Wilcoxon Two-sample Test Research Articles

Clinical Assessment of Prostate Displacement and Planning Target Volume Margins for Stereotactic Body Radiotherapy of Prostate Cancer.

Purpose: To assess the optimal planning target volume (PTV) margins for stereotactic body radiotherapy (SBRT) of prostate cancer based on inter- and intra-fractional prostate motion determined from daily image guidance.Methods and Materials: Two hundred and five patients who were enrolled on two prospective studies of SBRT (8 Gy × 5 fractions) for localized prostate cancer treated at a single institution between 2012 and 2017 had complete inter- and intra-fractional shift data available. All patients had scheduled kilovoltage planar imaging during SBRT with rigid registration to intraprostatic fiducials prior to each of four half-arcs delivered per fraction, as well as cone beam CT verification of anatomy prior to each fraction. Inter- and intra- fractional shift data were obtained to estimate the required PTV margins based on the classic van Herk formula. Inter- and intra-fractional motion were compared between patients with and without severe toxicities using the independent two-sample Wilcoxon test.Results: The margins required to account for inter-fractional motion were estimated to be 0.99, 1.52, and 1.45 cm in lateral (LR), longitudinal (SI), and vertical (AP) directions, respectively. The margins required to account for intra-fractional motion were estimated to be 0.19, 0.27, and 0.31 cm in LR, SI and AP directions, respectively. Large intra-fractional shifts were mostly observed in the SI and AP directions, with 2.0 and 5.4% of patients experiencing average intra-fractional motion >3 mm in the SI and AP directions, respectively, compared with none experiencing mean shifts >3 mm in the LR direction. Six patients experienced grade 3 gastrointestinal or genitourinary toxicity. There were no significant differences in mean inter- or intra-fractional motion in any of the cardinal directions compared to patients without severe toxicity (inter-fractional p = 0.46–0.99, intra-fractional p = 0.10–0.84).Conclusion: The inter- and intra-fractional margins estimated from this study are in line with prior reported values. Intra-fractional prostate motion was generally small with larger margins required for the SI and AP directions, notably just slightly exceeding the commonly used 3 mm posterior PTV margin even with realignment between half-arcs. Development of severe toxicity was not significantly associated with the degree of inter- or intra-fractional motion.

Abstract A23: Association of gut microbiome diversity with obesity and breast density in postmenopausal women

Abstract Purpose: The plausible roles of the gut microbiome (GM) in obesity as well as breast cancer have been discussed in recent reviews. The associations of GM with mammographic breast density (BD), a well-established strong breast cancer risk factor, also associated with body mass index (BMI), are poorly studied. We examined GM profiles in relation to BD and BMI in a sample of healthy postmenopausal women. Methods: Women were recruited in mammography clinics at Moffitt Cancer Center and via recruitment announcements at the University of Florida. Eligible women were postmenopausal, had a BMI ≤35 kg/m2, and had not taken oral/IV antibiotics within 30 days and/or more than two separate antibiotic regimens within the previous three months. All women provided a fecal sample and comprehensive information on breast cancer risk factors including body weight and height. Mammographic BD was available for 69 women recruited at Moffitt and was classified according to the American College of Radiology’s BI-RADS BD classification system. For this analysis, BD was dichotomized as low (BI-RADS I or II) or high (BI-RADS III and IV). DNA was isolated from fecal samples and the V1-V2 hypervariable regions of 16S rRNA amplified using barcoded primers for sequencing on the Illumina MiSeq platform. Chao1, Inverse Simpson, and Shannon indices were used to classify within sample diversity. The two-sample Wilcoxon test was used to examine associations of GM with BD and BMI. Associations were also examined according to the ratio of the two main phyla in the human GM (Firmicutes and Bacteroidetes; F/B ratio) that has been linked to obesity in previous studies. Results: Among 69 women with BD data, 39 had low BD and 30 had high BD. BMI was inversely associated with BD (mean BMI=23.8 in women with high BD and BMI=28.0 in women with low BD, p=1.07 × 10-5). The F/B ratio was not associated with BMI (median F/B ratio=0.90, 0.84, and 0.96 for normal weight, overweight, and obesity, respectively, p=0.57). Similar levels of diversity were found across weight groups according to the Shannon (4.05, 3.97, and 3.96, respectively, p=0.83); inverse Simpson (20.6, 20.1, and 19.3, respectively, p=0.97); and chao1 (433, 441, and 419, respectively, p=0.31) indices. F/B ratio and microbiota diversity were both suggestively greater in women with high vs. low BD (median F/B ratio=1.15 for high and 0.94 for low BD, p=0.35; Shannon index: 4.24 for high and 4.15 for low BD, p=0.14; inverse Simpson= 25.3 for high and 21.0 for low BD, p=0.15; chao1= 519 for high and 429 for low BD, p=0.17). Highest levels of alpha diversity were observed in women who had both high BD and low BMI. Taxonomic families that distinguished women with high vs. low BD included Ruminococcaceae, Mogibacteriaceae, Bacteroidaceae, Lachnospiraceae, Christensenellaceae, and Coriobacteriaceae. Conclusion: Results suggest that women with high and low BD may differ with respect to GM alpha diversity and GM composition. Citation Format: Lusine Yaghjyan, Xuefeng Wang, Maria Ukhanova, Yessica Martinez, Shannan Rich, Volker Mai, Kathleen Egan. Association of gut microbiome diversity with obesity and breast density in postmenopausal women [abstract]. In: Proceedings of the AACR Special Conference on the Microbiome, Viruses, and Cancer; 2020 Feb 21-24; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2020;80(8 Suppl):Abstract nr A23.

Satisfaction of Slovak women with psychosocial aspects of care during childbirth

ObjectiveThe objective of the study is to find out and assess satisfaction of Slovak women with psychosocial aspects of perinatal care. Design and settingThe research was designed as a quantitative cross-sectional study. The research data were collected in five pediatric outpatient clinics in Slovakia. ParticipantsThe research sample consisted of 360 women within 0–1 year after natural delivery (average time in months from childbirth: 6.22 ± 3.64) who visited the selected pediatric outpatient clinic in the period from October 2016 to January 2018. MethodsTo collect the relevant data, the original Czech questionnaire measuring psychosocial climate in maternity hospitals – KLI-P (Cronbach α = 0.95) was used to investigate the satisfaction of women with care during labor and delivery as well as with psychosocial aspects. The following six factors were assessed: (1) helpfulness and empathy of midwives and (2) of physicians, (3) superiority and lack of interest, (4) physical comfort and services, (5) control of a woman in labor and her participation in decision-making, (6) providing information. The received data were analyzed using descriptive statistics, the Shapiro–Wilk test, robust ANOVA, Post-hoc test, the Wilcoxon two-sample test, a G-test of independence and the Cochran–Armitage test of trend. FindingsWe found that most women (83.1%) were generally satisfied with their care during labor and delivery as well as with psychosocial support. In terms of psychosocial aspects, the highest level of satisfaction was attributed to the approach of the health professionals and the lowest one (61.5%) to the control and participation of delivering woman in decision-making. Both perception of the course of labor and delivery and skin-to-skin contact immediately after birth were shown to be statistically significant predictors of women's satisfaction. The aspect of age was found to be statistically significant in relation to the factor of control of a woman in labor and her participation in decision-making. Key conclusions and implications for practiceIt can be concluded that it is necessary to pay attention to the psychosocial aspects of health care during labor and delivery, with the emphasis on strengthening interventions in the field of participation of women in decision-making. Simultaneously, it is beneficial to emphasize and support the naturalness of childbirth so that women would associate childbirth with a positive experience. Finally, it is important to promote skin-to-skin contact right after birth.

The Difficulty of German Information Booklets on Psoriasis and Psoriatic Arthritis: Automated Readability and Vocabulary Analysis

BackgroundInformation-seeking Psoriasis or Psoriatic Arthritis patients are confronted with numerous educational materials when looking through the internet. Literature suggests that only 17.0-21.4% (Psoriasis, Psoriatic Arthritis) of patients have a good level of knowledge about psoriasis treatment and self-management. A study from 1994 found that English Psoriasis/Psoriatic Arthritis brochures required a reading level between grades 8-12 to be understandable, which was confirmed in a follow-up study 20 years later. As readability of written health-related text material should not exceed the sixth-grade level, Psoriasis/Psoriatic Arthritis material seems to be ill-suited to its target audience. However, no data is available on the readability levels of Psoriasis/Psoriatic Arthritis brochures for German-speaking patients, and both the volume and their scope are unclear.ObjectiveThis study aimed to analyze freely available educational materials for Psoriasis/Psoriatic Arthritis patients written in German, quantifying their difficulty by assessing both the readability and the vocabulary used in the collected brochures.MethodsData collection was conducted manually via an internet search engine for Psoriasis/Psoriatic Arthritis–specific material, published as PDF documents. Next, raw text was extracted, and a computer-based readability and vocabulary analysis was performed on each brochure. For the readability analysis, we applied the Flesch Reading Ease (FRE) metric adapted for the German language, and the fourth Vienna formula (WSTF). To assess the laymen-friendliness of the vocabulary, the computation of an expert level was conducted using a specifically trained Support Vector Machine classifier. A two-sided, two-sample Wilcoxon test was applied to test whether the difficulty of brochures of pair-wise topic groups was different from each other.ResultsIn total, n=68 brochures were included for readability assessment, of which 71% (48/68) were published by pharmaceutical companies, 22% (15/68) by nonprofit organizations, and 7% (5/68) by public institutions. The collection was separated into four topic groups: basic information on Psoriasis/Psoriatic Arthritis (G1/G2), lifestyle, and behavior with Psoriasis/Psoriatic Arthritis (G3/G4), medication and therapy guidance (G5), and other topics (G6). On average, readability levels were comparatively low, with FRE=31.58 and WSTF=11.84. However, two-thirds of the educational materials (69%; 47/68) achieved a vocabulary score ≦4 (ie, easy, very easy) and were, therefore, suitable for a lay audience. Statistically significant differences between brochure groups G1 and G3 for FRE (P=.001), WSTF (P=.003), and vocabulary measure (L) (P=.01) exist, as do statistically significant differences for G2 and G4 in terms of FRE (P=.03), WSTF (P=.03) and L (P=.03).ConclusionsOnline Psoriasis/Psoriatic Arthritis patient education materials in German require, on average, a college or university education level. As a result, patients face barriers to understanding the available material, even though the vocabulary used seems appropriate. For this reason, publishers of Psoriasis/Psoriatic Arthritis brochures should carefully revise their educational materials to provide easier and more comprehensible information for patients with lower health literacy levels.

Correlation of age-of-onset of Atopic Dermatitis with Filaggrin loss-of-function variant status

The genetic background of Atopic Dermatitis (AD) with chronic pruritus is complex. Filaggrin (FLG) is an essential gene in the epidermal barrier formation s. Loss-of-function (LOF) variants in FLG associated with skin barrier dysfunction constitute the most well-known genetic risk factor for AD. In this study, we focused on the frequency and effect of FLG loss-of-function variants in association with self-reported age-of-onset of AD. The dataset consisted of 386 whole-genome sequencing (WGS) samples. We observe a significant association between FLG LOF status and age-of-onset, with earlier age of onset of AD observed in the FLG LOF carrier group (p-value 0.0003, Wilcoxon two-sample test). We first tested this on the two most prevalent FLG variants. Interestingly, the effect is even stronger when considering all detected FLG LOF variants. Having two or more FLG LOF variants associates with the onset of AD at 2 years of age. In this study, we have shown enrichment of rare variants in the EDC region in cases compared with controls. Age-of-onset analysis shows not only the effect of the FLG and likely EDC variants in terms of the heightened risk of AD, but foremost enables to predict early-onset, lending further credence to the penetrance and causative effect of the identified variants. Understanding the genetic background and risk of early-onset is suggestive of skin barrier dysfunction etiology of AD with chronic pruritus

Kinematics differences between personal best and worst throws in actual javelin competition

ABSTRACTThis study examined kinematics differences between personal best and worst throws to determine movement corrections for javelin throwers. Eight elite Asian male throwers were filmed as participants in Taipei Athletics Open 2015 (age: 22.1 ± 2.2 years, height: 177.3 ± 3.3 cm, and weight: 82.1 ± 3.5 kg). A high-speed camera with a 300-Hz sampling rate was used to collect motion images in the sagittal plane. Three-dimensional software was used to digitise and analyse the kinematics of throwing images. The Wilcoxon two-sample test was used to compare the throwing posture and javelin kinematics for the longest and shortest throws. The statistical significance was set at α= .05. Javelin travel distance was 70.9 ± 5.9 m and 67.2 ± 6.3 m in longest (best) and shortest (worst) throws. The wrist velocity at release was greater in longest throws (22.7 ± 0.8 m/s), with lower velocity in shortest throws (21.6 ± 0.5 m/s). A greater elbow joint angle was found in the longest throw group. The joint angle was 166.7 ± 10.6° and 158.4 ± 13.5° in longest and shortest throw groups, respectively. Throwers can improve distance by extending the elbow to accelerate the forearm when releasing.

Lymphoma-Associated Pulmonary Embolism Burden in Hospital Admissions in the United States

Background: Cancer-associated pulmonary embolism (PE) is a common condition that increases morbidity and mortality among cancer patients. Lymphoma has one of the highest rates of venous thromboembolism in cancer patients. The National Inpatient Sample (NIS) Healthcare Cost and Utilization Project (HCUP) includes the largest all-payer inpatient hospital care data in the United States and therefore may represent a significant sample of clinically relevant pulmonary embolism in lymphoma patients. Methods: We utilized the NIS-HCUP database to extract the following data on hospitalizations from 2002 to 2014. We included in our analysis ICD-9 codes for acute PE as a primary or secondary diagnosis of admission and excluded iatrogenic, septic, chronic PE and PE related to obstetrical conditions. We divided our primary population of yielded weighted frequencies i.e. acute PE admissions into two groups: a group with lymphoma as a comorbid condition using Elixhauser comorbidity measures and a group without lymphoma. We identified baseline characteristics of each group including median age on admission, gender and race breakdown as well as common comorbidities' prevalence using Elixhauser comorbidity measures. We ran the analysis for the median length of stay, total charges, mortality scores, readmit scores and inpatient mortality using SAS software, version 9.4 (SAS Institute, Cary, North Carolina). Continuous variables were tested using Wilcoxon two-sample test. Results: We identified a total of 3,293,040 admissions of acute PE in the database from 2002 to 2014, with 98.5% (3,242,571) of the admissions in patients without lymphoma vs. 1.5% (50,469) in patients with lymphoma as a comorbidity. The breakdown of race was comparable across the two groups with the Caucasian race being predominant in lymphoma and non-lymphoma groups at 77.3% vs. 74.2% respectively [Table 1]. Male gender constituted the majority in the lymphoma group at 53.6% in contrast to the non-lymphoma group where female gender was the majority at 53.6%. [Table 2]. While median age on admission was higher in the lymphoma group compared with the non-lymphoma group (68.7 vs. 65 years respectively) , the prevalence of common comorbidities such as hypertension, paralysis, renal failure, heart failure, diabetes mellitus with and without complications were comparable across the two groups except for obesity prevalence which was higher in the non-lymphoma group. [Table 2] Median length of stay was marginally but significantly higher in the lymphoma group at 5.4 days (95% CI 5.33-5.53) vs. 4.96 (95% CI 4.95-4.97) days in the non-lymphoma group (p<0.001); as were the readmission scores with a median readmission score of 30 (95% CI 29.65-30.24) vs. 14 (95% CI 13.99-14.08) for lymphoma and non-lymphoma groups, respectively (p<0.001). We observed that total charges of hospitalization were significantly higher in the lymphoma group with a median of 31,899 US dollars (USD) per hospitalization (95% CI 31,174 - 32,622) compared with 27,784 USD (95% CI 27,704 - 27,864) in the non-lymphoma group. Ultimately, all-cause inpatient mortality was higher in the lymphoma group at 10.4% vs. 7.3% in the non-lymphoma group (Odds ratio 1.46, 95% CI 1.43-1.51, P-value <0.0001). Median mortality score was also significantly higher in the lymphoma group at 13.15 (95% CI 12.6-13.6) vs. 5.53 (95% CI 5.50-5.55) in the non-lymphoma group (p<0.001). Conclusion: Lymphoma was a comorbid diagnosis in 1.5% of patients admitted to the hospital with acute PE between 2002 and 2014 in the NIS-HCUP database. While the median age in the lymphoma group was higher, the prevalence of clinically significant comorbidities was comparable or higher in the non-lymphoma group. Lymphoma was associated with increased all-cause inpatient mortality in patients admitted with acute PE despite the study's limitation of not excluding other cancer patients from the control non-lymphoma group. Patients in the lymphoma group also had a higher risk of readmission in addition to having higher total charges per hospitalization and increased the length of stay. Efforts should continue to better prevent and treat pulmonary embolism in the lymphoma population. Disclosures No relevant conflicts of interest to declare.

2366. PCR Followed by Toxin EIA for the Diagnosis of C. difficile Infection

BackgroundIn June 2017 for the diagnosis of Clostridioides difficile infection (CDI), Renown Health transitioned from utilizing polymerase chain reaction (PCR) to a two-step algorithm of PCR followed by toxin enzyme immunoassay (EIA) if PCR was positive. Providers were encouraged to forgo treatment in patients that were PCR-positive and EIA-negative as recent literature suggests this may indicate colonization rather than infection. The purpose of this study was to assess the impact of implementation of the two-step algorithm for the diagnosis of CDI on antibiotic usage and patient outcomes.MethodsThis was a retrospective quasi-experimental study of adult inpatients at Renown Regional and South Meadows Medical Centers that were PCR positive before and after implementation of a two-step algorithm for the diagnosis of CDI. The pre-implementation period was defined between May 8, 2016 and May 7, 2017, and the post-implementation period was May 8, 2017 to May 7, 2018. Patients were excluded if they were admitted to a pediatric ward, tested for CDI at an outside facility, or if results were available following discharge. The primary outcome was inpatient days of metronidazole and non-parenteral vancomycin per PCR positive patient. Secondary outcomes included defined daily doses of therapy, proportion of untreated patients, time to resolution of diarrhea, all-cause in-hospital mortality, 30-day recurrence, all-cause 30-day readmission, length of stay, and 30-day CDI-related complications. CDI-related complication was a composite of ICU care, megacolon, ileus, surgical intervention. It was calculated that 242 patients were required to achieve at least 80% power to detect a 30% difference in antibiotic days between pre- and post-implementation of two-step C. difficile testing. Wilcoxon two-sample test was used for continuous data, and χ 2 or Fisher exact test were used for categorical data.ResultsSee figures.ConclusionIncorporation of C. difficile toxin EIA to PCR for the diagnosis of CDI resulted in a significant reduction in non-parenteral vancomycin and metronidazole days of therapy. Patient outcomes were not adversely affected by the addition of toxin EIA. The results suggests that toxin EIA may help differentiate between C. difficile colonization and active infection. Disclosures All authors: No reported disclosures.

Characteristics of correct diagnosis versus misdiagnosis of paediatric tracheobronchial foreign body.

PurposeTo characterize and compare children with correct diagnosis (CD) and misdiagnosis (MD) of tracheobronchial foreign body (TBFB).MethodsA retrospective study was performed to review the medical records of children with CD group and MD group of TBFB. CD was defined when TBFB was identified during the first hospital visit. Otherwise, MD was considered. Demographic information, including gender, age, and clinical information, including clinical presentations and characteristics of foreign bodies, were retrieved. These characteristics were compared between two groups by Student’s t-test or Wilcoxon two-sample test, or Chi-square analysis or Fisher’s exact test, when appropriate.ResultsA total of 462 children with final diagnosis of TBFB were identified, with 276 children having CD and 186 children having MD. The most common location to identify the TBFB was right main bronchus in both CD and MD groups. Children with the previous history of respiratory tract foreign body were more likely to receive the CD. Children in MD group were more likely to have fever, as well as wheezing and crackles during physical examination. They were more likely to have pneumonia. Most common TBFB were peanuts. The majority of the TBFB were removed by the flexible bronchoscope coupled with forceps.ConclusionCareful history taking and physical examination, especially for those children with unclear causes for their pneumonia or asthma, or children with no improvement on the treatments, should be performed to rule out the possibility of TBFB. Bronchoscopy should be performed if necessary.

Investigating Potential Biomarkers in Autism Spectrum Disorder.

BackgroundEarly identification and treatment of individuals with autism spectrum disorder (ASD) improves outcomes, but specific evidence needed to individualize treatment recommendations is lacking. Biomarkers that could be routinely measured within the clinical setting could potentially transform clinical care for patients with ASD. This demonstration project employed collection of biomarker data during regular autism specialty clinical visits and explored the relationship of biomarkers with clinical ASD symptoms.MethodsEighty-three children with ASD, aged 5–10 years, completed a multi-site feasibility study integrating the collection of biochemical (blood serotonin, urine melatonin sulfate excretion) and clinical (head circumference, dysmorphology exam, digit ratio, cognitive and behavioral function) biomarkers during routine ASD clinic visits. Parents completed a demographic survey and the Aberrant Behavior Checklist-Community. Cognitive function was determined by record review. Data analysis utilized Wilcoxon two-sample tests and Spearman correlations.ResultsParticipants were 82% male, 63% White, 19% Hispanic, with a broad range of functioning. Group means indicated hyperserotonemia. In a single regression analysis adjusting for race and median household income, higher income was associated with higher levels of blood serotonin and urine melatonin sulfate excretion levels (p = 0.004 and p = 0.04, respectively). Melatonin correlated negatively with age (p = 0.048) and reported neurologic problems (p = 0.02). Dysmorphic status correlated with higher reported stereotyped behavior (p = 0.02) and inappropriate speech (p = 0.04).ConclusionThis demonstration project employed collection of multiple biomarkers, allowed for examination of associations between biochemical and clinical measures, and identified several findings that suggest direction for future studies. This clinical research model has promise for integrative biomarker research in individuals with complex, heterogeneous neurodevelopmental disorders such as ASD.

Dexamethasone for the Reduction of Postoperative Pain Following Open Carpal Tunnel Release: A Randomized Controlled Trial

INTRODUCTION: Carpal tunnel syndrome is one of the most common neuropathies seen in the upper limb. Once the diagnosis is made, multiple treatment modalities are available for management of this condition. Conservative treatments include wrist splinting and corticosteroid injection. Injections often provide symptomatic relief for patients with mild to moderate disease, especially for pain.1 These injections are usually given either as sole treatment, or as a bridge before surgery can be performed. Definitive carpal tunnel release (CTR) surgery is performed either awake with local anesthesia or under procedural anesthesia. Postoperative pain is typically treated with a combination of NSAIDs and narcotics. Nationally, overconsumption of narcotics is a critical issue. The use of steroids in conjunction with local anesthesia has not been studied in the literature. Our objective was to determine whether the addition of dexamethasone to the local anesthesia given during CTR will reduce postoperative pain and the consumption of narcotics postoperatively. METHODS: We conducted a randomized, double-blinded study at a single academic institute. Patients undergoing an elective CTR surgery were included. Exclusion criteria included uncontrolled diabetics, minors, traumatic or emergent case, and patients undergoing a concomitant surgery. Included patients were randomized to either the control or treatment arms. Patients in the treatment arm were given an injection of 10 mg dexamethasone with their local anesthesia at surgery versus local anesthesia alone for the control group. Postoperatively, patients logged their pain scores on a 0–10 scale at set time intervals of 8 hours, 24 hours, 48 hours, 72 hours, and 1 week postoperatively. Patients were also asked to record how many narcotic, acetaminophen, or NSAID pain pills they used. Two-sample Wilcoxon and Matlab-pairs signed-rank tests were then performed to analyze the data. P values were adjusted with Hochberg’s method. RESULTS: Eighty-one patients were enrolled: 40 in the treatment arm and 41 in the control arm. Average pain scores were lower in the steroid group at 8 hours (2.23 SD 3.04 versus 3.45 SD 2.94; P = 0.017), 24 hours (2.61 SD 2.46 versus 3.23 SD 2.88; P = 0.351), and 48 hours (2.00 SD 2.19 versus 2.03 SD 2.51; P = 0.745). Pain scores were higher in the treatment arm at 72 hours (1.74 SD 2.09 versus 1.44 SD 1.87; P = 0.574) and 7 days (1.37 SD 1.76 versus 0.61 SD 1.08; P = 0.031). No P values exceed their Hochberg limits for significance. There was no significant difference in the number of acetaminophen pills (2.93 SD 6.93 versus 1.31 SD 2.96; P = 0.837), NSAID pills (3.56 SD 7.24 versus 2.30 SD 6.51; P = 0.678), and narcotic pills (4.17 SD 5.96 versus 4.36 SD 5.10; P = 0.325) between the 2 groups. CONCLUSION: Intraoperative dexamethasone administration during CTR did not reduce pain levels or number of narcotic pain pills taken in the first postoperative week. Further research evaluating non-narcotic pain reducing modalities for CTR is warranted. REFERENCE: 1. Middleton SD. Carpal tunnel syndrome. BMJ. 2014;6:g6437.

Clinical efficacy of different marginal forms of endocrowns: study protocol for a randomized controlled trial

BackgroundAfter root canal treatment, most tooth defects need to be restored. Onlay restoration is widely used to restore dental defects. Endocrown is a new type of onlay; however, dentists have yet to obtain a full understanding of the clinical effects of marginal forms of endocrowns. Here, we present a multicenter protocol to compare the clinical efficacy of two marginal forms (flat and 90-degree shoulder) for tooth restoration. The efficacy will be evaluated by marginal fit, marginal discoloration, and integrity of restoration.MethodsThe proposed flat and 90-degree shoulder marginal endocrown assessment trial is an open-label, parallel-group, multicenter randomized controlled trial involving two hospitals. A total of 200 patients will be included in this trial, and the following patient inclusion criteria will be applied: good oral hygiene habits, no periodontal diseases, receipt of standard root canal treatment, and need for endocrown restoration. Patients will be enrolled after providing signed informed consent and will be divided into two groups (flat and 90-degree shoulder endocrown) in accordance with a random number table. Treatment allocation will be balanced (1:1). Endocrowns will be cemented by dual-cured luting composite. Clinical evaluations will be performed at baseline and at 24 months after treatment in accordance with modified US Public Health Service criteria by two independent evaluators. The primary outcome will be marginal fit; secondary outcome measures will include debonding, marginal discoloration, and integrity of restoration. All acquired data will be analyzed by an independent statistician. Wilcoxon one-sample tests will be used for intra-group comparisons, and Wilcoxon two-sample tests will be used for inter-group comparisons. The Bonferroni method will be used to correct for multiple comparisons, and hierarchical logistic regression will be applied to determine central effects.DiscussionThe results of this trial will provide a clinical basis for clinicians to restore teeth by endocrowns and to improve long-term restoration for patients.Trial registrationClinicalTrials.gov identifier: NCT03398395. Registered on 12 January 2018.

Value of intravoxel incoherent motion diffusion weighted imaging in evaluating the microstructure changes in white matter hyperintensities

Objective: To investigate the value of intravoxel incoherent motion diffusion weighted imaging (IVIM DWI) in evaluating microstructure changes in elderly white matter hyperintensities (WMH) patients and to analyze the correlation between IVIM parameters and severity grading and cognitive scores. Methods: Sixty-two WMH patients in Zhejiang Hospital were collected from December 2014 to March 2018 and underwent conventional magnetic resonance (MR) plain scan and diffusion weighted imaging with different b values. The age was 60-92(74±10) years with 37 males, 25 females. The severity of WMH was assessed by T(2) fluid attenuated inversion recovery (FLAIR) sequence and Fazekas score,which were divided into two subgroups. Slow diffusion coefficient (D), fast diffusion coefficient (D(*)) and perfusion fraction (f) from IVIM parameters of double exponential model were compared between regions of WMH (deep WMH (DWMH) and periventricular WMH (PWMH)) and surrounding normal white matter (NWM).The Shapiro-Wilk test was used for normality tests, Kruskal-Wallis tests and Dwass-Steel-Critchlow-Fligner (DSCF) procedure were used for the comparison among these parameters. Furthermore, Wilcoxon two-sample test was used for the comparisons between different severity. Pearson correlation analysis was performed to determine whether these D, D(*), f values were correlated with the mini mental state examination (MMSE) scores. Results: D(D)WMH (0.83(0.72,0.99)×10(-3) mm(2)/s), D(PWMH)((1.13±0.25)×10(-3) mm(2)/s) were significantly higher than D(NWM) ((0.71±0.05)×10(-3) mm(2)/s)(P<0.01). f (DWMH) ((8.94%(7.46%,11.67%)), f (PWMH)(8.34%(6.73%,9.96%)) were significantly higher than f (NWM)(6.71%±1.72%)(P<0.01).D in DWMH were significantly lower than that in PWMH(P<0.01), there's no statistically difference between other groups. D in severe WMH (both DWMH and PWMH) were significantly higher than that in mild WMH (P=0.000 1, P=0.04). Only f in PWMH were positively associated with the MMSE scores (r=0.326 5,P<0.05). Conclusions: IVIM DWI can noninvasively assess the variation of microstructure diffusion and perfusion in WMH in one sequence,which may objectively reflect the severity of these lesions. This method has important clinical significance for better assessment and management of this disease.

Evaluation of cpDNA Barcodes in Selected Medicinal Plants of Mt. Arayat National Park, Pampanga, the Philippines

Objective: One common problem affecting herbal remedies is the incorrect identification of plants due to almost similar morphological characters. A promising technique to ensure correct identification of herbal medicine is the use of DNA barcoding where the gene markers either from Chloroplast (cpDNA) or Nucleus (nrDNA) are commonly used to authenticate plants. In this study, three chloroplast barcodes; matK, rbcL and trnL-F were evaluated to authenticate 20 selected medicinal plants of Mt. Arayat National Park (MANP), Pampanga, The Philippines. Methods: The genetic materials from the 20 selected medicinal plants were isolated, amplified, sequenced and aligned. All generated DNA barcodes were subjected to Kimura two-parameter model to calculate intergeneric and intrageneric variations while discriminatory power was determined using BLAST, neighbour-joining (NJ) and Wilcoxon two-sample test. Results: The results show 19 plant samples were successfully amplified. However, rbcL gave the highest sequencing success rate and identification rate up to species level over matK and trnL-F. Though, the three-cpDNA barcodes produced monophyletic clades revealing distinct association among species. The intergeneric divergences of rbcL, matK and trnL-F are significantly higher than their respective intrageneric divergences. This means the threecpDNA barcodes can effectively discriminate one species from another. Conclusion: The order of efficiency among the DNA barcodes is rbcL>matK>trnL-F. Nevertheless, the three-plastid barcodes could be used for practical and accurate authentication of medicinal plants while the baseline data in this study can be used for proper conservation of medicinal plants. Key words: BLAST, DNA barcoding, Medicinal plants, Monophyletic, Phylogeny.

Same-Day Medical Visit Increases Viral Suppression, Peter Ho Memorial Clinic, 2014–2015 and 2016–2017

Viral suppression (VS) in patients newly diagnosed with HIV is critical to reducing morbidity, mortality, and new transmissions. Rapid initiation of antiretroviral therapy (ART) is a promising model to improve VS, but patients must be seen expeditiously by a prescribing provider. Our retrospective study compared patients achieving VS after introduction of medical visits on the same day as HIV diagnoses from 2014 to 2017. The time to VS was evaluated using survival analysis. Wilcoxon two-sample tests evaluated median times to VS (after diagnosis and ART receipt). When 2016-2017 was compared with 2014-2015, a higher proportion of patients achieved VS (96% and 90%, respectively; p = .0292); the median time to VS decreased to 88 from 101 days after diagnosis and to 44 from 70 days after receipt of ART. As clinicians consider rapid ART initiation, a medical visit on the same day as HIV diagnosis is an intermediate intervention that may improve VS.

Patient reported outcomes and neuropsychological testing in patients with chronic non-cancer pain in long-term opioid therapy: a pilot study.

Background and aims Opioid consumption has increased dramatically in patients with chronic non-cancer pain (CNCP), but long-term consequences are still unclear. The aim of this study is to investigate the effects of long-term opioid treatment on pain, cognition, mood, sleep and quality of life in CNCP patients. Methods In this cross-sectional pilot study, two groups of patients with CNCP treated in a multidisciplinary pain center were selected: (1) opioid group: ≥30 mg morphine equivalent/day for >4 weeks, and (2) control group: no opioid consumption for >4 weeks. Socio-demographic data, alcohol consumption, smoking habits and body mass index (BMI) were registered and pain (brief pain inventory), mood (Hospital Anxiety and Depression Scale), sleep (Pittsburgh Sleep Quality Index) and quality of life (RAND 36-Item Health Survey) were assessed. Continuous Reaction Time and the Digit Span Test were used to evaluate cognitive function. Data was analyzed with a Fisher's exact test and Wilcoxon two-sample test. Results Forty-two patients with CNCP were included (21 in each group). No differences regarding socio-demographics, smoking/alcohol habits and duration, type, or intensity of pain were found. More patients in the opioid group had significantly higher BMI (62% above BMI 25 vs. 33.3%, p = 0.042). Consequently, the subsequent data analyses were controlled for BMI. The two groups did not differ in pain, cognition, anxiety, depression, sleep or quality of life but both showed lower values than the normal standards. Further, the opioid group presented a tendency to lower ratings regarding pain and social function and performed below the normal cut off in the continuous reaction time. Conclusions No significant differences between the two groups were found regarding any of the above-mentioned variables. Interestingly, the patients assessed, regardless of taking opioids or not, could be classified with moderate pain intensity, anxiety and low quality of sleep and life compared to norm standards. Implications The findings of this pilot study suggested that long-term opioid treatment may influence pain and quality of life among CNCP patients. A larger cohort is needed to verify these findings.

Resident Supervision and Patient Care: A Comparative Time Study in a Community-Academic Versus a Community Emergency Department.

The objective was to compare attending emergency physician (EP) time spent on direct and indirect patient care activities in emergency departments (EDs) with and without emergency medicine (EM) residents. We performed an observational, time-motion study on 25 EPs who worked in a community-academic ED and a nonacademic community ED. Two observations of each EP were performed at each site. Average time spent per 240-minute observation on main-category activities are illustrated in percentages. We report descriptive statistics (median and interquartile ranges) for the number of minutes EPs spent per subcategory activity, in total and per patient. We performed a Wilcoxon two-sample test to assess differences between time spent across two EDs. The 25 observed EPs executed 34,358 tasks in the two EDs. At the community-academic ED, EPs spent 14.2% of their time supervising EM residents. Supervision activities included data presentation, medical decision making, and treatment. The time spent on supervision was offset by a decrease in time spent by EPs on indirect patient care (specifically communication and electronic health record work) at the community academic ED compared to the nonacademic community ED. There was no statistical difference with respect to direct patient care time expenditure between the two EDs. There was a nonstatistically significant difference in attending patient load between sites. EPs in our study spent 14.2% of their time (8.5 minutes/hour) supervising residents. The time spent supervising residents was largely offset by time savings related to indirect patient care activities rather than compromising direct patient care.

Reading deficits in diabetic patients treated with panretinal photocoagulation and good visual acuity.

Patients with proliferative diabetic retinopathy (PDR) treated with panretinal photocoagulation (PRP) can have abnormal visual functioning that may be missed by Snellen visual acuity alone. We investigated reading deficits in patients treated with PRP for PDR using the Minnesota reading (MNREAD) test. Thirty patients treated with PRP and 15 controls underwent best-corrected visual acuity (BCVA), the MNREAD, frequency doubling perimetry (FDP), and fundus photography. Panretinal photocoagulation (PRP)-treated subjects were compared to controls on MNREAD results by two-sample t-tests and Wilcoxon tests and Pearson correlations were used to assess the association between performance on MNREAD and other central visual function tests within PRP subjects. Panretinal photocoagulation (PRP)-treated patients had reduced MNREAD acuity (p<0.0001) and increased critical print size (p=0.01) compared to controls but not a significantly reduced maximum reading speed (p=0.06). Logmar MNREAD acuity was strongly positive correlated with logMAR BCVA (r=0.58, p=0.0098) and strongly negatively correlated with FDP foveal threshold (r=-0.63, p=0.0030). Maximum reading speed was positively correlated with FDP foveal threshold (r=0.57, p=0.0143) and FDP mean deviation (r=0.51, p=0.0432). Visual acuity did not correlate with the sensitivities on the FDP. The MNREAD test reveals that PRP reduces reading ability and other aspects of macular function, and thus provides new understanding of how vision-related quality of life is impaired. These findings may lead to improved means to evaluate and enhance vision following treatment for PDR.

The Impact of Great Saphenous Vein Size on Gender, Clinical Severity, and Outcome of Patients Undergoing Vein Ablation for Varicose Veins

Policies of insurance carriers have used truncal vein size as a criterion for coverage. The objective of this study was to compare the effect of great saphenous vein (GSV) size ≥5 mm vs <5 mm on the patient’s presentation and clinical outcomes. Patients in a national cohort were prospectively captured in the Vascular Quality Initiative Varicose Vein Registry. From January 2015 to October 2017, the Vascular Quality Initiative Varicose Vein Registry database was queried for all patients undergoing varicose vein procedures. Clinical, Etiology, Anatomy, and Pathophysiology (CEAP) class, Venous Clinical Severity Score, and patient-reported outcomes were compared for GSV size <5 mm (group 1) vs size ≥5 mm (group 2) before and after the procedures. Two-sample Wilcoxon test was performed to assess the difference between the two groups as defined by GSV size. To assess for improvement after the procedure in this population, a matched pairs signed rank Wilcoxon test was performed for each group separately. During the study period, 5757 vein ablation procedures were performed for GSV: 770 GSV size <5 mm and 4987 GSV size ≥5 mm. Group 1 patients were more likely to be female (81.7% vs 68.4%; P = .001) and older (56.8 years vs 55.6 years; P = .012). CEAP scores were higher in group 2 compared with group 1 (P = .001). Maximal GSV diameter in group 2 was significantly higher (8.32 mm vs 3.86 mm; P = .001); 64% of group 2 underwent radiofrequency thermal ablation compared with 59.2% of group 1 (P = .001). There were no deaths in either group. Group 2 had more complications after the procedure (0.6% vs 0%; P = .027), required postoperative anticoagulation (8.8% vs 5%; P = .001), developed partial recanalization rate (0.8% vs 0.3%; P = .001), and missed more work days (2.32 days vs 1.6 days) compared with group 1. A similar rate of hematoma developed in both groups, but there was a higher rate of paresthesia in group 1. Both groups had improvement in the Venous Clinical Severity Score and HASTI (heaviness, achiness, swelling, throbbing, and itching) score. The degree of symptomatic improvement between the groups was similar (Table). All patients demonstrated improvement in both clinical outcomes and patient-reported outcomes after endovenous ablation regardless of size. Patients with preoperative GSV size ≥5 mm had similar improvement in symptoms but sustained an increased complication rate. Patients with smaller vein size should not be denied intervention or coverage on the basis of size criteria.TableVenous Clinical Severity Score (VCSS) and heaviness, achiness, swelling, throbbing, and itching (HASTI) improvements based on great saphenous vein (GSV) sizeGroup 1, GSV <5 mmGroup 2, GSV ≥5 mmP valueVCSS improvement2.783.16.833HASTI improvement5.615.71.719 Open table in a new tab

Abstract TP450: Implementation of Informal Caregiver and Veteran Dyadic Intervention: Acquiring New Skills While Enhancing Remaining Strengths

Objectives: ANSWERS-VA dyadic intervention, a strength-based protocol, was adapted for Veterans and their informal Caregivers (CGs). Immediate aims were to tailor the implementation for Veterans and CGs and test the short-term efficacy for improving outcomes of caregiving self-efficacy and caregiver appraisal of threat. Methods: Intervention protocol and materials were modified for telephone delivery to Veterans (n = 130) with definitive diagnosis of stroke and/or traumatic brain injury enrolled at two Level 1 Complexity VA Medical Centers and CGs. Dyads were recruited and randomly assigned to ANSWERS-VA or the attention control group and received 8 telephone sessions with one booster session. Acceptability and feasibility were assessed by participants in the intervention arm. Caregiver threat appraisal and self-efficacy of caregiving were measured in 52 informal CGs randomized to ANSWERS-VA (n = 20) or the attention control group (n = 32) at week 8. Comparisons of two groups in threat appraisal and caregiving self-efficacy were conducted using the Wilcoxon Two-Sample Test. Results: Veterans and CGs found ANSWERS-VA an acceptable and feasible approach and reported that sessions were: a) educational, thought- provoking and supportive while simultaneously facilitating communication about difficult issues; and b) provided practical and tailored skills. Preliminary data analyses indicate that CGs assigned to both groups were similar demographically. No significant changes were demonstrated in Caregiver threat appraisal ( p = 0.74) or caregiving self-efficacy ( p = 0.71) between both groups at 8 weeks. Conclusions: Implementing virtual, dyadic interventions to Veterans with ABI and their informal CGs presented unique challenges: 1) time-intensive processes in pre-implementation phase; 2) field's ambiguity regarding TBI diagnoses and screening protocols within VA Computerized Patient Record System; 3) transition to ICD-10 codes; 4) clear CG eligibility criteria; 5) telephone recruitment; 6) recruitment expertise; and 7) natural disaster, Hurricane Harvey. Though a small sample, analyzing for change in caregiving self-efficacy and caregiver appraisal at 8 weeks may have been premature to determine the short-term efficacy of ANSWERS-VA.