Two-sample Wilcoxon Rank-sum Research Articles

Voxel-by-voxel 4D flow MRI-based assessment of regional reverse flow in the aorta.

Complex and reverse flow in the aorta has been implicated in aneurysm development and stroke via retrograde embolization. To evaluate global and regional differences between standard 2D plane-based and volumetric voxel-based quantification of regional forward/reverse flow, and reverse flow fraction (RFF) in the aorta. Retrospective. In all, 35 subjects: 10 healthy controls (age: 57 ± 7 years, nine male), nine patients without aortic valve regurgitation (AR) (age: 63 ± 10 years, seven male), six patients with mild AR (age: 66 ± 6 years, five male), and 10 with moderate or severe AR (age: 60 ± 16 years, eight male). 4D flow MRI (3T and 1.5T) was employed to acquire 3D blood flow velocities with entire thoracic aorta in all subjects. Data analysis included standard 2D plane-based quantification of forward/reverse flow, and RFF-plane. In addition, a new semiautomatic workflow based on 3D segmentation and extraction of an aorta centerline was developed for voxel-by-voxel visualization (forward/reverse flow and RFF-voxel maps) and quantification of regional voxel-by-voxel forward/reverse flow in the entire thoracic aorta. Kruskal-Wallis tests were performed to test for differences between groups. A two-sample t-test or Wilcoxon rank sum test was used to compare voxel-based and plane-based results. Semiautomatic plane-based analysis showed excellent agreement with standard manual plane-based analysis for net flow and RFF-plane (RFF-plane: y = 0.99x-0.0, net flow: y = 1.00x-0.21, R > 0.99, P < 0.0001). Voxel-by-voxel maps demonstrated marked regional flow reversal in the ascending aorta in all patients and RFF-voxel was significantly increased (P < 0.001) compared to RFF-plane for all four groups, with the most pronounced differences for mild AR (18.0 ± 15.2% vs. 4.7 ± 5.4%). Voxel-based flow and RFF-voxel along the aorta showed areas with marked regional flow reversal (eg, vortex flow) compared to plane-based analysis. Voxel-based analysis demonstrated regional flow reversal that was not detected by plane-based analysis. 3 Technical Efficacy: Stage 1 J. Magn. Reson. Imaging 2018;47:1276-1286.

Anterior Ankle Incision Complications

Category: Ankle Introduction/Purpose: The anterior incision is commonly used for total ankle replacement (TAR), and anterior approach ankle arthrodesis. Historically, the anterior incision has demonstrated a high incidence of complications, specifically with early generation TAR. Modern TAR designs have provided instrumentation and techniques that better respect the vulnerability of the anterior soft tissues, potentially reducing the incidence of anterior incision related complications. To our knowledge, anterior wound healing rates have not been evaluated in the context of modern anterior approach ankle arthrodesis and arthroplasty. The purpose of this study was to evaluate and compare the incisional healing and complications of the anterior approach for ankle arthrodesis and arthroplasty. Methods: This was an IRB-approved retrospective review of wound healing and complications among 304 patients who underwent primary TAR or ankle arthrodesis via the anterior approach between August 1, 2011 and August 31, 2015. Of the 304 patients, 191 (62.8%) underwent TAR and 113 (37.2%) underwent arthrodesis. The surgical approach, intraoperative soft tissue handling, and postoperative protocol for the first 30 days was the same between groups. Demographics, clinical characteristics of the wound healing, and neurovascular status were analyzed using two-sample t-tests or Wilcoxon rank sum tests for continuous variables and chi-square or Fisher’s exact tests for categorical variables. To diminish the effect of selection bias, a subgroup analysis was performed comparing 91 TAR patients matched to an equal number of ankle arthrodesis patients based upon gender, age, diabetes, and smoking status. Results: The mean follow-up was 11.8 (range, 1.4 to 62.2) months. Overall, 19.7% of patients experienced delayed wound healing greater than 30 days, 15.8% required office-based wound care, 12.2% had a wound infection, 15.1% were prescribed antibiotics, 9.5% underwent wound debridement in the office, 4.6% had nerve injury, and 0.7% had a vascular injury. Implant revision or removal occurred in 10.5%, with a bias towards hardware removal in ankle arthrodesis. In the entire group of 304 patients, there was no difference between TAR and arthrodesis in risk of incisional wound challenges or complications nor neurovascular injury. In the subgroup matched for gender, age, diabetes status and smoking history there was no difference in outcomes. Conclusion: In this large cohort of 304 patients undergoing anterior approach to the ankle, postoperative complication rates were constant at all levels of analysis, with no difference seen between anterior ankle arthrodesis or ankle approach total ankle arthroplasty. This suggests that the primary determinates of complications were neither the demographic nor implant factors considered herein. The anterior ankle incision has a documented wound complication risk, regardless of the surgical procedure, and any modifiable risk factors remain elusive.

Blood transfusion knowledge of surgical residents: is an educational intervention effective?

Evidence-based transfusion education for surgical residents is crucial to improving practice. A pilot study was undertaken to assess the effectiveness of an education module for improving transfusion knowledge among surgical residents. Modules were developed and delivered by experts in surgery and transfusion medicine. They were delivered to residents in their first 2 years of training (Surgical Foundations), and to General Surgery residents across all years of training. Premodule and postmodule and retention knowledge assessments were used to assess efficacy. Median assessment scores for each group were compared using a two-sample Wilcoxon rank-sum analysis. Chi-square tests were used to compare each group's correct response rates for each question across the three tests. Median assessment scores of residents in the Surgical Foundations program improved from a mean of 60% premodule to 80% postmodule and remained at 80% in the retention assessment (p < 0.01). Improvements were seen in the areas of transfusion dose, preoperative blood management, management of reactions, and informed consent (p < 0.01). Assessment scores of General Surgery residents also improved from 59%, to 73%, and to 82%, with significant improvement (p < 0.01) between premodule and postmodule scores. Improvements in correct response rates were seen in the areas of management of anemia and permissive hypotension in trauma (p < 0.01). Transfusion knowledge of surgical residents was improved by a collaborative educational initiative. This could serve as a model for other training programs to improve resident knowledge of evidence-based transfusion practices. The efficacy of such interventions in changing practice remains untested.

Nilotinib Plus Ruxolitinib Produces Anti-Fibrotic Effect

Myelofibrosis (MP) is characterized by stem cell-derived clonal myeloproliferation and a reactive cytokine-driven inflammatory bone marrow fibrosis (BMF). BMF plays an important role in MF symptom such us extramedullary hematopoiesis that implies hepatosplenomegaly and bone marrow failure with anemia and thrombocytopenia.Ruxolitinib is the only drug approved for MF therapy. It was associated with significant reduction in symptomatic splenomegaly and improved constitutional symptoms (Harrison et al. N Engl J Med. 2012 Mar 1;366(9):787-98; Verstovsek et al. Haematologica2015 Apr;100(4):479-88). Recently, Masarova and co-workers reported a case a MF patient who achieved a complete remission, including the complete disappearance of BMF (Masarova et al. Blood. 2016 Jun 20).In a previous work (Arenas et al. Blood Volume 122, Issue 21 (ASH Annual Meeting Abstrat)), we tried to identify the most promising synergistic drugs combinations for a Ruxolitinib. Nilotinib was selected between a set of synergistic drug. It is a BCR-ABL inhibitor but also is a potent PDGF-R inhibitor. Interestingly, different studies reported an anti-fibrotic activity in liver (Liu et al. J Hepatol. 2011 Sep;55(3):612-25.) and skin (Akhmetshina et al. FASEB J. 2008;22(7):2214-22). For these reasons we decided study the effect of the combination of Ruxolitinib and Nilotinib in BMF.To determine the ideal concentration of TGF-β to induce collagen mRNA expression in HS27a, we treated the culture of HSP27a with increasing concentration of TGF-β (0.625-10 ng/mL) during 24h. The best TGF-β concentration was 2ng/mL, with a fold change of 2.74 (SD=0.89) (p<0.05) relative to control without TGF (figure 1).Figure 1: Fold change in COL1 mRNA expression in HSP27a cell line relative to control without TGF-β. Two-sample Wilcoxon rank-sum (Mann-Whitney) test was performed. * p<0.05. R: Ruxolitinib. N: Nilotinib.To assess the anti-fibrotic activity of Ruxolitinib and Nilotinib individually, we preincubated the HSP27a cultures with 0.1 - 0.5 µM of Ruxolitinib or 0.5 - 1 µM of Nilotinib during 1 h. After that, we added TGF-β during 24h. Both 0.5 - 1 µM of Nilotinib reduced the mRNA expression of COL1 with a fold change of 0.75 (SD = 17.6) (p<0.05) and 0.78 (SD = 11.5) (p<0.05) respectively, relative to control with TGF-β but without drug (figure 2).Figure 2: Fold change in COL1 mRNA expression in HSP27a cell line relative to control with TGF-β but without drugs. Two-sample Wilcoxon rank-sum (Mann-Whitney) test was performed. * p<0.05. R: Ruxolitinib. N: Nilotinib.Finally, to verify if the combination of both drug had the capacity of reducing COL1 expression, we pretreated the HS27a cultures with 0.1 µM of Ruxolitinib and 1 µM of Nilotinib simultaneously. The expression of COL1 were 74 % (SD = 27.32%) (p<0.05) relatively to control with TGF-β but without drug (figure 2).In conclusion, Nilotinib have synergistic and anti-fibrotic activity individually, but also in combination with Ruxolitinib. For these reasons, the combined therapy Ruxolitinib-Nilotinib could be a promising therapy to MF and these results support a clinical trial of this combination in MF patients. [Display omitted] [Display omitted] DisclosuresMartínez-López:Novartis: Honoraria, Speakers Bureau.

The Effectiveness of Real-Time Feedback with an Audible Pulse: A Preliminary Study in Renal Doppler Ultrasonography.

PurposeThe effectiveness of real-time feedback using an audible pulse in renal Doppler ultrasonography was evaluated.MethodsThis study was approved by the institutional review board of our hospital. Written informed consent was provided by all volunteers at enrollment. The 26 healthy volunteers enrolled in this study underwent Doppler ultrasound of both kidneys using audible and inaudible pulses in randomized order and at 1-week intervals. Doppler waveforms were obtained at the interlobar or arcuate arteries using a 2-mm Doppler gate. Each session was considered complete when reproducible waveforms were obtained for 5 s in three predefined regions of the kidney. The scan times needed to obtain waveforms of the right and left kidneys were recorded separately. Measurements were compared using a paired t-test and a two-sample Wilcoxon rank-sum test.ResultsThe total recorded Doppler sonography scan time for each kidney ranged from 33 to 146 s. The mean scan time was 56.83 s (right, 58.19 s; left, 55.46 s) in the audible session and 72.58 s (right, 72.08 s; left, 73.08 s) in the inaudible session. The scan times were significantly shorter in the audible than inaudible session (p<0.001), whereas the difference in the scan times between the right and left kidneys was not significant. The order of the sessions had no effect on the total scan time.ConclusionReal-time feedback using an audible pulse may encourage patient cooperation during breath-holding and can shorten the time needed to perform Doppler ultrasonography.

Postpartum laparoscopic sterilisation: A role in South African healthcare?

Objective. To assess the advantages and feasibility of performing postpartum sterilisations laparoscopically in a public healthcare facility in South Africa (SA). Methods. Retrospective review of postpartum sterilisations between June 2012 and December 2013 at Worcester Hospital, Western Cape, SA. A total of 78 postpartum sterilisations were included in the study (open n =26, laparoscopic n =52). Data analysis was performed using means and medians with range and standard deviations, two-sample Wilcoxon rank sum test, two-sample t -test and χ 2 test. Results. It was considered preferable to perform laparoscopic sterilisations than the open procedure on patients with a higher body mass index (BMI). Duration of surgery was shorter in the laparoscopic group, especially in patients with BMI >30, and more patients were discharged on the same day as surgery in the laparoscopic group. There were fewer overall complications in the laparoscopic group (odds ratio 0.35, 95% confidence interval 0.08 - 1.43). Conclusion. It is feasible to perform postpartum sterilisations laparoscopically in a public healthcare facility in SA. Advantages of the procedure are clinically significant and in keeping with international literature. Future research should be undertaken regarding acceptability of the procedure in the study population, laparoscopic training and the improvement of provision of requested postpartum sterilisations in public hospitals.

Decreased Anti-Tumor Cytotoxic Immunity among Microsatellite-Stable Colon Cancers from African Americans.

Colorectal cancer is a leading cause of cancer related deaths in the U.S., with African-Americans having higher incidence and mortality rates than Caucasian-Americans. Recent studies have demonstrated that anti-tumor cytotoxic T lymphocytes provide protection to patients with colon cancer while patients deficient in these responses have significantly worse prognosis. To determine if differences in cytotoxic immunity might play a role in racial disparities in colorectal cancer 258 microsatellite-stable colon tumors were examined for infiltrating immune biomarkers via immunohistochemistry. Descriptive summary statistics were calculated using two-sample Wilcoxon rank sum tests, while linear regression models with log-transformed data were used to assess differences in race and Pearson and Spearman correlations were used to correlate different biomarkers. The association between different biomarkers was also assessed using linear regression after adjusting for covariates. No significant differences were observed in CD8+ (p = 0.83), CD57+ (p = 0.55), and IL-17-expressing (p = 0.63) cell numbers within the tumor samples tested. When infiltration of granzyme B+ cells was analyzed, however, a significant difference was observed, with African Americans having lower infiltration of cells expressing this cytotoxic marker than Caucasians (p<0.01). Analysis of infiltrating granzyme B+ cells at the invasive borders of the tumor revealed an even greater difference by race (p<0.001). Taken together, the data presented suggest differences in anti-tumor immune cytotoxicity may be a contributing factor in the racial disparities observed in colorectal cancer.

Serological evidence of acute rubella infection among under-fives in Mwanza: a threat to increasing rates of congenital rubella syndrome in Tanzania.

BackgroundControl of rubella infection is essential for preventing congenital rubella syndrome (CRS) and one of the important steps is to define a target population for vaccination. Therefore this study was done to determine serological evidence of acute rubella infection among under-fives in order to anticipate the magnitude of rubella virus transmission in Tanzania.MethodsA cross-sectional study involving children aged between 1 and 59 months was conducted between September and October 2014 before national rubella vaccination campaigns commenced. Rubella IgM antibodies were detected using commercial indirect enzyme-linked immunosorbent assay (ELISA). Data were analyzed using STATA version 11.ResultsA total of230 under-fives were enrolled, their median age was 14 (Interquartile range (IQR) 7–26) months. The overall seroprevalence of rubella IgM antibodies was 10.9 % (25/230) with two confirmed cases of CRS. Two-sample Wilcoxon rank-sum test showed that the median age of rubella IgM seropositive children was significantly higher than that of IgM seronegative children (39 IQR: 18-51months vs. 14 IQR: 7–24 months, P < 0.001). On multivariate logistic regression analysis increase in age (OR: 1.07, 95 % CI; 1.03–1.1, P < 0.001) and residing in rural areas (OR: 8.07, 95 % CI; 1.43–45.6, P = 0.018) were independently found to predict acute rubella infection among under-fives.ConclusionOur findings indicate that rubella virus is prevalent in our setting posing a risk of transmitting to childbearing aged women hence increasing the risk of CRS. Increasing prevalence of acute infection with age in under-fives indicates the protective role of maternal antibodies among infants. The sustained vaccination programme of under-fives as effective measure to control CRS should be emphasized in developing countries.

A population's higher-risk sexual behaviour is associated with its average sexual behaviour—An ecological analysis of subpopulations in Ethiopia, Kenya, South Africa, Uganda and the United States

BackgroundGiven the large variation in the prevalence of sexually transmitted infections between populations it is important to characterize how sexual vary between populations. In this paper we assess how the distribution of lifetime sexual partners varies between populations. We ask: do populations with higher mean lifetime sexual partners merely differ by virtue of the presence of a core-group with increased number of partners or do the population distributions move as more coherent wholes? MethodsWe defined those in the top decile of lifetime sex partners in each country as constituting the higher-risk behaviour group (HRB). Spearman's correlation was used to evaluate the relationship between mean lifetime partners and prevalence of those in the HRB by ethnic group within Ethiopia, Kenya, South Africa, Uganda and the United States. In each case, data from nationally representative surveys were used. Two-sample Wilcoxon rank-sum were applied to test if there was a difference in the number of lifetime partners between the highest and lowest-risk subpopulations, separately for men and women. To account for autocorrelation, all analyses were conducted using means/medians excluding those in the HRB. A P-value of <0.05 was considered statistically significant. ResultsIn each country, a positive correlation existed between subpopulations’ mean lifetime partners and the prevalence of the HRB. Spearman's correlation varied from 0.20 to 0.99 for men and 0.74 to 1.0 for women. This association was statistically significant in 6 out of 10 comparisons. There was a statistically significant difference in the number of lifetime partners between the highest and lowest-risk ethnic groups in all countries except South Africa, where the difference was only significant for women. ConclusionsOur results suggest that sexual behaviours vary coherently between different populations. As such, sexually transmitted infection control efforts would benefit from including both targeted campaigns focusing on the HRB and population-strategies that seek to address factors responsible for high mean risk behaviour.

Idiopathic polyhydramnios: persistence across gestation and impact on pregnancy outcomes

PurposeTo investigate the likelihood of resolution of idiopathic polyhydramnios in pregnant women and compare outcomes between resolved and persistent cases. MethodsOne hundred and sixty-three women with idiopathic polyhydramnios who delivered at two medical centers during a 3 year period (January 2012–January 2015) were included in the study. Exclusion criteria included congenital fetal anomalies, maternal diabetes, isoimmunization, fetal infection, placental tumors or anomalies, and multiple gestation. Polyhydramnios was defined as SDP≥8cm or AFI≥24cm. Resolved cases were defined as those with AFI and/or SDP falling and remaining below 24cm and 8cm respectively. Pregnancy outcomes were compared between resolved and persistent cases. Two-sample t-test or Wilcoxon rank-sum test was used for continuous variables while chi-square test or Fisher's exact test was used for categorical measures. ResultsResolution was noted in 61 of 163 (37%) patients. There were no differences in maternal age, gravidity or parity between resolved and persistent cases. Mean gestational age at diagnosis of polyhydramnios and overall mean AFI were significantly lower in the cases that resolved (29.7±4.5 weeks vs 33.4±4.1 weeks, p<0.0001; 23.3±3.5cm vs 25.8 23.3±4.0cm, p=0.0002). Similar to AFI measurements, mean SDP was also lower in cases with resolution (p=0.002). There was no difference in induction rates, mode of delivery, amnioinfusion rates, meconium staining of amniotic fluid and fetal heart rate abnormalities influencing intrapartum management between the two groups. Induction of labor for fetal indication and rupture of membranes were significantly more common in the persistent group. Cesarean delivery for abnormal lie and fetal distress did not differ between the groups. There was an increased risk of macrosomia (>4000g) and preterm delivery (<37 weeks) in the persistent group (p<0.05). ConclusionsResolution rate was approximately 37% and more likely in cases diagnosed earlier in pregnancy and with lower mean amniotic fluid volume. Preterm delivery and macrosomia were more common in cases that persisted across gestation.

Sniff to see. Comparing sniffing position versus simple head extension position for glottic exposure - A prospective, randomized cross over study

Background: Traditional teaching dictates that direct laryngoscopy is best performed with the patient's head in the sniffing position. However, of late, many authors have challenged this concept. In a recent meta-analysis, based on studies involving 2759 participants researchers have found that sniffing position affords no added advantage over simple head extension. Our study highlights an important scientific fact overlooked in all previously done studies on the subject. Aim: We aimed to compare sniffing position and simple head extension position for ease of laryngoscopic intubation using an interval scale. Materials and Methods: A prospective single-blind crossover study of 200 patients, where glottic exposure in both positions was compared in the same patient using Cormack-Lehane (CL) grading and percentage of glottic opening (POGO) score. Intubation difficulty was compared using the intubation difficulty score. Results: In every study, CL grading, an ordinal scale, has been used for comparison of glottic exposure. In our set of patients, CL grading showed 'no change' in glottic exposure quality in 85% of the laryngoscopies. When we used POGO system of classification which is an interval scale, for the same laryngoscopies in the same patients, sniffing position improved exposure in 106 patients, whereas simple head extension position improved exposure in 76 patients. Only 18 patients showed no glottic exposure. Statistical Analysis: Two-sample Wilcoxon rank-sum (Mann-Whitney) test and Chi-square tests showed sniffing position to be significantly better position for glottic exposure and for ease of intubation. Conclusion: Sniffing position provides better glottis exposure and it is easier to intubate a patient in the sniffing position as compared to simple head extension position. Sniffing position should therefore be used as initial position when attempting intubation.

Inpatient Costs for Patients with Inflammatory Bowel Disease and Acute Pancreatitis

Introduction: Inflammatory bowel disease (IBD) is associated with an increased risk of acute pancreatitis. Hospitalizations for acute pancreatitis in patients with IBD are anticipated to be more economically complex. Our group examined differences in length of stay (LOS) and costs for patients with IBD hospitalized for acute pancreatitis and the general population. Methods: A retrospective study of the 2005-2011 National Inpatient Sample (NIS) was conducted. The NIS is the largest publicly available inpatient healthcare database in the US. The primary diagnoses of acute pancreatitis and co-diagnoses of IBD, ulcerative colitis (UC) and Crohn's disease (CD) were identified by ICD-9 codes. Continuous variables were reported as mean ± standard deviations and compared between IBD and controls by two-sample T-tests or Wilcoxon rank-sum tests, with normality assumptions based on the Shapiro-Wilk test. Categorical variables were analyzed by Chi-square tests or Fisher's exact tests. Propensity score matching method is widely used in observational studies to reduce selection bias. To fairly compare the outcomes of interest, we conducted 1:3 propensity score matching using a matching algorithm based on following: Age, gender, race, numbers of co-morbidities, procedure number, insurance, income quartiles, hospital bed size, hospital location, region and teaching status. Statistical analyses were performed on SAS 9.3 (Cary, NC), Windows platform. Results: There were a total of 4,291 hospitalizations of IBD patients with acute pancreatitis over the 7 year period and 379,627 hospitalizations of non-IBD patients with acute pancreatitis. The mean LOS of patients with acute pancreatitis and a co-diagnosis of IBD was 5.7 days versus 4.9 days for controls (p < 0.0001). Hospital costs were higher in patients with IBD compared to controls ($29,724.89 vs. $27,916.76 respectively, p < 0.0001). Survival rates were high in both groups, but slightly lower in patients with IBD (99.4% vs. 99.3% respectively). Higher LOS and costs were seen in patients with acute pancreatitis and a co-diagnosis of CD or UC (table 1). Rate of alcohol abuse was lower and drug abuse was higher in patients with a co-diagnosis of IBD (table 2). Conclusion: Our study suggests that cost and length of stay in patients with acute pancreatitis is influenced by a co-diagnosis of IBD. A co-diagnosis of CD or UC incurs a greater economic burden in patients with acute pancreatitis.Figure 1Figure 2

An In Vivo Evaluation of the Fit of Zirconium-Oxide Based, Ceramic Single Crowns with Vertical and Horizontal Finish Line Preparations.

Different types of tooth preparations influence the marginal precision of zirconium-oxide based ceramic single crowns. In this in vivo study, the marginal fits of zirconium-oxide based ceramic single crowns with vertical and horizontal finish lines were compared. Forty-six teeth were chosen in eight patients indicated for extraction for implant placement. CAD/CAM technology was used for the production of 46 zirconium-oxide-based ceramic single crowns: 23 teeth were prepared with vertical finishing lines, 23 with horizontal finishing lines. One operator accomplished all clinical procedures. The zirconia crowns were cemented with glass ionomer cement. The teeth were extracted 1 month later. Marginal gaps along vertical planes were measured for each crown, using a total of four landmarks for each tooth by means of a microscope at 50× magnification. On conclusion of microscopic assessment, ESEM evaluation was completed on all specimens. The comparison of the gap between the two types of preparation was performed with a nonparametric test (two-sample Wilcoxon rank-sum test) with a level of significance fixed at p < 0.05. All data were analyzed with STATA12. In the group with horizontal finish line preparations, the median value of the gap was 35.45 μm (Iqr, 0.33); for the vertical finish line group, the median value of the gap was 35.44 μm (Iqr, 0.40). The difference between the two groups was not statistically significant (two-sample Wilcoxon rank-sum test, p = 0.0872). Within the limitations of this study, the gaps of the zirconium-oxide-based ceramic CAD/CAM crowns with vertical and horizontal finish line preparations were not different.

A Randomized, Double-Blind, Sham-Controlled Trial of Transcranial Direct Current Stimulation in Attention-Deficit/Hyperactivity Disorder.

BackgroundCurrent standardized treatments for cognitive impairment in attention-deficit/hyperactivity disorder remain limited and their efficacy restricted. Transcranial direct current stimulation (tDCS) is a promising tool for enhancing cognitive performance in several neuropsychiatric disorders. Nevertheless, the effects of tDCS in reducing cognitive impairment in patients with attention-deficit/hyperactivity disorder (ADHD) have not yet been investigated.MethodsA parallel, randomized, double-blind, sham-controlled trial was conducted to examine the efficacy of tDCS on the modulation of inhibitory control in adults with ADHD. Thirty patients were randomly allocated to each group and performed a go/no-go task before and after a single session of either anodal stimulation (1 mA) over the left dorsolateral prefrontal cortex or sham stimulation.ResultsA nonparametric two-sample Wilcoxon rank-sum (Mann-Whitney) test revealed no significant differences between the two groups of individuals with ADHD (tDCS vs. sham) in regard to behavioral performance in the go/no go tasks. Furthermore, the effect sizes of group differences after treatment for the primary outcome measures—correct responses, impulsivity and omission errors—were small. No adverse events resulting from stimulation were reported.ConclusionAccording to these findings, there is no evidence in support of the use of anodal stimulation over the left dorsolateral prefrontal cortex as an approach for improving inhibitory control in ADHD patients. To the best of our knowledge, this is the first clinical study to assess the cognitive effects of tDCS in individuals with ADHD. Further research is needed to assess the clinical efficacy of tDCS in this population.Trial RegistrationClinicalTrials.gov NCT01968512

Association between serum uric acid levels and obesity among university students (China).

To evaluate the association between serum uric acid and obesity among university students who participated in routine health screening in 2013. In this cross-sectional study, 3529 subjects were analyzed. Obesity categories were classified by BMI levels references in China. And serum uric acid levels were classified by serum uric acid quartiles. Two-sample T-test and Wilcoxon Rank sum test were used to compare age, biochemical and anthropometric parameters of subjects of two genders. Rank correlation used to analyze relationship between serum uric acid and obesity. There were 1285 males (mean age, 19.8 ± 1.3 years) and 2244 females (mean age, 19.9 ± 1.3 years) in this study. Association between 2nd serum uric acid quartile and normal in male are significant and coefficient was 0.519. The 3rd serum uric acid quartile and normal in female was associated significantly (r = 0.173, p = 0.010). And associations between overweight and 3rd and 4th serum uric acid quartiles in female were significant (r = 0.128, p = 0.038 in 1st quartile and r = 0.282, p = 0.004 in 4th quartile). The 4th serum uric acid quartile and Obesity in two gender groups were significantly associated (r = 0.291, p = 0.000 in male and r = 0.484, p = 0.001 in female). High serum uric acid was positively associated with obesity in overweight and obesity group. However, the association was weak between two variables because serum uric acid influenced obesity with other related factors together.

Pattern of Optometry Practice and Range of Services in India

This study was conducted to evaluate the range of services provided by optometrists in various modes of optometric practice in India. An online questionnaire was administered to 1674 optometrists to collect information on the range of optometric services offered. Data were analyzed based on variables including sex, educational qualification, and modes of practice. Two-sample Wilcoxon rank sum tests, χ tests, and Fisher exact text were used to conduct inferential statistics. A total of 563 valid and completed survey questionnaires were received from graduates of 41 optometry institutes working across 23 states of India. Of these, 225 (40.0%) were female, 288 (51.2%) had completed postgraduate education, and 340 (60.5%) were involved in more than one mode of practice. The top three modes of practice were hospital-based practice (44.8%), academia (42.8%), and optical retail (33.0%). Of the 441, out of 563 (78.3%) respondents involved in patient care, the majority (98.4%) performed refraction and routine eye examination, 70.3% dispensed contact lenses, and 66.9% practiced optical dispensing. Lower involvement was seen in providing binocular-vision (45.1%) and low-vision services (30.2%). Higher education was associated with advanced level of practice (p < 0.05) except clinical investigative procedures. There was a significant association between postgraduate studies and involvement in academics and research (p < 0.01). Most optometrists are engaged in multiple modes of practice, with optical practice, hospital-based practice, and academia being the leading modes. Optometrists need to be more involved in providing the core optometric services of binocular vision and low vision. Higher education has an impact on the level of optometric practice.

Rate of Gleason 7 or higher prostate cancer on repeat biopsy after a diagnosis of atypical small acinar proliferation.

Limited information is known about the clinical significance of cancers diagnosed upon repeat biopsy for the indication of atypical small acinar proliferation (ASAP). With increasing concern regarding overdiagnosis and overtreatment of prostate cancer, and the reported rise in infectious complications related to prostate biopsy, we examined the outcomes of patients rebiopsied for a diagnosis of ASAP. Clinical, pathologic and outcomes data of patients diagnosed with ASAP on prostate biopsy at our institutions between 2000 and 2010 were abstracted through chart review. Statistical analyses included Fisher's exact and the two-sample Wilcoxon rank sum tests. Logistic regression evaluated risk factors for the probability of cancer following a diagnosis of ASAP. A total of 349 patients met the inclusion criteria with median follow-up of 4.4 years. Median age was 65.3 years with a median PSA of 5.3 ng ml(-1). Of men diagnosed with ASAP, 250/349 (71.6%) had a repeat biopsy within 1 year with 94/246 (38.2%) demonstrating prostate cancer; only 26/245 (10.6%) had ⩾Gleason 7 disease. Of men diagnosed with ASAP, 284/349 (81.4%) underwent biopsy at some time during follow-up. Prostate cancer was diagnosed in 132/279 (47.3%) of these men, 48/278 (17.3%) with ⩾Gleason 7 disease. Multivariate analyses suggested that older age, no previous biopsy and PSA density were predictive of cancer on repeat biopsy within 1 year from ASAP. Univariate analysis revealed PSA density was associated with the presence of ⩾Gleason 7 disease at 1 year and any time after a diagnosis of ASAP. The overall rate of intermediate- and high-grade prostate cancer found on repeat biopsy for ASAP is low. Further investigation into ways to further risk stratify these men may be warranted. However, until such tests become available, repeat biopsy of men diagnosed with ASAP remains prudent.

(458) Evaluation of anxiety in procedure naïve patients during cervical and lumbar epidural steroid injection procedures

In order to minimize patient anxiety and maximize patient comfort, pain practitioners frequently administer sedatives when performing spine injections. The lack of studies that identify patient and procedural risk factors for increased levels of anxiety during spine injections and the potential risk of neurologic injury in patients undergoing injection treatments while sedated represent major barriers to the development of safe, tailored sedation practices. This prospective observational cohort study was conducted with injection-naïve patients presenting for a routine cervical or lumbar epidural steroid injection for a pain related indication at a tertiary urban academic medical center to measure and compare anxiety levels in order to identify predictors of patient movement and vasovagal responses. Anxiety was measured using validated outcomes. The primary outcome measure was the Spielberger State Trait Anxiety Inventory (STAI) score. Numeric rating scale (NRS) for anxiety was also used. A two-sample Wilcoxon rank-sum test was used to compare STAI scores. NRS was analyzed with ANOVA and categorical variables were evaluated by using an c2 statistic. We found no group differences in age, gender, marital status, VAS pain score, duration of pain symptoms, or utilization of healthcare resources for pain symptom management. The mean STAI score was 43 ± 8 in the cervical group (n =139) and 44 ± 9 in the lumbar group (n = 140) (p = 0.35), a low level of anxiety (the lowest possible score is 20, and the highest score, representing the highest possible level of anxiety is 80). We found no between-group differences in anxiety at any point during the peri-procedure period. A vasovagal response was identified in 10% of the cervical group and in 3% of the lumbar group (p=0.04). Our results suggest that the practice of routine prevention or treatment of injection-related anxiety in the procedure-naïve general population should be re-evaluated. In order to minimize patient anxiety and maximize patient comfort, pain practitioners frequently administer sedatives when performing spine injections. The lack of studies that identify patient and procedural risk factors for increased levels of anxiety during spine injections and the potential risk of neurologic injury in patients undergoing injection treatments while sedated represent major barriers to the development of safe, tailored sedation practices. This prospective observational cohort study was conducted with injection-naïve patients presenting for a routine cervical or lumbar epidural steroid injection for a pain related indication at a tertiary urban academic medical center to measure and compare anxiety levels in order to identify predictors of patient movement and vasovagal responses. Anxiety was measured using validated outcomes. The primary outcome measure was the Spielberger State Trait Anxiety Inventory (STAI) score. Numeric rating scale (NRS) for anxiety was also used. A two-sample Wilcoxon rank-sum test was used to compare STAI scores. NRS was analyzed with ANOVA and categorical variables were evaluated by using an c2 statistic. We found no group differences in age, gender, marital status, VAS pain score, duration of pain symptoms, or utilization of healthcare resources for pain symptom management. The mean STAI score was 43 ± 8 in the cervical group (n =139) and 44 ± 9 in the lumbar group (n = 140) (p = 0.35), a low level of anxiety (the lowest possible score is 20, and the highest score, representing the highest possible level of anxiety is 80). We found no between-group differences in anxiety at any point during the peri-procedure period. A vasovagal response was identified in 10% of the cervical group and in 3% of the lumbar group (p=0.04). Our results suggest that the practice of routine prevention or treatment of injection-related anxiety in the procedure-naïve general population should be re-evaluated.

Clinical evaluation of marginal bone level change around multiple adjacent implants restored with splinted and nonsplinted restorations: a 10-year randomized controlled trial.

The management of occlusal forces on implant restorations may influence their long-term prosthetic success. The purpose of this randomized controlled trial was to compare marginal bone level changes around adjacent splinted and nonsplinted implants, functionally loaded with cemented restorations, up to 10 years in maxillae. During 2002 and 2003, all patients who received three adjacent implants in a private office and a university setting were included in this study. All implants featured an external-hexagon design and were placed in the posterior maxilla. Implants in the left maxilla were randomly selected to be restored with splinted cemented restorations; maxillary right implants were restored with nonsplinted cemented restorations. Marginal bone resorption was measured with intraoral radiographs yearly over a period of at least 10 years after placement of abutments and restorations. The amount of bone loss in each group was analyzed with the two-sample Wilcoxon rank-sum (Mann-Whitney) test because variable bone loss was normally distributed at the fifth year only. One hundred thirty-two implants were placed in 44 patients. Three implants failed at stage-two surgery. Five years after initial loading, two patients moved away and were lost to follow-up (6 implants in total); three additional patients did not complete the study (9 implants in total). Of the remaining 114 implants, 60 left implants were restored with splinted cemented restorations and 54 right implants were restored with nonsplinted cemented restorations. At 10 years, the splinted group showed a mean of 1.2 mm (interquartile range: 0.2 mm) of bone loss; the nonsplinted group showed 1.3 mm (interquartile range: 0.2 mm). A significant difference in bone loss was seen between the two groups. However, the difference of 0.1 mm was not considered clinically meaningful.

Abstract W P224: Higher Pre-Hospital Blood Pressure Prolongs Door to Needle Thrombolysis Times

Background: Per American Heart Association guidelines, blood pressure (BP) should be &lt; 185/110 to be eligible for intravenous tissue plasminogen activator (tPA). It is shown that door to needle (DTN) time is prolonged in patients who require anti-hypertensive medications prior to thrombolysis in the emergency department (ED). To our knowledge, no studies have focused on pre-hospital BP and its impact on DTN times. We hypothesize that DTN times are longer for patients with higher pre-hospital BP. Methods: We conducted a retrospective review of acute ischemic stroke patients who presented between 1/2010 and 12/2010 to our ED through Emergency Medical Services (EMS) within 3-hrs of symptom onset. Patients were identified from our registry and categorized into two groups: Pre-hospital BP ≥ 185/110 (Pre-hsp HBP) and &lt; 185/110 (Pre-hsp LBP). BP records were abstracted from EMS sheets. Two groups were compared using two-sample t-test or Wilcoxon rank sum test for continuous variables and Chi-square test or Fisher’s exact test for categorical variables. Results: A total of 107 consecutive patients were identified. Out of these, 75 patients (70%) were treated with tPA. Among the patients who received thrombolysis, 35% had pre-hospital BP ≥ 185/110 (n= 26/75). Greater number of patients required anti-hypertensive medications in ED in high BP group compared to low BP group (Pre-hsp HBP n= 14/26, 54%; Pre-hsp LBP n= 13/49, 27%, p &lt; 0.02). Mean door to needle times were significantly higher in Pre-hsp HBP group. (mean ± SD 87.5± 34.2 Vs. 59.7±18.3, p&lt;0.0001). Analysis of patients only within the Pre-hsp HBP group (n= 26) revealed that DTN times were shorter if patients received pre-hsp BP medications compared to patients in the same group who did not receive pre-hsp BP medication (n= 10 vs 16; mean ± SD 76.5 ± 25.7 Vs. 94.3 ± 37.7, p = 0.20) Conclusion: Higher pre-hospital BP is associated with prolonged DTN times and it stays prolonged if pre-hospital high BP remains untreated. Although the later finding was not statistical significant due to small sample size, pre-hospital blood pressure control could be a potential area for improvement to reduce door to needle times in acute ischemic stroke.