No Value Found With Routine Early Postoperative Radiographs after Implant Removal in Pediatric Patients.

BACKGROUND: Implants are routinely removed in pediatric patients. Fracture through the prior implant site is a common worry after implant removal. Early post-implant removal radiographs are routinely used to evaluate the prior implant removal sites and to assess when a patient may return to normal activities. To our knowledge, the value of early, routine postoperative radiographs after elective implant removal in pediatric patients has not been studied. METHODS: A retrospective patient cohort of pediatric patients who had implant removal from an extremity from 2017 to 2019 was used in this study. Data were collected for patient demographics, implant site, reason for primary surgery, complications, number of postoperative radiographs, radiation exposure, cost of imaging, and whether the postoperative plan was changed by imaging. RESULTS: Two hundred ninety patients were included in the study. Postoperative plans were changed only in 0.69% of patients (n = 2) because of abnormal 2-week radiographs and 1.72% (n = 5) because of abnormal 6-week radiographs. However, the event's proportion difference (change of management) was not statically significant ( P = 0.182) between those who had a radiograph obtained and those who did not. The mean follow-up time was 16 months. The mean number of postoperative radiographs obtained was 3.74, the mean cost per radiograph was $103, and the mean postoperative radiation exposure was 1.34 mSv. No fractures were observed after implant removal. DISCUSSION: A retrospective review of the value of early, postoperative radiographs after routine orthopaedic implant removal found that postoperative radiographs at 2 and 6 weeks did not change the postoperative plan for most of the patients. Postoperative radiographs have an average cost of $103, and radiation exposure equal to approximately 6 months of natural background radiation. LEVEL OF EVIDENCE: Level III.

Role of Different Low-Density Lipoprotein-Lowering Medications on Secondary Prevention of Atherosclerotic Cardiovascular Disease in Patients With Diabetes Mellitus.

Purpose The objective of this study was to explore the optimal cholesterol-lowering therapy for diabetic patients categorized as having a very high risk for future atherosclerotic cardiovascular disease (ASCVD) events. The primary medications under investigation were statins, ezetimibe, and proprotein convertase subtilisin-kexin type 9 (PCSK9) inhibitors (PCSK9-Is). The efficacy of different medication regimens helped to draw conclusions regarding the evolution of cholesterol management recommended under the American College of Cardiology's (ACC) 2013 and 2018 guidelines. Methods A retrospective chart review was conducted on a cohort of patients from a large, community-based cardiology practice. Inclusion criteria specified patients aged 30-82 with a past medical history of two or more ASCVD events or one ASCVD event and at least two high-risk comorbidities. Acquired data included demographics, all lipid panels, medications used, and ASCVD events between December 1, 2013, and December 31, 2019. The data were stored and encrypted on a REDCap account. Sub-group analysis was conducted on only diabetic patients, who were then categorized by medication regimen. The statistical analysis was completed using Fisher's exact test. A p-value <0.05 was considered significant. Results A total of 102 diabetic patients met the inclusion criteria. Our primary analysis determined the percentage of patients who achieved their goals on each medication regimen. The goal was defined as a low-density lipoprotein cholesterol (LDL-C) level of less than 70 mg/dL or at least a 50% reduction from baseline levels. The results are as follows: none (0%), statin (33.9%), ezetimibe (21.1%), statin + ezetimibe (73.5%), PCSK9-Is ± statin (83.3%), and PCSK9-Is and ezetimibe ± statin (100%). There proved to be a significant difference favoring all combination regimens over statins alone; however, there was no significant difference between these advanced regimens. A follow-up analysis determined if these patients were able to maintain their goals in the subsequent lipid panel after achieving their goals. The results are as follows: none (0%), statin (61.5%), ezetimibe (50%), statin + ezetimibe (77.8%), PCSK9-Is ± statin (100%), and PCSK9-Is and ezetimibe ± statin (66.6%). The only significant difference found was between PCSK9-Is ± statins and statins alone. Conclusions Our study revealed that regimens using PCSK9 inhibitors and ezetimibe, in addition to maximally tolerated statin therapy, were more effective than statin therapy alone in achieving the goal. On extended analysis, only PCSK9 inhibitors showed superior ability in terms of maintaining the goals for diabetic patients at very high risk for future ASCVD events. This implies that statins alone may be inadequate to properly treat this specific patient population. In the context of clinical practice, physicians could have heightened consideration for dual therapy consisting of maximally tolerated statins and a secondary agent in accordance with the 2018 ACC guidelines.

Comparison of DNA methylation patterns across tissue types in infants with tetralogy of Fallot.

BACKGROUND: Environmental factors may influence the development of tetralogy of Fallot (TOF), and DNA methylation patterns may reveal specific chemical signatures of perturbations during cardiac development. We investigated whether blood and buccal cells could be viable surrogates for myocardium. METHODS: We measured epigenome-wide DNA methylation at 866,895 5'-cytosine-phosphate-guanine-3' (CpG) sites in blood (n=3), buccal cells (n=3), and right ventricular myocardium (n=4) collected from infants with TOF and compared the percent of differentially methylated CpG sites across tissue types. Gene-specific DNA methylation profiles were also analyzed for ten representative genes associated with heart development. Welch's ANOVAs compared general methylation between tissue types. RESULTS: Comparison of DNA methylation profiles across blood, buccal, and myocardium suggested myocardium and buccal samples were most similar, differing in DNA methylation at only 1.3% (11,386) of CpG sites whereas myocardium and blood were most dissimilar, having 146,857 statistically dissimilar methylated CpG sites (~17% dissimilarity; adjusted p < 0.01 for each site). Buccal swabs were significantly more variable (p < .001) than either blood or myocardial samples. In gene-specific analyses, SCO2, GATA4, NOTCH4, WNT7A, and DKK2 showed conserved DNA methylation profiles across tissue types, while HAND1, JAG1, NKX2-5, TBX5 and TBX20 showed more distinctive tissue-specific patterns of DNA methylation. CONCLUSIONS: Compared with blood, buccal tissue more closely mirrors the myocardial methylome, with >10-fold similarity. Nevertheless, both buccal and blood tissue capture highly conserved DNA methylation patterns at specific genetic loci related to cardiac development. Buccal cheek swabs may be a useful surrogate tissue type for future investigations of TOF-specific epigenetic profiles.

Impact of Providing Peer Support on Medical Students' Empathy, Self-Efficacy, and Mental Health Stigma.

BACKGROUND: Peer-support programs in medical school can buffer feelings of inadequacy, anxiety, social isolation, and burnout, drawing upon the benefits of near-peer-support resources. This study examined the effects of providing support to students in a medical school peer-support program. METHODS: Using a pre-post, quasi-experimental study design, the investigators surveyed medical students who were peer supporters in their second through fourth years of medical school with four measures assessing (1) empathy, (2) self-efficacy, (3) mental health stigma, and (4) likelihood to assist peers with mental health problems to examine if serving as a volunteer peer supporter had any effect. Participants included 38 medical students that were actively enrolled peer supporters during the 2020-2021 year at a United States allopathic medical school. RESULTS: Medical students who participated as peer supporters were found to have higher ratings of empathy scores (Z = -1.964, p = 0.050, r = 0.34) and self-efficacy scores (Z = -2.060, p = 0.039, r = 0.35) after participation in the program. No significant changes were noted for mental health stigma or likelihood to assist peers with mental health problems. DISCUSSION: Peer-support programs present a low-cost, sustainable modality to promote wellbeing in medical students. There is a growing body of literature documenting the benefits of peer-support services. This brief, novel study examined the effects of providing peer support on the peer supporters and found higher self-reported ratings of empathy and self-efficacy after participation. These findings underscore peer-support programs as a valuable wellness resource not only for medical students who use the services but for those who provide them as well.