Minnesota Center Research Articles

Musculoskeletal infections associated with Nocardia species: a case series

Abstract. Background: Nocardia is an uncommon pathogen that has been reported to infect musculoskeletal structures. However, studies are largely limited to case reports, and little is known regarding management and outcomes of these infections. Methods: We performed a multicenter retrospective cohort study of adults with culture-confirmed musculoskeletal Nocardia infections at three Mayo Clinic centers in Arizona, Florida, and Minnesota from November 2011 through April 2022. Results: Nine cases of Nocardia musculoskeletal infection were identified. Seven (78 %) occurred in men, and the median age was 57.3 years (range 32.6–79.0). Specific infections included native joint septic arthritis with or without associated osteomyelitis (N=3), hardware-associated infection (N=1), sternal osteomyelitis (N=1), pyomyositis (N=2), bursitis (N=1), and tenosynovitis (N=1). Three cases (33 %) were associated with disseminated disease, all three occurring in solid organ transplant recipients. Surgical intervention was performed in all but the bursitis case. Length of treatment varied from 21 d for tenosynovitis to 467 d for osteomyelitis. The 1-year mortality was 22 %, and all fatal cases involved disseminated disease. Conclusion: Patients with localized nocardiosis affecting musculoskeletal structures generally have good outcomes, as opposed to those with disseminated infection. Management often required operative intervention, with one patient experiencing recurrence within 1 year.

A Bivariate Twin Study of Lifetime cannabis Initiation and Lifetime Regular Tobacco Smoking Across Three Different Countries

Regular cigarette smoking and cannabis consumption are strongly positively related to each other, yet few studies explore their underlying variation and covariation. We evaluated the genetic and environmental decomposition of variance and covariance of these two traits in twin data from three countries with different social norms and legislation. Data from the Netherlands Twin Register, FinnTwin12/16, and the Minnesota Center for Twin Family Research (total N = 21,617) were analyzed in bivariate threshold models of lifetime regular smoking initiation (RSI) and lifetime cannabis initiation (CI). We ran unstratified models and models stratified by sex and country. Prevalence of RSI was lowest in the Netherlands and prevalence of CI was highest in Minnesota. In the unstratified model, genetic (A) and common environmental factors (C) contributed substantially to the liabilities of RSI (A = 0.47, C = 0.34) and CI (A = 0.28, C = 0.51). The two liabilities were significantly phenotypically (rP = 0.56), genetically (rA = 0.74), and environmentally correlated in the unstratified model (rC = 0.47and rE = 0.48, representing correlations between common and unique environmental factors). The magnitude of phenotypic correlation between liabilities varied by country but not sex (Minnesota rP ~ 0.70, Netherlands rP ~ 0.59, Finland rP ~ 0.45). Comparisons of decomposed correlations could not be reliably tested in the stratified models. The prevalence and association of RSI and CI vary by sex and country. These two behaviors are correlated because there is genetic and environmental overlap between their underlying latent liabilities. There is heterogeneity in the genetic architecture of these traits across country.

Abstract PS07-04: Improved uptake and adherence to prevention medication with use of baby tamoxifen in patients at high risk for breast cancer

Abstract Background: Women at increased risk for breast cancer (BC) may benefit from taking prevention medication (PM) with tamoxifen (tam). Historical uptake to PMs for women who qualify has been low. Recent studies have shown baby tam (5mg/day) to have similar efficacy to standard dosing (20mg/day) with lower risk for adverse events (AEs) in women with DCIS or high risk intraepithelial lesions. Herein, we aimed to evaluate uptake, adherence, and tolerability of baby tam in women at increased risk for BC and those with DCIS. Methods: Women seen at the Mayo Clinic Breast Center in Minnesota or Florida who qualified for PM due to DCIS, high risk intraepithelial lesions (IELs) including LCIS and/or AH, or with increased risk based on validated BRCAT or IBIS model calculation (BCRAT 5 year risk ≥ 3% or IBIS 10 year risk ≥ 8%) were offered participation. All women received consultation with a breast specialist for discussion of PM rationale, benefits, side effects, and risks. Patients received baseline survey to assess understanding of their risk and role for PM and then 1 year follow-up survey to assess adherence and tolerability. Results: 41 patients consented for participation and 31 of those completed follow-up at 1 year.Median age of enrollment was 49 years. After initial consultation, 90% (n=37) reported good or complete understanding of BC risk. Of the 31 patients included in 1 year follow-up, 5 patients had DCIS, 13 had high-risk IELs, and 13 qualified based on BCRAT/IBIS calculation. Seventy-four percent (n= 23) of patients reported they took baby tam after consultation. No differences in age (p=0.89), education (p=0.13), or menopause status (p=0.11) between those who did and did not take medication were seen. Those who initiated baby tam were more likely to have DCIS or high risk IEL compared to those who did not (p < 0.001). Seventy-eight percent (n=18) of those who initiated baby tam were still taking medication at 1 year follow-up. Of patients who discontinued baby tam, all cited side effects as primary reason for discontinuation, with hot flashes (n=2), night sweats (n=2), and fatigue (n=2) being most common. Patients who continued medication had higher estimated BC risk compared to those who discontinued baby tam (IBIS 10 yr risk 12.7% vs 7.6%, p = 0.027). Patients with DCIS or high risk IEL were more likely to continue medication at 1 year compared to those patients who qualified for PM based on calculated BCRAT/IBIS score (p=0.05). Only 1 patient with DCIS and 1 patient with high-risk IEL discontinued baby tam at 1 year. Conclusions: Uptake to baby tam after informed discussion in patients who qualify is high, especially in those patients with high risk IELs or DCIS. Adherence and tolerability at 1 year follow-up is improved compared with traditional dosing of tam. Qualifying criteria for patients who did and did not take baby tamoxifen after informed consultation with breast specialist Citation Format: Lauren Cornell, Sandhya Pruthi, Karthik Ghosh, Klassen Christine, Pooja Advani. Improved uptake and adherence to prevention medication with use of baby tamoxifen in patients at high risk for breast cancer [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PS07-04.

Ketamine for Primary Analgosedation in Critically Ill Surgery and Trauma Patients Requiring Mechanical Ventilation.

Evaluate effectiveness and safety outcomes associated with the use of ketamine for primary analgosedation in the surgical/trauma ICU setting. Retrospective cohort study. Academic medical center in Minnesota. Patients admitted to the surgical ICU between 2015 and 2019 requiring mechanical ventilation and meeting one of three definitions for ketamine primary analgosedation were included: 1) no concomitant opioid infusion, 2) ketamine monotherapy for greater than or equal to 6 hours with subsequent opioid infusion, or 3) ketamine initiated concomitantly or within 4 hours of opioid and total opioid duration less than 4 hours. None. Use of ketamine, analgesics, and sedatives were evaluated. Pain, sedation, and delirium assessments immediately before and during ketamine infusion were collected and compared with reported goals. Concomitant analgesics, sedatives, and psychotropics were recorded. Reported failures due to ineffectiveness and toxicity were collected. Of 164 included patients, 88% never received a concomitant opioid infusion (primary analgosedation definition 1), 12% met alternative criteria for primary analgosedation (definitions 2 and 3). A majority, 68%, were surgical admissions and mean Acute Physiology and Chronic Health Evaluation III score was 90 (± 30). Median mechanical ventilation duration was 2.5 days (1.1-4.5) and ICU length of stay of 4.9 days (3-8). The median ketamine infusion dose and duration were 0.18 mg/kg/hr (0.1-0.3) and 30 hours (15.1-51.8). Concomitant infusions of propofol and dexmedetomidine were administered in 49% and 29% of patients, respectively. During ketamine infusion, the median percent of total pain scores at goal was 62% (33-96%), while 64% (37-91%) of Richmond Agitation Sedation Scale scores were at goal, and 47% of patients were Confusion Assessment Method-ICU positive during the ketamine infusion. Hallucinations were documented in 14% of patients and ketamine failure occurred in 11% of patients. Ketamine may be an effective primary analgosedation option in intubated surgical ICU patients, but prospective randomized studies are needed to evaluate this strategy.

Fracture Risk Among Living Kidney Donors 25 Years After Donation

Living kidney donors may have an increased risk of fractures due to reductions in kidney mass, lower concentrations of serum 1,25-dihydroxyvitamin D, and secondary increases in serum parathyroid hormone. To compare the overall and site-specific risk of fractures among living kidney donors with strictly matched controls from the general population who would have been eligible to donate a kidney but did not do so. This survey study was conducted between December 1, 2021, and July 31, 2023. A total of 5065 living kidney donors from 3 large transplant centers in Minnesota were invited to complete a survey about their bone health and history of fractures, and 16 156 population-based nondonor controls without a history of comorbidities that would have precluded kidney donation were identified from the Rochester Epidemiology Project and completed the same survey. A total of 2132 living kidney donors and 2014 nondonor controls responded to the survey. Statistical analyses were performed from May to August 2023. Living kidney donation. The rates of overall and site-specific fractures were compared between living kidney donors and controls using standardized incidence ratios (SIRs). At the time of survey, the 2132 living kidney donors had a mean (SD) age of 67.1 (8.9) years and included 1245 women (58.4%), and the 2014 controls had a mean (SD) age of 68.6 (7.9) years and included 1140 women (56.6%). The mean (SD) time between donation or index date and survey date was 24.2 (10.4) years for donors and 27.6 (10.7) years for controls. The overall rate of fractures among living kidney donors was significantly lower than among controls (SIR, 0.89; 95% CI, 0.81-0.97). However, there were significantly more vertebral fractures among living kidney donors than among controls (SIR, 1.42; 95% CI, 1.05-1.83). This survey study found a reduced rate of overall fractures but an excess of vertebral fractures among living kidney donors compared with controls after a mean follow-up of 25 years. Treatment of excess vertebral fractures with dietary supplements such as vitamin D3 may reduce the numbers of vertebral fractures and patient morbidity.

Genome-wide association study meta-analysis of dizygotic twinning illuminates genetic regulation of female fecundity.

Genome-wide association study meta-analysis of dizygotic twinning illuminates genetic regulation of female fecundity.

Continuous Renal Replacement Therapy and Mortality in Critically Ill Obese Adults.

The outcomes of critically ill adults with obesity on continuous renal replacement therapy (CRRT) are poorly characterized. The impact of CRRT dose on these outcomes is uncertain. This study aimed to determine if obesity conferred a survival advantage for critically ill adults with acute kidney injury (AKI) on CRRT. Secondarily, we evaluated whether the dose of CRRT predicted mortality in this population. A retrospective, observational cohort study performed at an academic medical center in Minnesota. The study population included critically ill adults with AKI managed with CRRT. The primary outcome of 30-day mortality was compared between obese (body mass index [BMI] ≥ 30 kg/m2) and nonobese (BMI < 30 kg/m2) patients. Multivariable regression assessed was used to assess CRRT dose as a predictor of outcomes. An analysis included dose indexed according to actual body weight (ABW), adjusted body weight (AdjBW), or ideal body weight (IBW). Among 1033 included patients, the median (interquartile range) BMI was 26 kg/m2 (23-28 kg/m2) in the nonobese group and 36 kg/m2 (32-41 kg/m2) in the obese group. Mortality was similar between groups at 30 days (54% vs. 48%; p = 0.06) but lower in the obese group at 90 days (62% vs. 55%; p = 0.02). CRRT dose predicted an increase in mortality when indexed according to ABW or AdjBW (hazard ratio [HR], 1.2-1.16) but not IBW (HR, 1.04). In critically ill adults with AKI requiring CRRT, short-term mortality appeared lower in obese patients compared with nonobese patients. Among weight calculations, IBW appears to be preferred to promote safe CRRT dosing in obese patients.

"We want to be heard": A Qualitative Study of Mental Health Care Access among Patients of an Urban Federally Qualified Health Center.

Although depression is common in primary care, challenges to timely intervention exist, particularly for communities of color and lower socioeconomic status. Our objective was to understand barriers and facilitators to mental healthcare access among a sample of patients receiving care at a federally qualified health center (FQHC) in Minnesota, United States. We qualitatively interviewed 34 patients of an urban FQHC, purposively sampled on race/ethnicity, insurance status, language, and depression symptom status (based on Patient Health Questionnaire-9 responses). We inductively and deductively analyzed interview data, leveraging theory in both the codebook development and analysis processes. Participants, who were predominantly English-speaking, female, not privately insured, and people of color, shared numerous barriers and facilitators to accessing mental healthcare. Prominent barriers primarily concerned healthcare providers, including perceived dismissal of mental health concerns and challenges with provider continuity. Additional barriers included the costs of mental health care, communication breakdowns, the patient portal, and community-specific perceptions of mental health. Prominent facilitators included clinic organizational factors (internal and external) and staff friendliness and warmth. Other factors including consideration of patients' financial situation, integrated management of behavioral and physical health conditions, language concordant staff, the telehealth visit modality, and the clinic's social mission were also raised as facilitating access. Patient voices from a single FQHC illustrate the challenges and possibilities of providing mental healthcare in safety net settings. Clinical, strategy, and policy solutions can be tailored to minimize barriers and optimize facilitators documented herein.

Use of Venovenous Extracorporeal Membrane Oxygenation in Patients With Acute Respiratory Distress Syndrome Caused by Fungal Pneumonia.

Background: Patients with fungal pneumonias sometimes progress to acute respiratory distress syndrome (ARDS). Mortality has been reported as high as 60% to 90% in this group. Venovenous extracorporeal membrane oxygenation (VV-ECMO) can be used to support such patients, however, outcomes are not well understood. Patients and Methods: This was a retrospective study across the four adult ECMO centers in Minnesota for one decade (2012-2022). The outcomes of interest were duration of ECMO, survival rate, and complications. Data were extracted from the electronic medical record and analyzed using descriptive statistics. Results: Fungal pneumonia was the etiology of ARDS in 22 of 422 (5%) adults supported with VV-ECMO during the 10-year study period. Median patient age was 43 years (interquartile range [IQR], 35-56) and 68% were male. By type of fungal infection, 16 (72%) had blastomycosis, five (22%) had pneumocystis, and one (5%) had cryptococcus. Of the 16 patients with blastomycosis two were immunosuppressed whereas all five of the pneumocystis patients were immunosuppressed. The overall survival rate was 73%; most patients with blastomycosis (67%) and pneumocystis (80%) survived to hospital discharge. The duration of ECMO support was greater for the pneumocystis group (median, 30 days; IQR, 21-43) compared with blastomycosis (median, 10 days; IQR, 8-18). Conclusions: Our findings support the use of VV-ECMO for ARDS caused by fungal pneumonias in select immunocompetent and immunocompromised patients. Although survival was high, patients with pneumocystis required longer ECMO runs.

Increasing COVID-19 Vaccination Coverage for Newcomer Communities: The Importance of Disaggregation by Language

The COVID-19 pandemic has disproportionately affected refugee, immigrant, and migrant populations. Vaccines are essential for decreasing transmission and severity of COVID-19 infection. Understanding differences in vaccination coverage based on preferred language is crucial for focusing efforts to decrease COVID-19-related disparities. Four sites in the Minnesota Center of Excellence in Newcomer Health collaboratively evaluated completion of primary COVID-19 vaccination series on or before December 31, 2021, for patients who were 12 years or older on June 30, 2021, by preferred language. The non-English/non-Spanish speaking population included 46,714 patients who spoke 174 languages; COVID-19 vaccination coverage by language ranged from 26.2% to 88.0%. Stratifying vaccination coverage by specific language is a critical first step toward dismantling disparities and shaping interventions that best meet the needs of communities served.

Outcomes of transplant recipients with pretransplant Nocardia colonization or infection.

Specific pretransplant infections have been associated with poor posttransplant outcomes. However, the impact of pretransplant Nocardia isolation has not been studied. We performed a retrospective study from three centers in Arizona, Florida, and Minnesota of patients with Nocardia infection or colonization who subsequently underwent solid organ or hematopoietic stem cell transplantation from November 2011 through April 2022. Outcomes included posttransplant Nocardia infection and mortality. Nine patients with pretransplant Nocardia were included. Two patients were deemed colonized with Nocardia, and the remaining seven had nocardiosis. These patients underwent bilateral lung (N = 5), heart (N = 1), heart-kidney (N = 1), liver-kidney (N = 1), and allogeneic stem cell transplantation (N = 1) at a median of 283 (interquartile range [IQR] 152-283) days after Nocardia isolation. Two (22.2%) patients had disseminated infection, and two were receiving active Nocardia treatment at the time of transplantation. One Nocardia isolate was resistant to trimethoprim-sulfamethoxazole (TMP-SMX) and all patients received TMP-SMX prophylaxis posttransplant, often for extended durations. No patients developed posttransplant nocardiosis during a median follow-up of 1.96 (IQR 0.90-6.33) years. Two patients died during follow-up, both without evidence of nocardiosis. This study did not identify any episodes of posttransplant nocardiosis among nine patients with pretransplant Nocardia isolation. As patients with the most severe infections may have been denied transplantation, further studies with larger sample sizes are needed to better analyze any impact of pretransplant Nocardia on posttransplant outcomes. However, among patients who receive posttransplant TMP-SMX prophylaxis, these data suggest pretransplant Nocardia isolation may not impart a heightened risk of posttransplant nocardiosis.

Simultaneous selection of multiple important single nucleotide polymorphisms in familial genome wide association studies data

We propose a resampling-based fast variable selection technique for detecting relevant single nucleotide polymorphisms (SNP) in a multi-marker mixed effect model. Due to computational complexity, current practice primarily involves testing the effect of one SNP at a time, commonly termed as ‘single SNP association analysis’. Joint modeling of genetic variants within a gene or pathway may have better power to detect associated genetic variants, especially the ones with weak effects. In this paper, we propose a computationally efficient model selection approach—based on the e-values framework—for single SNP detection in families while utilizing information on multiple SNPs simultaneously. To overcome computational bottleneck of traditional model selection methods, our method trains one single model, and utilizes a fast and scalable bootstrap procedure. We illustrate through numerical studies that our proposed method is more effective in detecting SNPs associated with a trait than either single-marker analysis using family data or model selection methods that ignore the familial dependency structure. Further, we perform gene-level analysis in Minnesota Center for Twin and Family Research (MCTFR) dataset using our method to detect several SNPs using this that have been implicated to be associated with alcohol consumption.

An Efficient Bayesian Method for Estimating the Degree of the Skewness of X Chromosome Inactivation Based on the Mixture of General Pedigrees and Unrelated Females

Skewed X chromosome inactivation (XCI-S) has been reported to be associated with some X-linked diseases. Several methods have been proposed to estimate the degree of XCI-S (denoted as γ) for quantitative and qualitative traits based on unrelated females. However, there is no method available for estimating γ based on general pedigrees. Therefore, in this paper, we propose a Bayesian method to obtain the point estimate and the credible interval of γ based on the mixture of general pedigrees and unrelated females (called mixed data for brevity), which is also suitable for only general pedigrees. We consider the truncated normal prior and the uniform prior for γ. Further, we apply the eigenvalue decomposition and Cholesky decomposition to our proposed methods to accelerate the computation speed. We conduct extensive simulation studies to compare the performances of our proposed methods and two existing Bayesian methods which are only applicable to unrelated females. The simulation results show that the incorporation of general pedigrees can improve the efficiency of the point estimation and the precision and the accuracy of the interval estimation of γ. Finally, we apply the proposed methods to the Minnesota Center for Twin and Family Research data for their practical use.

Transplantation and immigration: Comparing infectious complications and outcomes between foreign-born and US-born kidney transplant recipients in Minnesota.

Foreign-born kidney transplant recipients (FBKTRs) are at increased risk for reactivation of latent infections that may impact outcomes. We aimed to compare the etiology of infections and outcomes between FBKTR and United States KTRs (USKTR). We performed a retrospective study of patients who underwent kidney transplantation between January 1, 2014 and December 31, 2018 at two transplant centers in Minnesota. Frequency and etiology of infections as well as outcomes (graft function, rejection, and patient survival) at 1-year post-transplant between FBKTR and USKTR were compared. Of the 573 transplant recipients, 124 (21.6%) were foreign-born and 449 (78.4%) US-born. At least one infection occurred in 411 (71.7%) patients (38.2% bacterial, 55% viral, 9.4% fungal). Viral infections were more frequent in FBKTR, particularly BK viremia (38.7%vs. 21.2%, p < .001). No statistical differences were found for bacterial or fungal infections; no parasitic infections were identified in either group. No geographically-restricted infections were noted aside from a single case of Madura foot in a FBKTR. Rejection episodes were more common in USKTR (p = .037), but stable/improving graft function (p = .976) and mortality (p = .451) at 1-year posttransplantation were similar in both groups. After adjusting for covariates, previous transplantation was associated with a higher number of infections (IRR 1.35, 95% confidence intervals 1.05-1.73, p = .020). Although viral infections were more frequent in FBKTR, overall frequency and etiology of most infections and outcomes were similar between FBKTR and USKTR suggesting that comprehensive transplant care is providing timely prevention, diagnosis, and treatment of latent infections in FBKTR.

Past Flight, and: Gone

Past Flight, and: Gone Holly Day (bio) Past Flight Sometimes, poemsare as elusiveas orgasms. However,when it comesto losing my placein a poem I can only blame myself. [End Page 178] Gone There's this guy who walks past me every morning when I take the dog out.He's super friendly and says hi to everyone, even when he's on the other side of the street.Today, I passed him and I said hi but he looked down on the ground,his face covered in a mask, hands shoved deep in his pockets,body tucked into itself to take up as little space as possible.He didn't say anything.This is what this disease has done to us.This is what this disease has done to him. My dog sees other dogs in the neighborhood that she usuallygets to sniff and say hi to but we can't do that anymore, she tugs at her leashand I yank her back towards the house, we can't stop.There's this lady that owns this dog that usually just runs around the neighbor- hoodand her dog runs up to us and I have to pull my dog away quickly, say"We can't play today, I'm sorry," and the lady who owns the doglooks so sad, as if I rejected her dog out of some kind of spite, like I rejected her.This is what this disease has done to our neighborhood.This is what this disease has done to my dog. Inside, my daughter fights with the inadequate wireless connection for her schoolwork,the same connection I've used for years without complaint, but suddenlynothing is good enough, our house isn't big enough,it grows smaller by the day. Every door in our house is shut. We all have a room,a place to get away from each other to hide.There's mention of escape in every conversation,something that'll have to take place in some unspecified future.This is the thing that's killing me.This is the thing we're all learning to live with. [End Page 179] Holly Day holly Day's writing has recently appeared in Analog SF, The Hong Kong Review, and Appalachian Journal. She currently teaches at the Loft Literary Center in Minnesota and the Richard Hugo House in Washington. Copyright © 2023 University of North Dakota

Medication abortion and uterine aspiration for undesired pregnancy of unknown location: A retrospective cohort study

ObjectiveTo compare days to diagnosis of pregnancy location for same-day medication abortion and same-day uterine aspiration with delayed treatment (expectant management) in patients with undesired pregnancy of unknown location (PUL). Study designWe conducted a retrospective cohort study at a single Planned Parenthood health center in Minnesota. We reviewed electronic health records and included patients presenting for induced abortion diagnosed with PUL (positive high-sensitivity urine pregnancy test and no evidence of intrauterine or extrauterine pregnancy on transvaginal ultrasonography) without symptoms or ultrasonographic imaging concerning for ectopic pregnancy (low risk). The primary outcome was days to pregnancy location clinical diagnosis. ResultsOf 19,151 abortion encounters in 2016–2019, 501 (2.6%) had a low-risk PUL. Participants chose delay-for-diagnosis before treatment (148, 29.5%), immediate treatment medication abortion (244, 48.7%), or immediate treatment uterine aspiration (109, 21.8%). Median days to diagnosis were significantly lower in the immediate treatment uterine aspiration group (2 days, IQR 1–3 days, p < 0.001) and similar for immediate treatment medication abortion (4 days, IQR 3–9 days, p = 0.304) compared with delay-for-diagnosis (3 days, IQR 2–10 days). Thirty-three low-risk participants (6.6%) were treated for ectopic pregnancy, but no difference in ectopic rate was detected among groups (p = 0.725). Participants in the delay-for-diagnosis group were more likely to be nonadherent with follow-up (p < 0.001). For participants who completed follow-up, abortion completion rate was lower for immediate treatment medication abortion (85.2%) compared with immediate treatment uterine aspiration (97.6%, p = 0.003). ConclusionsFor patients with undesired PUL, diagnosis of pregnancy location was fastest with immediate treatment uterine aspiration and similar for expectant management and immediate treatment medication abortion. Medication abortion efficacy may be reduced in treatment of undesired PUL. ImplicationsFor PUL patients desiring induced abortion, the option of proceeding at initial encounter may help improve access and patient satisfaction. Uterine aspiration for PUL may help diagnose pregnancy location more quickly.

A picture is worth a thousand words: A culturally-tailored video-based approach to diabetes education in Somali families of children with type 1 diabetes

ObjectivesType 1 diabetes (T1D) is highly prevalent in Somali immigrant children and hemoglobin A1c (HbA1c) levels are elevated in this population compared to non-Hispanic Whites. Current self-management diabetes education has not been tailored to this population. We aimed to improve delivery of T1D education to Somali immigrants by developing and testing a culturally-appropriate video-based curriculum. MethodsThis cross-sectional study involved Somali youth ≤ 19 years with T1D followed at two pediatric tertiary centers in Minnesota. Ten Somali-language T1D education videos were developed (∼60 min for total program) based on core ADA curriculum and tailored to address cultural concerns and misconceptions. A diabetes knowledge questionnaire was administered to parents of all participants and to children aged ≥12 years. Pre- and post-educational session questionnaire mean scores were compared using a paired t-test to assess knowledge improvement immediately post-video education (primary endpoint) and retention at 3 months (secondary endpoint). HbA1c was measured pre- and 6 months post education (exploratory endpoint). ResultsTwenty-two Somali parents of 22 children participated (mean age 12.3 ± 4 years; 36 % female), 12 children ≥12 years. Diabetes knowledge scores significantly improved immediately post-video education compared to baseline (p = 0.012). This improvement persisted 3 months later (p = 0.0008). There was no significant change in mean HbA1c from baseline at 6 months post education (9.0 ± 1.5 % vs 9.3 ± 1.9; p = 0.6). ConclusionCulturally and linguistically tailoring diabetes education materials to African immigrants and delivering it audio-visually could improve effectiveness of diabetes education and increase knowledge and retention compared to simply translating standard diabetes education materials. The effect on HbA1c needs further study with a larger sample size.

Changes in patterns of traumatic brain injury in the Michigan Trauma Quality Improvement Program database early in the COVID-19 pandemic.

The authors' objective was to investigate the impact of the global COVID-19 pandemic on hospital presentation and process of care for the treatment of traumatic brain injuries (TBIs). Improved understanding of these effects will inform sociopolitical and hospital policies in response to future pandemics. The Michigan Trauma Quality Improvement Program (MTQIP) database, which contains data from 36 level I and II trauma centers in Michigan and Minnesota, was queried to identify patients who sustained TBI on the basis of head/neck Abbreviated Injury Scale (AIS) codes during the periods of March 13 through July 2 of 2017-2019 (pre-COVID-19 period) and March 13, 2020, through July 2, 2020 (COVID-19 period). Analyses were performed to detect differences in incidence, patient characteristics, injury severity, and outcomes. There was an 18% decrease in the rate of encounters with TBI in the first 8 weeks (March 13 through May 7), followed by a 16% increase during the last 8 weeks (May 8 through July 2), of our COVID-19 period compared with the pre-COVID-19 period. Cumulatively, there was no difference in the rates of encounters with TBI between the COVID-19 and pre-COVID-19 periods. Severity of TBI, as measured with maximum AIS score for the head/neck region and Glasgow Coma Scale score, was also similar between periods. During the COVID-19 period, a greater proportion of patients with TBI presented more than a day after sustaining their injuries (p = 0.046). COVID-19 was also associated with a doubling in the decubitus ulcer rate from 1.0% to 2.1% (p = 0.002) and change in the distribution of discharge status (p = 0.01). Multivariable analysis showed no differences in odds of death/hospice discharge, intensive care unit stay of at least a day, or need for a ventilator for at least a day between the COVID-19 and pre-COVID-19 periods. During the early months of the COVID-19 pandemic, the number of patients who presented with TBI was initially lower than in the years 2017-2019 prior to the pandemic. However, there was a subsequent increase in the rate of encounters with TBI, resulting in overall similar rates of TBI between March 13 through July 2 during the COVID-19 period and during the pre-COVID-19 period. The COVID-19 cohort was also associated with negative impacts on time to presentation, rate of decubitus ulcers, and discharge with supervision. Policies in response to future pandemics must consider the resources necessary to care for patients with TBI.

Cardiovascular Magnetic Resonance Imaging Phenotypes and Long-term Outcomes in Patients With Suspected Cardiac Sarcoidosis

In patients with sarcoidosis with suspected cardiac involvement, late gadolinium enhancement (LGE) on cardiovascular magnetic resonance imaging (CMR) identifies those with an increased risk of adverse outcomes. However, these outcomes are experienced by only a minority of patients with LGE, and identifying this subgroup may improve treatment and outcomes in these patients. To assess whether CMR phenotypes based on left ventricular ejection fraction (LVEF) and LGE in patients with suspected cardiac sarcoidosis (CS) are associated with adverse outcomes during follow-up. This cohort study included consecutive patients with histologically proven sarcoidosis who underwent CMR for the evaluation of suspected CS from 2004 to 2020 with a median follow-up of 4.3 years at an academic medical center in Minnesota. Demographic data, medical history, comorbidities, medications, and outcome data were collected blinded to CMR data. CMR phenotypes were identified based on LVEF and LGE presence and features. LGE was classified as pathology-frequent or pathology-rare based on the frequency of cardiac damage features on gross pathology assessment of the hearts of patients with CS who had sudden cardiac death or cardiac transplant. Composite of ventricular arrhythmic events and composite of heart failure events. Among 504 patients (mean [SD] age, 54.1 [12.5] years; 242 [48.0%] female and 262 [52.0%] male; 2 [0.4%] American Indian or Alaska Native, 6 [1.2%] Asian, 90 [17.9%] Black or African American, 399 [79.2%] White, 5 [1.0%] of 2 or more races (including the above-mentioned categories and Native Hawaiian or Other Pacific Islander), and 2 [0.4%] of unknown race; 4 [0.8%] Hispanic or Latino, 498 [98.8%] not Hispanic or Latino, and 2 [0.4%] of unknown ethnicity), 4 distinct CMR phenotypes were identified: normal LVEF and no LGE (n = 290; 57.5%), abnormal LVEF and no LGE (n = 53; 10.5%), pathology-frequent LGE (n = 103; 20.4%), and pathology-rare LGE (n = 58; 11.5%). The phenotype with pathology-frequent LGE was associated with a high risk of arrhythmic events (hazard ratio [HR], 12.12; 95% CI, 3.62-40.57; P < .001) independent of LVEF and extent of left ventricular late gadolinium enhancement (LVLGE). It was also associated with a high risk of heart failure events (HR, 2.49; 95% CI, 1.19-5.22; P = .02) independent of age, pulmonary hypertension, LVEF, right ventricular ejection fraction, and LVLGE extent. Risk of arrhythmic events was greater with an increasing number of pathology-frequent LGE features. The absence of the pathology-frequent LGE phenotype was associated with a low risk of arrhythmic events, even in the presence of LGE or abnormal LVEF. This cohort study found that a CMR phenotype involving pathology-frequent LGE features was associated with a high risk of arrhythmic and heart failure events in patients with sarcoidosis. The findings indicate that CMR phenotypes could be used to optimize clinical decision-making for treatment options, such as implantable cardioverter-defibrillators.

Robust association tests for quantitative traits on the X chromosome.

The genome-wide association study is an elementary tool to assess the genetic contribution to complex human traits. However, such association tests are mainly proposed for autosomes, and less attention has been given to methods for identifying loci on the X chromosome due to their distinct biological features. In addition, the existing association tests for quantitative traits on the X chromosome either fail to incorporate the information of males or only detect variance heterogeneity. Therefore, we propose four novel methods, which are denoted as QXcat, QZmax, QMVXcat and QMVZmax. When using these methods, it is assumed that the risk alleles for females and males are the same and that the locus being studied satisfies the generalized genetic model for females. The first two methods are based on comparing the means of the trait value across different genotypes, while the latter two methods test for the difference of both means and variances. All four methods effectively incorporate the information of X chromosome inactivation. Simulation studies demonstrate that the proposed methods control the type I error rates well. Under the simulated scenarios, the proposed methods are generally more powerful than the existing methods. We also apply our proposed methods to data from the Minnesota Center for Twin and Family Research and find 10 single nucleotide polymorphisms that are statistically significantly associated with at least two traits at the significance level of 1 × 10-3.