for grief was medium. Considering the small sample size and the delayed group’s mean depression score surpassing the clinical cutoff (CESD score &gt; 16), the clinical relevance of these findings cannot be ruled out. Future upstream FCG PC interventions initiated long before end of life should continue to examine intervention effects on FCG after-death outcomes. Clinical trial information: NCT01245621.

Molecular Diagnosis of H1N1 Virus

Abstract Background Influenza A viruses are medically significant pathogens responsible for higher mortality and morbidity throughout the world. Swine influenza is known to be caused by influenza A subtypes H1N1, H1N2, and H3N2, which are highly contagious, and belongs to the family Orthomyxoviridae. Efficient and accurate diagnosis of influenza A in individuals is critical for monitoring of a constantly evolving pandemic. A rapid result is important, because timely treatment can reduce disease severity and duration. Rapid antigen tests were among the first-line diagnostic tools for the detection of pandemic H1N1 (2009) virus infection during the initial outbreak. Current study focuses on the significant approach of the usage of molecular method utilizing real-time PCR for the detection of type A influenza virus (H1N1 subtype) in humans. Methods A total of 2000 mixed nasal/throat swab specimens collected in commercial viral transport from Apollo hospitals, Hyderabad were submitted to Institute of Preventive Medicine for molecular testing by reverse transcriptase polymerase chain reaction (RT-PCR) from 2009 to 2015 from its affiliated primary care clinics. Results Among the 2000 samples collected, 700 samples were positive for Human Inf A, swine Inf A, and Swine Inf H1 (fourth table in the article). One thousand two hundred samples were negative for Human Inf A, swine Inf A, and Swine Inf H1, and 100 samples were positive for Influenza A only. Conclusion The molecular testing of H1N1 patients helped the clinicians in timely diagnosis and treatment of these patients during the pandemic surveillance. The RT-PCR test has higher sensitivity and specificity; hence it is considered to be the best tool to use during the pandemic surveillance, as compared to the any other commercial antigen-based tests, which show a variable performance, with the sensitivities of tests from different manufacturers ranging from 9 to 77%.

Immunization costs and programmatic barriers at an urban HIV clinic.

Although the increasing number of recommended immunizations is essential for patients infected with human immunodeficiency virus (HIV), the potentially uncompensated costs of expanded immunizations will present significant challenges for clinics and health systems serving HIV-infected patients. We estimated costs of providing Gardasil, Prevnar, and Zostavax to eligible patients at a US Ryan White Part C academically affiliated HIV clinic in 2013. Clinic expenditures were calculated using vaccine price and administrative fees. Revenue was calculated using insurance reimbursement data for vaccination and administration. Three scenarios were used: 100% uptake of vaccines, adjusted uptake based on published rates, and adjusted reimbursement according to pre-Affordable Care Act (ACA) insurance status. 2887 patients (27% Medicare, 13% Alabama Medicaid, 26% Commercial, 34% Uninsured), received care with wide variation in immunization reimbursement ($0 to $210) by insurance and vaccine. The net yield (revenue minus expenditure) was calculated for each vaccine. Prevnar was most costly: annual net yield of -$60 691. Provision of all 3 vaccines would lead to a net yield of -$97 122. Adjusting for reduced uptake led to annual clinic losses of $44 119. Using pre-ACA reimbursement for immunization of the uninsured led to reduced clinic losses (-$62 326), attributable to reimbursement via Ryan White funds. A cost analysis of 3 vaccines shows great variation in insurance coverage, with potential losses of almost $100 000 for one HIV clinic if eligible patients received vaccinations in one calendar year. Adequate, cost neutral reimbursement should be instituted if medical providers and health systems are to achieve Advisory Committee on Immunization Practices immunization recommendations for both HIV positive and negative adults.

Development and Impact of a Novel Academic Primary Care Compensation Model.

Traditional productivity-based compensation models do not align well with newer population-based approaches to primary care. There are few published examples of academic general internal medicine compensation models that explicitly reward population health management, including care for patients between visits. To describe the development and implementation of an academic general internal medicine compensation plan based upon actual work performed, compare satisfaction across primary care specialties, and evaluate work-related outcomes. Observational study. Forty-seven general internists who practice in affiliated academic and community clinics. Clinician satisfaction with compensation plan, workforce stability, panel data, and productivity. The compensation plan change was associated with higher provider satisfaction. Sixty-five percent (31/47) of participants within general internal medicine reported being satisfied or very satisfied, as compared to 24 % (22/90 participants) for family medicine and 22 % (5/23 participants) for general pediatrics (p < 0.05). In the first 4 years of the compensation plan change, no general internists left to join other local groups. General internal medicine increased its number of physicians by 19 %. The number of established general internists accepting new patients increased from 17 to 48 %, while the relative value units per full-time equivalent declined by 3 %. An equitable compensation model that aligns with population management goals and work performed outside the clinical visit can lead to improved satisfaction and retention of faculty in an academic general internal medicine division, along with improved access for the patient population.

Sustained Blood Pressure Control Following Discontinuation of a Pharmacist Intervention for Veterans.

Clinical pharmacists are utilized in Veterans Health Administration (VHA) facilities to assist with management of patients with chronic conditions including hypertension. The goal of this study was to examine blood pressure (BP) control after discontinuation of an intensive pharmacist-managed intervention. The study was conducted at a single Midwest VHA medical center and two affiliated community-based outpatient clinics. Patients with uncontrolled BP received an intensive pharmacist intervention for the first 6months. Patients were then stratified based on whether their BP was controlled or not and were randomized to either continue the intervention for another 24months (30month total time period) or the intervention was discontinued following one-time receipt of educational materials. Mean systolic and diastolic BPs were reduced (P<.001) in diabetic patients (8.0±14.4mm Hg and 4.0±9.1mm Hg, respectively) and in nondiabetic patients (14.0±16.4mm Hg and 5.0±10.0mm Hg, respectively) following the 6-month intervention, with 54% of the total sample achieving BP control. BP control and the reduction in mean BP was maintained to a similar degree in both study groups at 12, 18, 24, and 30months. There were no significant differences in BP at any of the follow-up periods in patients who did and did not receive the continued pharmacist intervention. This study found that BP control was maintained for at least 24months following discontinuation of an intensive pharmacist intervention. These findings were seen in both the group that had a continued pharmacist intervention and in the group that had a one-time educational session when the intervention was discontinued. This study suggests that once BP control is achieved following a pharmacist intervention, patients can be referred back to their primary care provider for continued follow-up.

Effectiveness of an urban emergency department call-back system in the successful linkage to treatment of sexually transmitted infections.

There is a high incidence of asymptomatic sexually transmitted infections (STIs) in emergency department (ED) patients. There is no historical indication, physical examination finding, or rapidly available laboratory testing specific for detecting STIs in women. This study was conducted to describe the performance of an ED call-back system for STI screening and linkage to care for treatment. Success was defined as the ability to contact STI-positive women who were undertreated and confirm their return for definitive treatment. This retrospective, observational study of women 16 years and older evaluated those undertreated for STIs in the ED during the 13-month study period. A structured chart review was performed to determine the proportion of patients returning to an affiliated hospital ED or clinic for treatment after contact by telephone or letter. Of 361 patients identified as undertreated, 29.4% (95% confidence interval [CI] 24.7-34.1) did not return for definitive treatment. The method of contact was associated with patient return for treatment. Of the 276 patients contacted by telephone, 19.6% did not return for treatment (95% CI 14.9-24.3); of the 83 patients contacted by letter, 60.2% did not return for treatment (95% CI 49.7-70.8; P < 0.0001). A large proportion of patients undertreated for an STI did not return despite a notification of need for further treatment. This study had a high rate of successful telephone contact (76.5%), but contact did not substantially increase the overall proportion of patients who were linked to care and returned to the ED for treatment.

Seroprevalence of human fascioliasis in Van province, Turkey.

Fasciola hepatica is a rare zoonotic parasite that infects the liver of many mammals including humans. The aim of this study was to determine the seroprevalence of fascioliasis in Van province by ELISA (antibody detection) on the assumption that not all cases could be detected by stool examination alone. A total of randomly selected 1,600 patients, directed from affiliated outpatient clinics to Yüzüncü Yıl University Medical Faculty Parasitology Laboratory, were enrolled in the study. Their mean age was 44.44±19.00 years. Blood samples were collected from all the patients, and their stool samples were examined. For the stool examination, native-lugol and sedimentation (in formalin-ethyl acetate) methods were employed. ELISA for F. hepatica was performed on the blood samples from all patients. Seropositive patients were treated with triclabendazole. F. hepatica was detected by ELISA in 89 (5.6%) of the 1,600 patients, but eggs were identified on the stool examination in only 29 (1.8%) patients. The prevalence of F. hepatica was higher in females (7.2%) than in males (4.2%) and was higher in the ≥36-year age group (6.7%) than in the ≤35-year age group (4.4%). Abdominal pain (93.3%), fatigue (88.8%), and weight loss (69.7%) were the most common symptoms. Eosinophilia was present in 89.9% of the patients. All seropositive patients had a history of eating raw aquatic plants. Stool examination alone is not sufficient to diagnose F. hepatica. Serological tests such as ELISA must be used together with stool examination.

Medication assisted treatment discontinuation in pregnant and postpartum women with opioid use disorder

BackgroundIncreasing use of opioids has led to an increase in the number of pregnant and postpartum women in medication assisted treatment (MAT) for opioid use disorder. MethodsWe (1) conducted a systematic review of published literature on MAT discontinuation (methadone and buprenorphine) in pregnant and postpartum women and (2) determined methadone discontinuation rates in a retrospective cohort (2006–2013) of pregnant and postpartum women in a university affiliated methadone clinic. ResultsWe found limited generalizable literature reports of discontinuation rates, with a range of prenatal discontinuation rates from 0 to 33% and rates which spanned various prenatal and postnatal periods from 26 to 64%. In our cohort of 229 women, 251 pregnancies were reported, with a prenatal methadone discontinuation rate of 11.0%. Based on a Cox proportional hazards model controlling for age, pregnancy outcome, and duration of treatment prior to delivery, the probability of methadone discontinuation at or before 6 months postpartum was 56.0%. Duration of methadone treatment prior to delivery was inversely associated with risk for postpartum discontinuation of treatment (HR=0.98, 95% CI (0.96, 0.99)). ConclusionsWe conclude that the postpartum period is a time of increased risk for discontinuation of MAT. More accurate assessment of rates of pre- and postpartum MAT discontinuation, as well as further investigation of factors affecting these rates, is warranted. Development and testing of interventions to encourage early prenatal enrollment in MAT and improve postnatal retention in MAT would benefit pregnant women and new mothers with opioid use disorder.

2089557 High Body Mass Index is Strongly Correlated With Decreased Image Quality in Focused Bedside Echocardiography

We sought to correlate obesity as measured by Body Mass Index (BMI) with image quality of focused bedside echocardiography (FOCUS) performed by emergency physicians. We conducted a prospective observational study between Nov. 2012 and Mar. 2014 in patients presenting to two academic emergency departments and an affiliated bariatric surgery outpatient clinic, in a convenience sample of emergency and ambulatory adult patients. 20 patients were enrolled in each of three BMI categories: < 30, 30-39, and ≥ 40. FOCUS was performed on each patient by an ultrasound fellowship-trained EP in the supine and left lateral decubitus positions. The heart was imaged in the subxiphoid, parasternal long axis, and parasternal short axis views. The resulting video clips were interpreted by a second ultrasound fellowship-trained EP who was blinded to BMI. Each clip was assigned two scores on a scale from 1 to 5 for image quality, one score for the ability to discern the myocardial/pericardial interface and another for the ability to visualize global left ventricular function. Scores of 1-2 were considered technically limited (TLS) and would be insufficient for diagnosis. 23 males and 37 females were enrolled. The median age was 49 years and the median BMI was 35.6. There was a significant difference in the percentage of TLS examinations between BMI categories for both image quality scores. For the pericardial interface, there were 10% TLS in the BMI < 30 category, 10% in the BMI 30-39 category, and 50% in the BMI ≥ 40 category (p=0.0069). For left ventricular function there were 10% TLS in the BMI < 30 category, 25% in the BMI 30-39 category, and 55% in the BMI ≥ 40 category (p=0.0107). Additionally, there was an overall negative linear correlation between BMI and image quality for the pericardial interface (r = –0.65, p<0.0001) and left ventricular function (r = –0.60, p<0.0001). Our findings suggest that there is a decrease in the quality of FOCUS images as BMI increases for both the myocardial/pericardial interface and left ventricular function. Emergency physicians should be aware of the potential limitations of focused bedside echocardiography in this patient population.

Sports-Specialized Intensive Training and the Risk of Injury in Young Athletes

Background: Data are lacking regarding the independent risk of injury related to intense single-sport training or growth rate in young athletes. Purpose: To determine whether sports specialization, weekly training volumes, and growth rates are associated with increased risk for injury and serious overuse injury in young athletes. Study Design: Case-control study; Level of evidence, 3. Methods: Injured athletes aged 7 to 18 years were recruited from 2 hospital-based sports medicine clinics and compared with healthy controls from affiliated primary care clinics undergoing sports physicals (2010-2013). Participants completed surveys reporting hours per week spent in organized sports, physical education class, and free play, as well as degree of sports specialization and Tanner stage. Heights and weights were measured. Injury details were obtained from athlete surveys and electronic medical records. Results: Of 1214 athletes enrolled, 1190 (50.7% male) had data satisfactory for analysis. There were 822 injured participants (49.5% male; unique injuries, n = 846) and 368 uninjured participants (55% male). Injured athletes were older than uninjured athletes (14.1 ± 2.1 vs 12.9 ± 2.6 years; P < .001) and reported more total hours of physical activity (19.6 ± 9.2 vs 17.6 ± 8.9 h/wk; P < .001) and organized sports activity (11.2 ± 2.6 vs 9.1 ± 6.3 h/wk; P < .01). After accounting for age and hours in sports activity spent per week, sports-specialized training was an independent risk for injury (odds ratio [OR], 1.27; 95% CI, 1.07-1.52; P < .01) and serious overuse injury (OR, 1.36; 95% CI, 1.08-1.72; P < .01). Young athletes participating in more hours of sports per week than number of age in years (OR, 2.07; 95% CI, 1.40-3.05; P < .001) or whose ratio of organized sports to free play time was >2:1 hours/week had increased odds of having a serious overuse injury (OR, 1.87; 95% CI, 1.26-2.76; P < .01). Growth rates were similar between injured and uninjured athletes (4.8 cm/y for both groups; P = .96). Conclusion: Injured young athletes were older and spent more hours per week in organized sports. There is an independent risk of injury and serious overuse injury in young athletes who specialize in a single sport. Growth rate was not related to injury risk. The study data provide guidance for clinicians counseling young athletes and their parents regarding injury risks associated with sports specialization.