Oklahoma Health Sciences Center Research Articles

193: A RARE CASE OF UNILATERAL FLASH PULMONARY EDEMA

1University of Oklahoma Health Sciences Center, Oklahoma City, OK 2University of Oklahoma Health Sciences Center, Oklahoma City, OK

Thrombocytopenia Is a Biomarker for Response in Patients Treated with Anti PD-1/Pdl-1 Therapy

Background: Immunotherapy directed against the PD-1/PDL-1 (programmed cell death protein [ligand] 1) pathway has shown activity across a range of malignancies. Immune-related adverse events have been shown to be associated with the efficacy of PD-1/PDL-1 inhibitors in patients with melanoma and non-small cell lung cancer. Thrombocytopenia has been reported in up to 33% of patients receiving anti PD-1/PDL-1 therapy. Our hypothesis is that immune-mediated thrombocytopenia may be a biomarker for response to anti PD-1/PDL-1 therapy.Methods: We collected data on 250 patients aged 18 years and older who were treated with anti PD-1/PDL-1 therapy at the University of Oklahoma Health Sciences Center between January 2014 and January 2016. Initial platelet count at baseline as well as nadir platelet count during treatment were examined. Patient's clinicopathologic characteristics were analyzed using simple descriptive statistics [median (range) for continuous covariates and n (%) for categorical variables]. Kaplan Meier Analysis was performed to assess how thrombocytopenia was associated with overall survival (OS) and progression free survival (PFS). Patients were grouped according to their nadir platelet count: normal platelets (≥150k), grade 1 (75k-150k), and combined grades 2, 3, 4 (<75k). Cox proportional hazard regression models were used to assess the association of thrombocytopenia with OS and PFS adjusted for various covariates. The objective of the study is to assess whether the degree of thrombocytopenia correlates with the PFS and OS in patients receiving anti PD-1/PDL-1 therapy.Results: A total of 250 patients were reviewed in this study. After excluding 27 patients with baseline platelet count <100k and 14 patients with missing platelet count data, 209 patients were included in the analysis. Fifty-five percent were females. Median age at diagnosis was 62 (23-91) years. The most common cancer diagnoses were lung cancer (21.1%), melanoma (17%), and ovarian cancer (9%). Nivolumab was the most commonly used agent (40.9%), followed by Pembrolizumab (38.4%). Median number of treatments received was 5. Median platelet count at baseline was 227 (102-535). Median nadir platelet count was 180 (4-552). Thrombocytopenia of any grade was observed in 70 (33%) patients .The number of patients with grade 1, 2, and 3/4 were 56 (26.8%), 1 (0.5%) and 13 (6.2%), respectively. Median follow-up time was 226 days. Univariate analysis showed that patients with grade I thrombocytopenia had higher PFS and OS when compared to patients who did not develop thrombocytopenia [HR 0.48 (95% CI, 0.29-0.81), P = 0.0053 and HR 0.49 (95% CI, 0.27-0.9), P = 0.0209, respectively]. When adjusted for age, cancer type, performance status, and line of treatment, grade 1 thrombocytopenia remained positively associated with survival outcome [HR 0.50 (95% CI, 0.29-0.87), P = 0.0146 for PFS and HR 0.40 (95% CI, 0.21-0.77), P = 0.0061 for OS]. Only 14 patients had grade 2-4 thrombocytopenia, and there was no statistically significant difference in survival compared to patients with no thrombocytopenia [adjusted HR 0.52 (95% CI, 0.2-1.38), P = 0.189 for OS].Conclusion: Our study shows that in patients treated with anti PD-1/PDL-1 therapy, grade 1 thrombocytopenia appears to be positively correlated with survival outcomes. This survival advantage was not seen with higher grades of thrombocytopenia. PD-L1 was recently shown to be expressed on human platelets; thus, thrombocytopenia is likely immune-mediated. Thrombocytopenia may be a biomarker for efficacy of immune checkpoint therapy. The predictive significance of thrombocytopenia in patients receiving PD-1/PDL-1 therapy warrants further investigations. DisclosuresNo relevant conflicts of interest to declare.

Meeting the Medical Students: Transformation and Closure for Donor Families

Beginning in 2000, our institution inaugurated the Anatomical Donor Luncheon. This event occurs during orientation week for all incoming first‐year medical students. The families of our anatomical donors are invited to lunch where they meet the medical students who have been assigned to their deceased family member to learn human anatomy through dissection. Both students and donor families are informed that the venue provides an opportunity to promote the humanistic aspects of medicine. The families are asked to provide the medical students with the social history of their deceased family member, but are not given specific instructions on how to do so. The effect of this encounter on student attitudes has been previously reported. In the current study, we evaluated the reactions and attitudes of the donor families after meeting the medical students. Focus group questions were developed to explore the experience of donor families who met with first year medical students during the luncheon. The focus group comments were digitally recorded and transcribed, keeping the identities of responders anonymous. The audio data was subsequently destroyed. The constant comparative method was used for coding the textual data. One meta‐theme and three sub‐themes were identified. The meta‐theme was Donor Family Participants Experience Transformation and Closure. The subthemes included Motivating Factors for Donor Luncheon Participation, Impressions of the Venue, and Positive or Negative Experiences. Our data suggests that the Donor Luncheon was a mechanism for families to find closure on the death of their loved one and transformed their hesitation regarding body donation into excitement and appreciation. The institutional review board of the University of Oklahoma Health Sciences Center approved this study.This abstract is from the Experimental Biology 2018 Meeting. There is no full text article associated with this abstract published in The FASEB Journal.

Effect of body mass index and albumin level on outcomes of patients receiving anti PD-1/PD-L1 therapy.

213 Background: Obesity has been previously investigated for its role in cancer and promoting tumor growth, at least partially by inducing a chronic inflammatory state. However, it’s unclear how this would play out in the era of immunotherapy, where inflammation has been linked to treatment response. Albumin, a marker of nutritional status, is also a negative inflammatory marker. Patients with low albumin levels have been known to have a poor prognosis. In this study, we aim to assess the association of body mass index (BMI) and albumin level with outcomes of patients treated with immunotherapy. Methods: We retrospectively evaluated the outcomes of 198 patients, aged 18 years or older, treated with anti PD-1/PD-L1 at the University of Oklahoma Health Sciences Center from 2014 to 2017. Simple descriptive statistics were created for all covariates. Kaplan Meier and Cox Proportional Hazard regression were performed to assess how categorical and continuous variables were related to overall survival (OS) and progression free survival (PFS). A final multi-variable model was created using all variables associated with OS and PFS. Results: The median age was 62 years and the median follow-up time was 272 days. Melanoma was the most common diagnosis (25.7%) followed by lung cancer (23.5%) and ovarian cancer (11.5%). Higher BMI was associated with better outcomes. BMI (≥30 vs &lt; 30) unadjusted was significantly associated with better OS (236 vs 133 days, p = 0.04) and PFS (316 vs 210 days, p = 0.01). As a continuous variable, a higher BMI was significantly associated with a better OS but not PFS with HR 0.96 (95% CI 0.93-0.99, p = 0.04) and HR 0.98 (95% CI 0.95-1.01, p = 0.09) respectively. BMI was not associated with OS or PFS in a multivariate analysis. Albumin level at initiation of treatment was not associated with OS (p = 0.12) or PFS (p = 0.19). Conclusions: In this single institution cohort, BMI had a significant effect on outcomes of patients receiving anti PD-1/PD-L1 agents. This warrants further investigation of BMI as a prognostic factor.

Efficacy of PD-1/PD-L1 therapy: Do proton pump inhibitors affect the outcome?

208 Background: Recent studies have shown that manipulating the gut microbiome modulates the efficacy of anti-PD1/PD-L1 directed therapy leading to increase in the activity of CD8+ T-cells. Proton Pump inhibitors (PPIs) affect the gut microbiome. The objective of this study was to investigate the effects of PPIs use on agents that target the PD-1/PD-L1 pathway in patients treated with these agents. Methods: We looked at the outcomes of 158 patients aged 18 years or older, treated at the University of Oklahoma Health Sciences Center between 2014 and 2016. The primary aim of this study was to investigate whether survival of patients treated with agents that target PD-1/PD-L1 pathway was affected by PPI use. The secondary objective was to identify if there is any difference in the immune related side effect profile between PPI users and non-users. The overall survival (OS) and progression free survival (PFS) were compared between PPI users and nonusers using the log-rank tests. Survival curves were generated using the Kaplan-Meyer method. The proportions of Grade 3 or 4 colitis or pneumonitis were compared between PPI users and nonusers using the Fisher’s exact test. SAS 9.4 was used for the statistical analysis and a 0.05 significance level was used. Results: The majority of patients were females (57%). The median age was 63 years. Lung cancer was the most common diagnosis (20%) followed by melanoma (20%) and ovarian cancer (12%). Nivolumab was the most commonly used agent (47%) followed by Pembrolizumab (22%), other investigational agents (22%) and Atezolizumab (7%). The median follow-up time from the date of first PPI dose was 7 months. There was no statistically significant difference in OS or PFS between PPI users and nonusers (p = 0.77). There were no significant differences in proportions of Grade 3 or 4 colitis between PPI users and nonusers (5% vs. 5.26%, p &gt; .99). Similarly, there were no significant differences in proportions of Grade 3 or 4 pneumonitis between PPI users and nonusers (6.25% vs. 1.75%, p = 0.40). Conclusions: Use of PPI does not affect the outcome of patients receiving agents that target PD1/PD-L1 pathway. The incidence of important immune related side effects was similar between PPI users and non-users.

Katherine Morris: assessment and management of co-morbidities in pancreatic cancer surgery

Katherine Morris ( Figure 1 ),Associate Professor,Department of Surgery,University of Oklahoma Health Sciences Center. After completing a mathematics degree at the University of Washington Dr. Morris studied medicine at Oregon Health and Science University (OHSU), where her interest was drawn to surgery. After medical school, she completed her general surgery residency at OHSU. During that residency, she completed two years of research in surgical oncology.

Didactic Content and Experiential Aging Simulation for Developing Patient-Centered Strategies and Empathy for Older Adults.

The number of people over 65 years of age is increasing, and many of those individuals will have sensorineural hearing loss in addition to other chronic health conditions. Future hearing health care providers need to be sensitive to the needs of elderly patients. The purpose of this article is to describe an experiential learning curriculum used in the Doctor of Audiology program in the Department of Communication Sciences and Disorders at the University of Oklahoma Health Sciences Center. The curriculum uses simulations of sensory disorders common in the elderly to transform knowledge and active experience into patient-centered, empathetic counseling skills and strategies to use with older adults with hearing loss.

ПСИХОЛОГИЧЕСКИЕ АСПЕКТЫ ПРОФИЛАКТИКИ ФЕТАЛЬНОГО АЛКОГОЛЬНОГО СИНДРОМА У БЕРЕМЕННЫХ ЖЕНЩИН РЕПРОДУКТИВНОГО ВОЗРАСТА

The article observes the study results of knowledge, attitudes and alcohol behavior in pregnant women within fetal alcohol prevention program in childbearing age women. The theoretical and methodological basis of the study is Health Belie/Model and the method of dual-focused brie/ intervention. The study was conducted on the basis of the psychology department ofSaint Petersburg State University. Data were collected in 10 women's consultation clinics ofSaint Petersburg. The sample included 280 women of childbearing age. Methods of psychological research are presented by materials developed by the «FAS research team» according to the study goals. The results showed that the developed preventive program and its components (brief intervention and passive information] achieve their main goal, program implementation reduces or stops the use of alcohol by pregnant women, in other words, it virtually eliminates the risk of developing FAS and FASD in a future child. This program was carried out as a part of the project supported by grant R01AA016234 «Prevention of FASD in Russian Children», principal investigator: Tatiana N. Balachova, The University of Oklahoma Health Sciences Center (USA), from the NIH / National Institute on Alcohol Abuse and Alcoholism and Fogarty International Center.

A comprehensive review of PA education programs' pain medicine curriculum

Johnna Yealy is program director at the University of Tampa developing PA program in Tampa, Fla. Todd Doran is the division chief and program director at the University of Oklahoma Health Science Center in Oklahoma City, Okla.

An Association Between Prenatal Acetaminophen Use and ADHD: The Benefits of Large Data Sets.

* Abbreviation: ADHD — : attention-deficit/hyperactivity disorder Attention-deficit/hyperactivity disorder (ADHD) is a prevalent disorder defined by a combination of symptoms that are likely due to malfunctions in those areas of the brain that are associated with executive functions, including the prefrontal cortex,1 caudate nucleus,2 and cerebellar vermis.3 Over the years, multiple factors have been identified that probably contribute to its possible etiology. The most prominent has been genetics; ADHD is often identified by a high familial pattern with a high concordance in twin studies.4 However, no specific gene, gene pattern, or marker gene has been able to explain all but a small amount of the variance. In addition, environmental factors both … Address correspondence to Mark L. Wolraich, MD, Pediatrics/CSC, University of Oklahoma Health Sciences Center, 1100 NE 13th St, Oklahoma City, OK 73117. E-mail: mark-wolraich{at}ouhsc.edu

Keeping Residents in the Dark: Do Night-Float Rotations Provide a Valuable Educational Experience?

To qualify and characterize resident overnight activity. A prospective 3-phase study was conducted of surgical residents with attention to activities performed on the overnight rotation: needs assessment, direct observation of activities, and feedback. This study was conducted at the University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma. This is both a tertiary referral center and the only American College of Surgeons (ACS) verified level 1 trauma center in the state. This study included current surgical residents within the residency program. During the study period, 270 pages were individually recorded, with 60% of these pages defined as time-sensitive activities. In addition, most of the pages involved pressing patient-care issues irrespective of postgraduate year level. Analyses revealed that residents spend most of their time performing educational activities (62%). On feedback, residents reported overall satisfaction with the learning opportunities during night-shift (6.4/7.0) and indicated their perceptions of an adequate balance of service and education on night float (6.6/7.0). This correlates with our annual rotation assessment where residents identify night-float as an overall positive experience which provides educational benefit. Work-hour restrictions induce residency programs to adapt to new training models. Our results report a breakdown of resident activities while on night-float and demonstrate that overnight shifts continue to provide important educational opportunities during training.

Prediction of 6-minute walk performance in patients with peripheral artery disease

BackgroundPeripheral artery disease (PAD) is a highly prevalent disease that impairs walking ability. Walking tests, such as the 6-minute walk test (6MWT) and 4-meter walk test, are commonly used to assess exercise endurance and ambulatory function over a short distance, respectively. The 6MWT performance is predictive of PAD severity and disease outcomes, but it is not feasible in many clinical settings because it requires a long walkway to serve as the test route and lengthens clinic visits. As an alternative, the 4-meter walk test is convenient, inexpensive, and repeatable, but whether it accurately predicts endurance performance in the long-distance 6MWT is not known. The goal of this study was to develop a statistical model to predict 6MWT gait speed from 4-meter walk test results and clinical characteristics among patients with PAD. MethodsMeasures of 6MWT gait speed were derived from 183 patients with symptomatic PAD who were evaluated at the University of Oklahoma Health Sciences Center (2004-2012). The testing procedures and research personnel remained constant throughout the duration of the study. Independent variables included demographic and clinical information and 4-meter walk test gait speed. Fivefold cross validation and manual backward selection were used for model selection. Adjusted R2 and corrected Akaike information criterion were applied to quantify the predictive performance of the regression models. ResultsA total of 183 people (54% male; mean age, 65 [standard deviation (SD), 10] years) with moderate PAD severity (ankle-brachial index [ABI]; mean, 0.72 [SD, 0.24]) performed the walking tests. Participants covered an average distance of 335 (SD, 97) m distance in the 6MWT. The 4-meter walk gait speed, ABI, and dyspnea were independent predictors of 6MWT speed in the multivariate model (adjusted R2 = 0.55). The model resulted in 95% prediction interval widths of 30 m for mean and 260 m for individual predicted 6MWT distance measures. ConclusionsSlower 4-meter walking speed, lower ABI, and presence of dyspnea all predict slower 6MWT gait speed, which corresponds to shorter 6MWT distance. Prediction of group means is reasonably precise; however, prediction of individual patient 6MWT performance is imprecise relative to between-group differences that are clinically important.

Observed toxicities in elderly gynecologic cancer patients treated on phase I clinical trials: The University of Oklahoma Health Sciences Center experience

Observed toxicities in elderly gynecologic cancer patients treated on phase I clinical trials: The University of Oklahoma Health Sciences Center experience

Interview with Amr H Sawalha: epigenetics and autoimmunity.

Amr H Sawalha is Professor of Internal Medicine and Marvin and Betty Danto Research Professor of Connective Tissue Research at the University of Michigan, Department of Internal Medicine, Division of Rheumatology. He also holds faculty appointments at the Center for Computational Medicine and Bioinformatics and the Graduate Program in Immunology at the University of Michigan. He was recently appointed as Guest Professor at Central South University in Changsha, China. He received his medical degree from Jordan University of Science and Technology and completed his residency training in internal medicine at the University of Oklahoma Health Sciences Center, and his fellowship in rheumatology at the University of Michigan. His research focus is the genetics and epigenetics of complex autoimmune and inflammatory diseases, including lupus and systemic vasculitis. He has authored over 100 peer-reviewed manuscripts, book chapters and review articles, and is on the editorial board of several journals in his field. He has been elected as a member of the American Society for Clinical Investigation, and has received numerous awards, including the Edmund L Dubois, MD, Memorial Lectureship Award from the American College of Rheumatology in recognition for his work in lupus. He is Chair of the Lupus Foundation of America research subcommittee and is a member of the Vasculitis Foundation Medical and Scientific Advisory Board. He also provides clinical care and teaching in the rheumatology outpatient and inpatient services, and he is the director of the NIH-funded rheumatology training grant at the University of Michigan.

Fructose in Breast Milk Is Positively Associated with Infant Body Composition at 6 Months of Age

Dietary sugars have been shown to promote excess adiposity among children and adults; however, no study has examined fructose in human milk and its effects on body composition during infancy. Twenty-five mother–infant dyads attended clinical visits to the Oklahoma Health Sciences Center at 1 and 6 months of infant age. Infants were exclusively breastfed for 6 months and sugars in breast milk (i.e., fructose, glucose, lactose) were measured by Liquid chromatography-mass spectrometry (LC-MS/MS) and glucose oxidase. Infant body composition was assessed using dual-energy X-ray absorptiometry at 1 and 6 months. Multiple linear regression was used to examine associations between breast milk sugars and infant body composition at 6 months of age. Fructose, glucose, and lactose were present in breast milk and stable across visits (means = 6.7 μg/mL, 255.2 μg/mL, and 7.6 g/dL, respectively). Despite its very low concentration, fructose was the only sugar significantly associated with infant body composition. A 1-μg/mL higher breast milk fructose was associated with a 257 g higher body weight (p = 0.02), 170 g higher lean mass (p = 0.01), 131 g higher fat mass (p = 0.05), and 5 g higher bone mineral content (p = 0.03). In conclusion, fructose is detectable in human breast milk and is positively associated with all components of body composition at 6 months of age.

Impact of Duration of Neutropenia and Lymphopenia on AML Patients Undergoing Induction Chemotherapy

Background:Various demographic, clinical and cytogenetic factors have been shown to affect the outcome of patients with acute myeloid leukemia (AML). Some of these risk factors are well-described with performance status and patient age being principal predictors of early death while cytogenetic and molecular factors allow stratification into prognostic categories. However, several critical factors have not been adequately assessed. Typically AML patients treated with standard induction chemotherapy will have cytopenias requiring intervention. Often the neutropenia is prolonged and results in neutropenic fevers and a high risk of infections. We hereby describe a single institution retrospective analysis at the University of Oklahoma Health Sciences Center (OUHSC) in which we evaluate the effect of duration of days with at risk absolute neutrophil (ANC) and absolute lymphocyte counts (ALC) and the occurrence of neutropenic fever on survival and response rates of AML patients.Methods:This is a retrospective chart review of AML adult patients who were diagnosed and treated at OUHSC between 2000 and 2014 and were undergoing initial induction chemotherapy. Outcomes of interest were overall survival (OS), event free survival (EFS: in case of relapse or death) and complete response (CR). Variables of interest wereneutropenic fever, and duration of decreased ANC and ALC counts (ANC<500, ANC<100, ALC<500, ALC<100). Institution policy did not allow granulocytes colony stimulating factors use because of the interference with bone marrow aspirate results. Nonetheless it was rarely used in few cases of septic shock, so this variable was not included in this analysis. Descriptive and bivariate analyses were conducted to evaluate the variables of interest and the outcomes.Models were used to assess the relationship between the variables of neutropenic fever, duration of decreased counts (ANC<500, ANC<100, ALC<500, ALC<100) and the outcome of interest after adjusting for age, race, gender, risk group andwhite blood count (WBC). Multivariable Cox proportional hazard models were used for OS and EFS and multivariable logistic regression models were used for CR. SAS 9.4 was used for all analyses. An alpha of 0.05 was used.Results:A total of 153 patients were analyzed. Mean age was 50 years, 35.7 % female, 64.3% male. Based on cytogenetics 16.9% were in favorable category, 28.6% in intermediate, 25.3% in unfavorable risk group, and 29.2% unknown. Mean number of weeks with ANC <500 was 3.58 (25 days), ANC <100 was 2.81 (20 days), ALC < 500 was 4.47 (31 days), ANC <100 was 3.24 (23 days). Incidence of neutropenic fever was 86.9%. Total number of positive cultures was 55.2%, of which 78.3% were bacterial, 25.3% fungal and 7.7% viral.After adjustment for age, race, gender, WBC and risk group, both neutropenic fever and duration during which ANC < 100 were associated with worse OS (p value <0.05) while duration of ANC< 500 was not significant (p value < 0.0576). When we considered EFS, the duration where ANC<500, ANC <100, and neutropenic fever occurrence were significant (p value <0.05).The hazard ratio of death is 3.15 for those with neutropenic fever compared to those without.With regard to CR, duration of ANC < 100 was significant (p value 0.0272). The duration of ALC <500 or <100 was not significant for OS nor EFS. Examining duration of neutropenia, for every week with ANC <500, there was a 9% higher hazard ratio of death after adjusting for other covariates.Conclusion:In this single-institution, retrospective study, we identified that the duration of neutropenia along with the presence of neutropenic fever during induction therapy adversely affected OS and EFS. Shorter duration of neutropenia significantly correlated with CR. Duration of days with ALC count <500 was not predictive of OS nor EFS. Larger studies are needed to examine the prognostic significance of neutropenia duration and its relationship to OS and CR. Neutropenia duration during induction chemotherapy may be an important risk factor in making decisions regarding future treatments including allogeneic transplant tolerability and aggressiveness of consolidation chemotherapy.It is important to look at this variable in more intensive induction regimens (using higher dose of cytarabine or adding a nucleoside analogue) as prolonged neutropenia may be a marker of poor general health rather than the induction regimen. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

The impact of maternal adiposity specialization on infant birthweight: upper versus lower body fat

BackgroundThe specialization of human fat deposits is an inquiry of special importance in the study of fetal growth. It has been theorized that maternal lower-body fat is designated specifically for lactation and not for the growth of the fetus. ObjectiveOur goal was to compare the contributions of maternal upper-body versus lower-body adiposity to infant birth weight. We hypothesized that upper-body adiposity would be strongly associated with infant birth weight and that lower-body adiposity would be weakly or negligibly associated with infant birth weight—after adjusting for known determinants. Study designIn this prospective cohort study, 355 women initiated medical pre-natal care during the first trimester of pregnancy at The University of Oklahoma Health Sciences Center during 1990–1993. Maternal anthropometric measurements were assessed at the first clinic visit: (a) height; (b) weight; (c) circumferences of the upper arm, forearm, and thigh; and, (d) skin-fold measurements of the bicep, subscapular region, and thigh. ResultsInfant birth weight was regressed on known major determinants to create the foundational model. Maternal anthropometric variables subsequently were added one at a time into this multiple regression model. The highest contribution by a single anthropometric variable to infant birthweight was, in order: subscapular skin-fold, forearm circumference, and thigh circumference. With one upper-body (subscapular skin-fold) and one lower-body (circumference of the thigh) adiposity measure in the model, the z-score regression coefficient (s.e.) was 85.7g (30.8) [p=0.0057] for maternal subscapular skin-fold and 19.0g (31.6) [p=0.5477] for circumference of the thigh. When the second-best upper-body contributor to infant birthweight (circumference of the forearm) was entered with one lower-body measure into the model, the z-score regression coefficient (s.e.) was 77.5g (38.5) [p=0.0451] for maternal forearm circumference and 14.1g (38.5) [p=0.7146] for circumference of the thigh. When both subscapular skinfold and forearm circumference were added to the model in place of BMI, the explained variance (r2=0.5478) was similar to the model using BMI (r2=0.5487). ConclusionUpper-body adiposity – whether operationalized by subscapular skin-fold or circumference of the forearm – was a markedly larger determinant of infant birth weight than lower-body adiposity.

A method for safely resecting anterior butterfly gliomas: the surgical anatomy of the default mode network and the relevance of its preservation.

OBJECTIVE Gliomas invading the anterior corpus callosum are commonly deemed unresectable due to an unacceptable risk/benefit ratio, including the risk of abulia. In this study, the authors investigated the anatomy of the cingulum and its connectivity within the default mode network (DMN). A technique is described involving awake subcortical mapping with higher attention tasks to preserve the cingulum and reduce the incidence of postoperative abulia for patients with so-called butterfly gliomas. METHODS The authors reviewed clinical data on all patients undergoing glioma surgery performed by the senior author during a 4-year period at the University of Oklahoma Health Sciences Center. Forty patients were identified who underwent surgery for butterfly gliomas. Each patient was designated as having undergone surgery either with or without the use of awake subcortical mapping and preservation of the cingulum. Data recorded on these patients included the incidence of abulia/akinetic mutism. In the context of the study findings, the authors conducted a detailed anatomical study of the cingulum and its role within the DMN using postmortem fiber tract dissections of 10 cerebral hemispheres and in vivo diffusion tractography of 10 healthy subjects. RESULTS Forty patients with butterfly gliomas were treated, 25 (62%) with standard surgical methods and 15 (38%) with awake subcortical mapping and preservation of the cingulum. One patient (1/15, 7%) experienced postoperative abulia following surgery with the cingulum-sparing technique. Greater than 90% resection was achieved in 13/15 (87%) of these patients. CONCLUSIONS This study presents evidence that anterior butterfly gliomas can be safely removed using a novel, attention-task based, awake brain surgery technique that focuses on preserving the anatomical connectivity of the cingulum and relevant aspects of the cingulate gyrus.

Depression in adult patients with primary immune thrombocytopenia

Depression in adult patients with primary immune thrombocytopenia

A Journey Worth Taking: Exploring a Hybrid Embedded Library Instruction Model Through Three Distinct Cases

ABSTRACTTo facilitate systematic learning and to complement the limitations of conventional one-shot library instruction sessions, a hybrid embedded instruction model was designed and implemented for undergraduate students and residents in three disciplines at the University of Oklahoma Health Sciences Center. Variations of hybrid instruction are explored, including models that combine face-to-face interactions, online content delivery, flipped instruction techniques, and individual consultations. The hybrid model highlights benefits of collaborative teaching between course faculty members and librarians and enhances the relevance of library instruction for users.