Wald Chi-square Research Articles

Abstract WP255: Association Between Asymptomatic Intracranial Large Artery Stenosis and Neurofilament Light Chain: The Northern Manhattan Study

Introduction: The Neurofilament light chain (NfL) is a neuronal cytoplasmic protein and a reliable biomarker for assessing axonal damage in neurological diseases and traumatic brain injury. Asymptomatic intracranial large artery stenosis (ILAS) has been associated with higher risk of stroke and dementia. Although widely studied in the last few years, the role of NfL concentrations in ILAS is not well understood. Methods: We leveraged data from stroke-free participants in the population-based cohort Northern Manhattan Study (NOMAS) for a pilot study. Arterial stenosis was measured on magnetic resonance angiography in 11 intracranial large arteries and graded as 0 = no stenosis, 1 ≤ 50%, 2 = 50-69%, 3 ≥ 70% stenosis and 4 = flow gap. An asymptomatic Intracranial Large Artery Stenosis (ILAS) score was then developed to reflect the global stenotic burden, with a range of 0 to 44. We also dichotomized the ILAS score into any stenosis > 50% versus none to reflect a more clinically relevant definition of ILAS. NfL concentrations were measured in plasma using Quanterix Simoa™ platform. We conducted generalized linear models adjusting for demographic and vascular risk factors and Wald Chi-Square test to analyze the association between NfL and ILAS score. Results: We included 79 stroke-free NOMAS participants (66% women, 77% Hispanic/Latino, and 75% with hypertension). The mean concentration of NFL was 0.19±0.10 pg/mL with a mean intra-assay coefficient of variation equal to 8.2%. In a model adjusted for age, sex, race/ethnicity, hypertension, diabetes, dyslipidemia and smoking, a higher ILAS score was associated with increased levels of NfL (B=0.01 ± 0.004, p=0.007). In an adjusted model, any stenosis >50% was also associated with increased levels of NfL (B=0.11 ± 0.03, p<0.001). Conclusions: The increased levels of plasma NfL associated with asymptomatic ILAS suggest neuronal injury that may implicate development of neurodegeneration. Confirming these results in a larger sample and longitudinal evaluation of NfL may advance the understanding of the mechanisms by which ILAS may increase the risk of dementia.

Co-Utilization of HIV, Substance Use, Mental Health Services Among Women With Current Substance Use: Opportunities for Integrated Care?

The syndemic of HIV, substance use (SU), and mental illness has serious implications for HIV disease progression among women. We described co-utilization of HIV care, SU treatment, and mental health treatment among women with or at risk for HIV. We included data from women with or at risk for HIV (n = 2559) enrolled in all 10 sites of the Women's Interagency HIV Study (WIHS) from 2013 to 2020. Current SU was defined as self-reported, non-medical use of drugs in the past year, excluding use of only marijuana. Tobacco and alcohol were assessed separately. We described co-utilization of SU treatment, tobacco and alcohol use treatment, HIV care, and mental health care in the past year among women who were eligible for each service. We compared service utilization by those who did/did not utilize SU treatment using Wald Chi-square tests. Among women with current SU (n = 358), 42% reported utilizing SU treatment. Among those with current SU+HIV (n = 224), 84% saw their HIV provider, and 34% saw a mental health provider. Among women with current SU+heavy alcohol use (n = 95), 18% utilized alcohol use treatment; among current SU+tobacco use (n = 276), 8% utilized tobacco use treatment. Women who utilized SU treatment had higher utilization of alcohol use treatment (59% vs. 5%; P < .001) and tobacco use treatment (12% vs. 5%; P = .028). HIV care engagement was high regardless of SU treatment. We found high engagement in SU and HIV care, but low engagement in alcohol and tobacco use treatment. Integrated SU treatment services for women, including tobacco/alcohol treatment and harm reduction, are needed to optimize treatment engagement and HIV care continuum outcomes.

Effects of different antiviral mouthwashes on the surface roughness, hardness, and color stability of composite CAD/CAM materials.

To evaluate the effect of COVID-19 preventive mouthwashes on the surface hardness, surface roughness (Ra), and color change (ΔE) of three different polymer-based composite CAD/CAM materials (Vita Enamic (ENA), Grandio Block (GB), Lava Ultimate (LU)). A total of 100 rectangular-shaped specimens with dimensions of 2 mm × 7 mm × 12 mm were obtained by sectioning three different CAD/CAM blocks and randomly divided into five subgroups according to the 30 days of mouthwash immersion protocol as follows: Control: artificial saliva, PVP-I: 1% povidone-iodine, HP: 1.5% hydrogen peroxide, CPC: mouthwash containing 0.075% cetylpyridinium chloride, EO: mouthwash containing essential oils. Microhardness, Ra, and ΔE values were measured at baseline and after 30 days of immersion protocols. Data were analyzed using the Wald Chi-square, two-way ANOVA, and post hoc Tukey tests. The independent factors (materials and solutions) significantly influenced the microhardness and color (p < 0.001). Ra of the materials was not affected by any of the mouthwashes (p > 0.05). The microhardness and color of each material varied significantly after immersion in PvP-I and HP (p < 0.05). The highest percentage change in microhardness, Ra, and ΔE was found in LU immersed in PvP-I and HP mouthwashes, while the lowest change was found in ENA groups (p < 0.05). Within the limitations of this study, it was found that the surface hardness and color of tested polymer-based composite CAD/CAM materials are susceptible to degradation and change after 30 days of immersion in 1% PvP-I and 1.5% HP mouthwashes.

12‐month cognitive outcome after acute geriatric TBI not associated with U.S. Military Veteran status

AbstractBackgroundTraumatic brain injury (TBI) increases risk for cognitive decline and Alzheimer’s disease/related dementias (ADRD), and Veterans may be at increased risk of both TBI and cognitive decline due to combat/training related exposures and other risk factors. However, it is unknown whether older Veterans are more likely to experience a poor cognitive outcome after acute TBI compared to civilians.MethodWe examined 112 male Veterans and 320 male civilians (55+) who experienced an acute TBI and enrolled in Transforming Research and Clinical Knowledge in Traumatic Brain Injury (TRACK‐TBI). Data were collected at baseline (i.e., emergency room visit) on demographic and injury characteristics. Cognitive and TBI recovery data (i.e., Rivermead Postconcussive Questionnaire, Brief Symptom Inventory, Satisfaction with Life Scale, and Glascow Outcome Scale‐Extended) were collected at 2 weeks, 6 months, and 12 months. We calculated descriptive statistics and compared across Veterans and civilians. 12‐month cognitive outcome was defined as performance &lt;9th percentile on 2+ cognitive tests, and/or decline from 2‐week or 6‐month score &gt;90% reliable change index on two+ tests. We used propensity weighting to address missing cognitive outcome data and conducted a logistic regression analysis to examine association of Veteran status with classification of cognitive outcome.ResultVeterans were older and less likely to be Hispanic compared to civilians but did not differ on race, education, history of head injury, or injury severity. At 12 months post‐TBI, Veterans endorsed worse mood and satisfaction with life (p’s = 0.05), but these results were attenuated by adjustment for prior TBI and injury severity. In adjusted models Veterans did not differ from civilians on a measure of overall TBI outcome (p = 0.45) or postconcussive symptoms (p = 0.32). Moreover, there was no association between Veteran status and cognitive outcome (Wald chi square = 2.66, p = 0.45).ConclusionRisk of poor cognitive outcome following TBI does not differ between older male Veterans and civilians, and mood and life satisfaction outcomes were worse for Veterans but impacted by injury severity and prior head injury. These findings have implications for understanding risk for cognitive decline and ADRD among older men who experience an acute TBI as well as tailoring care, including provision of psychosocial support, for these patients.

Transfusion Requirements in Hospitalized Patients with Sickle Cell Disease Taking Either Voxelotor or Hydroxyurea

Background Sickle Cell Disease is a cause of anemia frequently requiring blood transfusions. Current treatments for Sickle Cell Anemia include Hydroxyurea, or the recently approved medication in 2019, Voxelotor. Although recent research, such as the HOPE study, has shown that Voxelotor increases hemoglobin levels when compared to Hydroxyurea, there is limited data regarding the requirement of blood transfusions in patients with Sickle Cell Disease when comparing the two medications. We conducted a retrospective cohort study to determine the requirement of blood transfusions in hospitalized patients with Sickle Cell Disease who were on either taking Voxelotor or Hydroxyurea. Methods This retrospective cohort study identified 8,815 patients across several facilities diagnosed with Sickle Cell Disease who were taking outpatient Voxelotor or Hydroxyurea. Patients who had CKD Stage 4 or 5, ESRD, pregnancy, major surgery, normal hemoglobin levels, and elevated liver enzymes were excluded with a final sample of 6,240. Patients were stratified into two groups based on the treatment they were on, a group taking Voxelotor (243 patients 3.92%) and a group taking Hydroxyurea (5961 96.08%) outpatient. We assessed patient's characteristics such as age, sex, race, smoking status and events during hospitalization. The primary outcome was the number of blood transfusions required with either treatment. Zero-inflated Poisson regression was used to determine the quantity and prediction of blood transfusions required according to different characteristics. Results Of the 6,240 with Sickle Cell Disease who were either on Voxelotor or Hydroxyurea the mean age was 31.32 years, 58.11% were female and 41.89% were male, 94.63% were African-American and 5.37% were non-African-Americans. The medication group was not significantly associated with the log count of transfusions (ie. increased number of transfusions), when controlling for other variables (χ 2 = 0.81, p = 0.367). The odds ratio is 0.425, indicating that patients on Voxelotor are 0.4247 times as likely to be in the “certain zero” group as those on Hydroxyurea - in other words, patients taking Hydroxyurea are 2.354 (1/0.425) times as likely to be in the “certain zero” group (i.e., patients on Hydroxyurea are 2.354 times as likely to not need a transfusion compared to patients taking Voxelotor). Conclusion Hospitalized patients with Sickle Cell Disease taking Voxelotor or Hydroxyurea outpatient have similar blood transfusions requirements when controlling for other variables. In the case of Voxelotor, it is known to increase hemoglobin levels more than Hydroxyurea in patients with Sickle Cell Disease, but there is limited data regarding the end requirements of blood transfusions when comparing the two medications. Our study is the first to identify that there was no increased requirement in the quantity of blood transfusions (Wald Chi Square 26.36, p&amp;lt;.0001, CI 0.3063~ 0.5890) when comparing each medication group. However, the limitation is having a relatively small sample size, and possible confounders from the patients and the disease itself. Further research is required to investigate this.

Peripherally Inserted Central Venous Catheter in newborns admitted to the Intensive Care Unit: adverse events

Objective: To analyze factors associated with the occurrence of Adverse Events (AE) related to the Peripherally Inserted Central Catheter (PICC) in Newborns (NB). Method: cross-sectional, descriptive and analytical study, carried out in the Neonatal Intensive Care Unit of a reference hospital, from January to March 2019. The sample consisted of 225 PICCs. The occurrence of AEs was considered as an outcome, and the hierarchical variables were considered explanatory: distal (sociodemographic) and proximal (NB clinics). Wald's chi-square was used for the initial selection of variables (p&lt;0.20) and Poisson regression, with robust variance, for model adjustment (p&lt;0.05). The t test was used to compare the mean occurrence of AE with the insertion of the PICC, at the 5% level. In the final model, the insertion site, scalp vein (p&lt;0.001), and reason for removal (p&lt;0.001) of the PICC were significant for the occurrence of AE. Comparing the averages between occurrences and non-occurrences of AEs, it was verified that only the weight of the NBs was significant (p=0.002), due to prematurity. Conclusion: AEs are related to inadequate management of PICC maintenance and choice of vein.

Relationship Between Sexually Transmitted Infections and Social Determinants of Health in Durham County, North Carolina, United States.

Sexually transmitted infections (STIs) are increasing in the United States, and certain populations are more at risk than others. One explanation for this is inequities in underlying social determinants of health (SDOH). We analyzed chlamydia, gonorrhea, and syphilis cases in Durham County, North Carolina, from 01/01/2020 to 12/31/2020 by select SDOH at the census tract level. We included 48 variables of interest, including variables related to income, education, transportation, and health insurance. For each variable, we modeled STI incidence at the census tract level using Poisson regression. Wald's chi-square was used to determine which variables were significantly associated with STI incidence. Of 24 variables that were statistically associated with STI incidence at the census tract level, 9 were negatively associated and 15 positively associated with STI incidence. Having employer health insurance was most strongly associated with lower-than-expected STI incidence, and having Medicaid insurance, no health insurance, using public transportation, and income below the poverty level were most strongly associated with higher-than-expected STI incidence. Lastly, STI incidence was not associated with race or ethnicity overall across Durham County, except in historically marginalized areas, where we found higher-than-expected STI incidence. We found that lacking health insurance, having Medicaid insurance, using public transportation, and income below the poverty level were most strongly associated with higher-than-expected STI incidence. Strategies to combat increasing STIs may include improving access to health insurance, reducing barriers to cost-effective and timely transportation to medical appointments, and raising wages to bring individuals out of poverty.

A real-world study for timely assessing the diabetic macular edema refractory to intravitreal anti-VEGF treatment.

Early Identifying and characterizing patients with diabetic macular edema (DME) is essential for individualized treatment and outcome optimization. This study aimed to timely investigate optical coherence tomography (OCT) biomarkers of DME refractory to intravitreal anti-vascular endothelial growth factor (VEGF) therapy. We retrospective reviewed 72 eyes from 44 treatment-naïve patients who were treated with intravitreal anti-VEGF for DME. OCT scans prior to anti-VEGF were evaluated for serous retinal detachment (SRD), size of outer nuclear layer cystoid changes, diffuse retinal thickening, integrity of the inner segment-outer segment (IS-OS) junction, quantity and location of hyperreflective foci, vitreomacular interface abnormalities, and epiretinal membrane (ERM). The Baseline best-corrected visual acuity (BCVA) and central macular thickness was recorded at baseline and 4 months after treatment with anti-VEGF. The main outcome measure was the correlation between spectral-domain OCT measurements and BCVA response at baseline and after anti-VEGF treatment (mean change from baseline; ≥ 10 Early Treatment Diabetic Retinopathy Study letters in BCVA). Partially continuous IS-OS layers (partially vs. completely continuous: β, -0.138; Wald chi-square, 16.392; P<0.001) was predictor of better response to anti-VEGF treatment. In contrast, ERM (present vs. absent ERM: β, 0.215; Wald chi-square, 5.921; P=0.015) and vitreomacular traction (vitreomacular traction vs. posterior vitreous detachment: β=0.259; Wald chi-square=5.938; P=0.015) were the predictors of poor response. The improvement of BCVA trended toward the OCT predictive value of central macular thickness reduction; however, this was not significant. Partially continuous IS-OS layers is predictive of better response to anti-VEGF therapy in DME. Meanwhile, ERM is a significant predictor of poor response.

How do experts in psychiatric genetics view the clinical utility of polygenic risk scores for schizophrenia?

Polygenic risk scores (PRS) are promising for identifying common variant-related inheritance for psychiatric conditions but their integration into clinical practice depends on their clinical utility and psychiatrists' understanding of PRS. Our online survey explored these issues with 276 professionals working in psychiatric genetics (RR: 19%). Overall, participants demonstrated knowledge of how to interpret PRS results. Their performance on knowledge-based questions was positively correlated with participants' self-reported familiarity with PRS (r = 0.21, p = 0.0006) although differences were not statistically significant (Wald Chi-square = 3.29, df = 1, p = 0.07). However, only 48.9% of all participants answered all knowledge questions correctly. Many participants (56.5%), especially researchers (42%), indicated having at least occasional conversations about the role of genetics in psychiatric conditions with patients and/or family members. Most participants (62.7%) indicated that PRS are not yet sufficiently robust for assessment of susceptibility to schizophrenia; most significant obstacles were low predictive power and lack of population diversity in available PRS (selected, respectively, by 53.6% and 29.3% of participants). Nevertheless, 89.8% of participants were optimistic about the use of PRS in the next 10 years, suggesting a belief that current shortcomings could be addressed. Our findings inform about the perceptions of psychiatric professionals regarding PRS and the application of PRS in psychiatry.

The Predictive Value of Cystatin C for AKI in Patients with COVID-19

Objective. To evaluate a potential of cystatin C blood concentration to predict acute kidney injury (AKI) in patients with severe and extremely severe pneumonia associated with a COVID-19.Materials and methods. An observational prospective study of 117 patients with severe and extremely severe pneumonia associated with a COVID-19 in an ICU setting was conducted in 2020-2022 (site: multi-functional Medical Center, 1586 Military Clinical Hospital of the Ministry of Defense of Russia, Moscow Region, Russia). Routine laboratory tests and instrumental examinations were performed according to generally accepted protocols. Cystatin C concentrations in blood (s-CysC) and urine (u-CysC) were measured by immunoturbidimetric method.Results. AKI was diagnosed in 21 (17.9%) patients, kidney dysfunction without AKI was found in 22 (18.8%) patients with severe and extremely severe pneumonia associated with COVID-19. s-CysC and u-CysC levels in the group of patients with AKI were statistically significantly higher compared to the levels in the group of patients without AKI. The levels of s-CysC obtained within Day 1 — T (-1), and Day 2 — T (-2) prior to AKI onset turned out to be the independent factors for AKI development in patients with severe and extremely severe pneumonia associated with COVID-19: OR 5.37, Wald chisquare 5.534 (CI: 1.324; 21.788); P=0.019 and OR 3.225, Wald chi-square 4.121 (CI: 1.041; 9.989); P=0.042, respectively. s-CysC T (-2) value is informative, and s- CysC T (-1) is a highly informative predictor of AKI development in severe and extremely severe pneumonia associated with COVID-19: ROC AUC 0.853 (95% CI, 0.74-0.966), P&lt;0.001) with 90% sensitivity and 73% specificity at a cut-off of 1.67 mg/L, and ROC AUC 0.905 (95% CI, 0.837-0.973), P&lt;0.001) with 90% sensitivity and 73% specificity at a cut-off of 1.69 mg/l, respectively. Serum CysC levels started increasing 3 days prior to AKI onset, outpacing the increase of SCr levels. The u-CysC levels were not predictive of AKI development. Impaired renal function probability was increasing with patients' age (P&lt;0.0001).Conclusions. Serum CysC seems to be a statistically significant predictor of AKI. s-CysC levels started increasing 3 days prior to AKI onset, surpassing the increase of SCr levels in patients with severe and extremely severe pneumonia associated with COVID-19. Urine CysC did not achieve statistical significance as a predictor for AKI, although u-CysC concentrations were significantly higher on days 3, 2, 1 prior to AKI onset and on the day of AKI onset in the group of patients with AKI.

Health seeking behavior of in tuberculosis patients during COVID-19 pandemic and lockdown in a tertiary care center

Background: The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) emerged in India in 2020 having originated from China in late 2019. There is no study on the impact of covid management burden on tuberculosis (TB) management. Study on the effect of lockdown on TB management is also unknown. This is a pilot study. Method: It is hypothesised that only people who are severely symptomatic will get tested for TB and severely sick patients will get admitted during the lockdown period. Data from outpatient TB clinic and inpatient ward were analysed. Results: During the lockdown of 5 months saw severe fall in the attendance of the outpatient to 727 patients which was almost 44.44% of the pre lockdown patients, sputum positive among them were 160, positivity rate was 21.69. The total inpatients admission in the lockdown period of 6 months was 130 with average of 26 per month (36% of normal). The Wald chi-square for outpatient p=0.00 with CI=43.30-63.81. The Wald chi-square test for inpatient admission p=0.00 with CI=31.66-49.52. The results of inpatients admission showed that only sick and serious patients approached hospital in the lockdown period. Conclusions: The results in the outpatient setting showed that mild to moderate symptomatic patients may not seek consultation only severe cases approached healthcare leading to spread.

Factors influencing suboptimal pathologic margins and re-excision following breast conserving surgery for ductal carcinoma in-situ

IntroductionRe-excisions following breast conserving surgery (BCS) are common, occurring more frequently in ductal carcinoma in-situ (DCIS) than its’ malignant counterpart. Although one quarter of patients with breast cancer will have DCIS, there is limited information available regarding factors predisposing to inadequate pathologic margins, and the need for re-excision. MethodsRetrospective review of patients treated for DCIS between the years 2010–2016 was conducted. Patients with DCIS undergoing BCS were identified and evaluated for demographic and pathologic factors associated with suboptimal pathologic margins and re-excision. Multivariate analysis with Wald Chi-Square testing was performed. Results241 patients underwent BCS with suboptimal margins (SOM) in 51.7% (123/238), with 27.8% undergoing re-excision (67/241). Tumor size was the most influential variable, positively associated with SOM (OR = 10.25, CI: 5.50–19.13) and re-excision (OR = 6.36, CI: 3.92–10.31). Patient age was inversely associated with SOM (OR = 0.58, CI: 0.39–0.85) and subsequent re-excisions (OR = 0.56, CI: 0.36–0.86). Low tumour grade was associated with re-excision (OR = 1.31, CI: 0.63–2.71), while ER negative disease was associated with SOM (OR = 2.24, CI: 1.21–4.14). DiscussionInadequate pathologic margins following BCS, and subsequent re-excision rates are common in patients with DCIS, and consistent with the literature. Tumour size is the dominant factor driving this occurrence, with patient age and tumour grade also impacting outcomes.

Relating parental stress with sleep disorders in parents and children.

To assess whether child sleep disorders positively correlate with parental insomnia, hypersomnia, and sleep apnea, and whether parental and child sleep disorders simultaneously positively associate with parental stress. Potential modifying influences of these associations by age, sex, and marital status will be considered. Analyses are based on 14,009 employees aged 18-64 with dependent children (n = 44,157) insured by Deseret Mutual Benefit Administrator (DMBA) in 2020. Rate ratios are adjusted for age, sex, and marital status. The rate of parental stress is 3.00 (95% CI 2.33-4.85) times greater for those with insomnia and 1.88 (95% CI 1.59-2.22) times greater for those with sleep apnea. There is no increased risk of stress for those with hypersomnia. The number of dependent children filing one or more medical claims for a sleep disorder is 2.0%. Mean age is significantly older among those with a sleep disorder (17.1 vs. 14.4, t p < .0001). Child sex is not associated with the risk of having a sleep disorder. The rate of employee insomnia is 111% greater if their child has a sleep disorder, and employee sleep apnea is 115% greater if their child has a sleep disorder. The association between child sleep disorders and sleep apnea decreases with employee age (Wald chi-square p = 0.0410). The rate of employee stress is 90% greater if their child has a sleep disorder, 189% greater if they have insomnia, and 81% greater if they have sleep apnea. The strength of the association between insomnia and stress is greater for women (Wald Chi-square p = 0.0114), between sleep apnea and stress is greater for women (Wald chi-square p = 0.0010), and between sleep apnea and stress is greater for singles (Wald chi-square p = 0.0010). Better understanding the connection between parent and child sleep problems and parent stress, and modifying influences, may improve treatment of these disorders.

Risk Factors for Early Mechanical Failure and Revision in Modern Total Ankle Replacements

Category: Ankle Arthritis; Ankle Introduction/Purpose: Total ankle replacements (TAR) have rapidly advanced in terms of volume, technique, design, and indications. However, they are still at risk for failure and need for revision, even early in the postoperative period. Although recently there has been extensive research on TAR, many studies are limited in their power and sample size to assess risk factors for failure/revision. Using a large multi-surgeon retrospective database, we sought to describe the incidence and etiology of mechanical failure across modern implants. We also aimed to identify risk factors for early mechanical failure. We hypothesized that greater body mass index (BMI) and ipsilateral hindfoot fusion would be predictors of mechanical failure, and that implants with greater extent of tibial fixation (stems and keels) would be protective against mechanical failure. Methods: This is a single-center retrospective review of TAR patients in a prospective database. Adults undergoing primary TAR using any implant (Cadence, Inbone, Infinity, Invision, Salto, STAR, Vantage, Zimmer) who were minimum 2 years post-surgery were included. Exclusion criteria included revision TAR or patients undergoing ankle fusion takedown and conversion to TAR. Five surgeons contributed patients. Demographics, etiology of arthritis, operative data, and postoperative complications, reoperations, and revisions were collected. Revisions and reoperations were classified by standard criteria. Cause of revision was recorded. There were 560 TARs eligible for 2-year follow-up (mean 3.9 +- 1.1 years postoperative), with mean follow-up of 2.2 +- 1.4 years (range 1-71 months). The cohort had mean age 63.8 +- 9.1 years, BMI 29.4 +- 5.2 kg/m2, and 57% were male. Kaplan- Meier survival plots were created. Risk factors for revision due to mechanical failure were analyzed using multivariable logistic regression with partial Wald chi square statistics. Results: Most implants were low-profile (n=444, 79.3%), with 28 implants having tibial keels (5%) and 88 with tibial/talar stems (15.7%). There were 25 (4.5%) revisions of tibial and/or talar components at mean 1.6 years after index surgery (Figure). Preoperative coronal deformity did not impact revision rates (p=0.433). Patients who underwent revision for mechanical failure had significantly higher rates of concomitant hindfoot fusion (20% vs. 8.4%, p=0.047) and greater BMI (31.4 kg/m2 vs. 29.3 kg/m2, p=0.04). In multivariable logistic regression, hindfoot fusion was just short of statistical significance (odds ratio [OR] 2.96, p=0.056), and BMI was not significant (OR 1.05, p=0.417). Stemmed or keeled implants did not significantly decrease revision rates compared to low-profile implants, although the revision rate of stemmed implants was substantially low (1/88, 1.1%). Conclusion: Among 560 modern TAR implants, short-term survivorship was 95% at 2-year follow-up, which is consistent with existing studies. Patients who underwent revision for early mechanical failure had significantly higher BMI and rates of hindfoot arthrodesis. However, these variables fell short of statistical significance in multivariable regression, suggesting that there are either additional factors contributing to revision, or a larger cohort is needed. In addition, these results are likely biased by surgeons' tendencies to use stemmed implants in patients with hindfoot fusions. Further research is warranted to determine if stemmed implants provide a protective effect in these high-risk patients.

Managing Opioid Withdrawal in an Outpatient Setting With Lofexidine or Clonidine.

BackgroundThere is a need for improved strategies for managing abrupt opioid withdrawal when transitioning patients with opioid use disorder to comprehensive longitudinal care strategies such as naltrexone maintenance treatment. In addition, alpha-2 adrenergic agonists are used to ameliorate withdrawal symptoms, but current data characterizing real-world treatment are lacking.MethodsA retrospective chart review was conducted in outpatients undergoing abrupt opioid withdrawal managed with lofexidine (0.18 mg, 1-4 tablets 4x daily for 7 days, pro re nata [PRN or as needed]) or clonidine (0.2 mg, 1 tablet 3x daily for 10 days, PRN). Withdrawal outcomes were characterized at 30 days of follow-up. Binomial logistic regression was used to assess a potential association of the two treatments with different likelihoods of opioid cessation success in this real-world outpatient practice.ResultsIn cases treated with lofexidine (n=166) and clonidine (n=432), respectively, 40% and 10% were opioid-free, 6% and 2% continued long-term buprenorphine or methadone, 17% and 36% relapsed, and 37% and 52% were lost to follow-up at 30 days post-withdrawal. Among patients returning for follow-up care, 63% of patients treated with lofexidine and 21% treated with clonidine were opioid-free. Lofexidine was associated with a higher likelihood of opioid cessation success relative to clonidine (OR=6.47; Wald Chi-square=53.79, p<0.001).ConclusionAmong outpatients returning for follow-up care, nearly two-thirds of those managed with lofexidine reached opioid-free status at 30 days post-withdrawal, which was a higher likelihood than those managed with clonidine, thus allowing their transition to comprehensive care, including naltrexone.

Initial clinical and treatment patterns of advanced differentiated thyroid cancer: ERUDIT study.

BackgroundUp to 30% of differentiated thyroid cancer (DTC) will develop advanced-stage disease (aDTC) with reduced overall survival (OS).ObjectiveThe aim of this study is to characterize initial diagnosis of aDTC, its therapeutic management, and prognosis in Spain and Portugal.MethodsA multicentre, longitudinal, retrospective study of adult patients diagnosed with aDTC in the Iberian Peninsula was conducted between January 2007 and December 2012. Analyses of baseline characteristics and results of initial treatments, relapse- or progression-free survival ((RP)FS) from first DTC diagnosis, OS, and prognostic factors impacting the evolution of advanced disease were evaluated.ResultsTwo hundred and thirteen patients (median age: 63 years; 57% female) were eligible from 23 hospitals. Advanced disease presented at first diagnosis (de novo aDTC) included 54% of patients, while 46% had relapsed from early disease (recurrent/progressive eDTC). At initial stage, most patients received surgery (98%) and/or radioiodine (RAI) (89%), with no differences seen between median OS (95% CI) (10.4 (7.3–15.3) years) and median disease-specific-survival (95% CI) (11.1 (8.7–16.2) years; log-rank test P = 0.4737). Age at diagnosis being <55 years was associated with a lower risk of death (Wald chi-square (Wc-s) P < 0.0001), while a poor response to RAI to a higher risk of death ((Wc-s) P < 0.05). In the eDTC cohort, median (RP)FS (95% CI) was of 1.7 (1.0–2.0) years after RAI, with R0/R1 surgeries being the only common significant favourable factor for longer (RP)FS and time to aDTC ((Wc-s) P < 0.05).ConclusionIdentification of early treatment-dependent prognostic factors for an unfavourable course of advanced disease is possible. An intensified therapeutic attitude may reverse this trend and should be considered in poor-performing patients. Prospective studies are required to confirm these findings.

Investigating the relationship between infraorbital canal morphology and maxillary sinus size.

The purpose of the current study was to investigate relationships between maxillary sinus (MS) dimensions and the bony structures associated with the infraorbital nerve (ION). Computed tomographic scans of 87 adult crania (174 sides) from four morphologically diverse groups (West Africans, East Africans, North Asians, Europeans) were utilized. Seven primary variables were collected: infraorbital canal (IOC) type; infraorbital foramen (IOF) shape; distance from the foramen rotundum to IOF (FR-IOF); distance from the posterior wall of the infraorbital groove to IOF (IOG-IOF); and MS length, breadth, and height. Chi-square analyses indicated a significant association between IOC-type and IOF-shape (Pearson chi-square=12.710; p-value=.013), with the most common pattern being oval IOFs and Type-I IOCs (45.68% of the sample; 74/162 sides). Analysis of covariance indicated a significant effect of ancestry (F=8.333; p < .001) and MS length (F=15.406; p < .001) on IOG-IOF distance. Ordinal regression analyses indicated that MS length (Wald chi-square=7.103; p=.008) also maintained a significant effect on IOC-type, while multinominal regression analyses indicated that none of the measured parameters had a significant effect on IOF-shape. These results have clinical implications: recognizing IOC-type and IOF-shape relative to the MS is important to avoid ION damage during medical procedures. Overall, this study found most individuals possess Type-I IOCs (housed in the maxillary sinus roof) and oval-shaped IOFs. Most aspects of the ION pathway, including IOC-type and IOF-shape, were not influenced by ancestry or sex. However, antero-posteriorly longer MSs tend to possess Type-III IOCs protruding into the sinus, which could lead to surgical complications.

Feasibility of pilates for pregnant women: A randomised trial

ObjectiveTo investigate the feasibility and preliminary effects of Pilates exercises in primigravida women. DesignSingle-blind randomized controlled feasibility trial. SettingCommunity Pilates classes. ParticipantsLow-risk pregnant women. InterventionsPregnant women were randomly assigned to Pilates exercises (experimental) group for 6 consecutive weeks or usual antenatal care, the control group. Main outcomesThe primary outcome was feasibility of Pilates classes. Secondary outcomes included quality of life, pain, and mobility. Results21 women were recruited to the trial. Eleven were randomly allocated to the experimental group and 10 to the control group. Retention of participants was excellent for the Pilates group (100%) compared to 70% in the control group. There were no adverse events. The Pilates group showed greater gains in quality of life on the SF-12 from the pre-test (M = 81.0, SD = 11.8) to the post-test (M = 83.3, SD = 8.52) compared to the control group (pre-test M = 69.78, SD = 15.9) (post-test M = 68.1, SD = 16.05) (Wald Chi-Square = 5.597, p = 0.018). Although the duration of labour was shorter in the Pilates group (Mdn = 215, IQR: 279 min) than usual care (Mdn = 458.5, IQR: 305 min), the difference was not statistically significant. There were no significant differences between groups for pain, mobility, abdominal separation, urinary continence, analgesia, or the mode of birth. ConclusionsModified Pilates appears feasible and safe for low-risk pregnant women. Further research is needed in on this topic.

Effects of an opioid stewardship program on opioid consumption and related outcomes after multilevel lumbar spine fusion: a pre- and postimplementation analysis of 268 patients.

Opioid stewardship programs combine clinical, regulatory, and educational interventions to minimize inappropriate opioid use and prescribing for orthopedic and spine surgery. Most evaluations of stewardship programs quantify effects on prescriber behavior, whereas patient-relevant outcomes have been relatively neglected. The authors evaluated the impact of an opioid stewardship program on perioperative opioid consumption, prescribing, and related clinical outcomes after multilevel lumbar fusion. The study was based on a retrospective, quasi-experimental, pretest-posttest design in 268 adult patients who underwent multilevel lumbar fusion in 2016 (preimplementation, n = 141) or 2019 (postimplementation, n = 127). The primary outcome was in-hospital opioid consumption (morphine equivalent dose [MED], mg). Secondary outcomes included numeric rating scale pain scores (0-10), length of stay (LOS), incidence of opioid-induced side effects (gastrointestinal, nausea/vomiting, respiratory, sedation, cognitive), and preoperative and discharge prescribing. Outcomes were measured continuously during the hospital admission. Differences in outcomes between the epochs were assessed in bivariable (Wilcoxon signed-rank or Fisher's exact tests) and multivariable (Wald's chi-square test) analyses. In bivariable analyses, there were significant decreases in preoperative opioid use (46% vs 28% of patients, p = 0.002), preoperative opioid prescribing (MED 30 mg [IQR 20-60 mg] vs 20 mg [IQR 11-39 mg], p = 0.003), in-hospital opioid consumption (MED 329 mg [IQR 188-575 mg] vs 199 mg [100-372 mg], p < 0.001), the incidence of any opioid-related side effect (62% vs 50%, p = 0.03), and discharge opioid prescribing (MED 90 mg [IQR 60-135 mg] vs 60 mg [IQR 45-80 mg], p < 0.0001) between 2016 and 2019. There were no significant differences in postanesthesia care unit pain scores (4 [IQR 3-6] vs 5 [IQR 3-6], p = 0.33), nursing floor pain scores (4 [IQR 3-5] vs 4 [IQR 3-5], p = 0.93), or total LOS (118 hours [IQR 81-173 hours] vs 103 hours [IQR 81-132 hours], p = 0.21). On multivariable analysis, the opioid stewardship program was significantly associated with decreased discharge prescribing (Wald's chi square = 9.45, effect size -52.4, 95% confidence interval [CI] -86 to -19.0, p = 0.002). The number of lumbar levels fused had the strongest effect on total opioid consumption during the hospital stay (Wald's chi square = 16.53, effect size = 539, 95% CI 279.1 to 799, p < 0.001), followed by preoperative opioid use (Wald's chi square = 44.04, effect size = 5, 95% CI 4 to 7, p < 0.001). A significant decrease in perioperative opioid prescribing, consumption, and opioid-related side effects was found after implementation of an opioid stewardship program. These gains were achieved without adverse effects on pain scores or LOS. These results suggest the major impact of opioid stewardship programs for spine surgery may be on changing prescriber behavior.

Clinical characteristics of 114 patients with iridocorneal endothelial syndrome

Objective: To investigate the clinical features in patients with iridocorneal endothelial (ICE) syndrome. Methods: A retrospective case series study. Data of clinical manifestations of patients with ICE syndrome including clinical subtypes, presenting visual acuity, clinical features and secondary glaucoma were collected from January 2014 to May 2020 in the Eye Hospital, School of Ophthalmology and Optometry, Wenzhou Medical University. The Wald's Chi-square test of generalized estimating equations was performed to analyze the differences in three clinical subtypes. Results: A total of 127 eyes of 114 subjects (64 females and 50 males) were included. Mean±SD age at presentation was (49±13) years. There were 53 patients (46.5%) with Chandler's syndrome (CS), 36 patients (31.6%) with progressive iris atrophy (PIA), 24 patients (21.0%) with Cogan-Reese syndrome (CRS) and one patient (0.9%) with an undetermined subtype. And 101 patients (88.6%) had uniocular ICE syndrome. Approximately 81.7% (49/60), 56.1% (23/41) and 41.7% (10/24) of eyes presented visual acuity <0.3 in patients with CS, PIA and CRS, respectively. Corneal edema was most common in CS (52.5%, 32/61), followed by PIA (29.3%, 12/41) and CRS (20.8%, 5/24). Corectopia was found in 95.8% (23/24) of eyes with CRS, 95.1% (39/41) of eyes with PIA and 78.7% (48/61) of eyes with CS. Polycoria was observed in 29.3% (12/41) of eyes with PIA, 3.3% (2/61) of eyes with CS and 8.3% (2/24) of eyes with CRS. Ectropion uvea was most common in CRS (54.2%, 13/24), followed by 16.4% (10/61) in CS and 12.2% (5/41) in PIA. Glaucoma was found in 94 eyes (74.0%, 94/127). Among them, 60.7% (37/61) of CS, 80.5% (33/41) of PIA and 95.8% (23/24) of CRS had secondary glaucoma. The difference of presenting visual acuity, corneal edema, corectopia, polycoria, ectropion uveae and secondary glaucoma in three clinical subtypes all had statistical significance (Wald χ2=13.87, 10.77, 965.78, 11.45, 15.00, 222.04; all P<0.05). And 86.2% of eyes (81/94) had glaucoma surgeries and 41 eyes (43.6%, 41/94) had the intraocular pressure well controlled with various interventions. Conclusions: ICE syndrome is mostly uniocular and more common in middle-aged patients. CS is the most common clinical subtype with poor presenting visual acuity. About 3/4 of eyes have secondary glaucoma, and the majority of them require surgical interventions, but prognoses are discouraging.