A pilot study of stored low titer group O whole blood + component therapy versus component therapy only for civilian trauma patients.

BACKGROUND: This pilot assessed transfusion requirements during resuscitation with whole blood followed by standard component therapy (CT) versus CT alone, during a change in practice at a large urban Level I trauma center. METHODS: This was a single-center prospective cohort pilot study. Male trauma patients received up to 4 units of cold-stored low anti-A, anti-B group O whole blood (LTOWB) as initial resuscitation followed by CT as needed (LTOWB + CT). A control group consisting of women and men who presented when LTOWB was unavailable, received CT only (CT group). Exclusion criteria included antiplatelet or anticoagulant medication and death within 24 hours. The primary outcome was total transfusion volume at 24 hours. Secondary outcomes were mortality, morbidity, and intensive care unit- and hospital-free days. RESULTS: Thirty-eight patients received LTOWB, with a median of 2.0 (interquartile range [IQR] 1.0-3.0) units of LTOWB transfused. Thirty-two patients received CT only. At 24 hours after presentation, the LTOWB +CT group had received a median of 2,138 mL (IQR, 1,275-3,325 mL) of all blood products. The median for the CT group was 4,225 mL (IQR, 1,900-5,425 mL; p = 0.06) in unadjusted analysis. When adjusted for Injury Severity Score, sex, and positive Focused Assessment with Sonography for Trauma, LTOWB +CT group patients received 3307 mL of blood products, and CT group patients received 3,260 mL in the first 24 hours (p = 0.95). The adjusted median ratio of plasma to red cells transfused was higher in the LTOWB + CT group (0.85 vs. 0.63 at 24 hours after admission; p = 0.043. Adjusted mortality was 4.4% in the LTOWB + CT group, and 11.7% in the CT group (p = 0.19), with similar complications, intensive care unit-, and hospital-free days in both groups. CONCLUSION: Beginning resuscitation with LTOWB results in equivalent outcomes compared with resuscitation with CT only. LEVEL OF EVIDENCE: Therapeutic (Prospective study with 1 negative criterion, limited control of confounding factors), level III.

Choice of Intensive Lifestyle Change and/or Metformin after Shared Decision Making for Diabetes Prevention: Results from the Prediabetes Informed Decisions and Education (PRIDE) Study.

INTRODUCTION: While the Diabetes Prevention Program Study demonstrated that intensive lifestyle change and metformin both reduce type 2 diabetes incidence, there are little data on patient preferences in real-world, clinical settings. METHODS: The Prediabetes Informed Decisions and Education (PRIDE) study was a cluster-randomized trial of shared decision making (SDM) for diabetes prevention. In PRIDE, pharmacists engaged patients with prediabetes in SDM using a decision aid with information about both evidence-based options. We recorded which diabetes prevention option(s) participants chose after the SDM visit. We also evaluated logistic regression models examining predictors of choosing intensive lifestyle change ± metformin, compared to metformin or usual care, and predictors of choosing metformin ± intensive lifestyle change, compared to intensive lifestyle change or usual care. RESULTS: Among PRIDE participants (n = 515), 55% chose intensive lifestyle change, 8.5% chose metformin, 15% chose both options, and 21.6% declined both options. Women (odds ratio [OR] = 1.60, P = 0.023) had higher odds than men of choosing intensive lifestyle change. Patients >60 years old (OR = 0.50, P = 0.028) had lower odds than patients <50 years old of choosing metformin. Participants with higher body mass index (BMI) had higher odds of choosing intensive lifestyle change (OR = 1.07 per BMI unit increase, P = 0.005) v. other options and choosing metformin (OR = 1.06 per BMI unit increase, P = 0.008) v. other options. CONCLUSIONS: Patients with prediabetes are making choices for diabetes prevention that generally align with recommendations and expected benefits from the published literature. Our results are important for policy makers and clinicians, as well as program planners developing systemwide approaches for diabetes prevention.

Connecting Provider to home: A home-based social intervention program for older adults.

OBJECTIVE: Patients with multiple medical conditions and complex social issues are at risk for high utilization and poor outcomes. The Connecting Provider to Home program deployed teams of a social worker and a community health worker (CHW) to support patients with social issues and access to primary care. Our objectives were to examine the impact of the program on utilization and satisfaction with care among older adults with complex social and medical issues. DESIGN: Retrospective quasi-experimental observational study with matched comparator group. SETTING: Community-based program in Southern California. PARTICIPANTS: Four hundred twenty community dwelling adults. INTERVENTION: Community-based healthcare program delivered by a social worker and CHW team for older adults with complex medical and social needs. MEASUREMENTS: Acute hospitalization and emergency department (ED) visits in the 12 months preceding and following enrollment in the pilot program. A "difference-in-difference" analysis using a matched comparator group was conducted. Comparator group data of patients receiving usual care were obtained. Surveys were conducted to assess patient satisfaction and experiences with the program. RESULTS: The mean age of patients was 74 years, and the program demonstrated statistically significant reductions in acute hospitalizations and ED use compared with 700 comparator patients. Pre/post-acute hospitalizations and ED visits were reduced in the intervention group. The average per patient per year reduction in acute hospitalizations was -0.66, whereas the average per patient reduction in ED use was -0.57. Patients enrolled in the program reported high levels of satisfaction and rated the program favorably. CONCLUSIONS: A care model with a social worker and CHW can be linked to primary care to address patient social needs and potentially reduce utilization of healthcare services and enhance patient experiences with care.

Reducing Emergency Department Visits Among Patients With Diabetes by Embedding Clinical Pharmacists in the Primary Care Teams.

BACKGROUND: Pharmacists are effective at improving control of cardiovascular risk factors, but it less clear whether these improvements translate into less emergency department (ED) use and fewer hospitalizations. The UCMyRx program embed pharmacists in primary care. OBJECTIVE: The objective of this study was to examine if the integration of pharmacists into primary care was associated with lower ED and hospital use for patients with diabetes. DESIGN: This was a quasi-experimental study with a comparator group. SUBJECTS: The analytic sample included patients with diabetes with uncontrolled cardiovascular risk factors (A1C >9%, blood pressure >140/90 mm Hg, low-density lipoprotein-cholesterol >130 mg/dL) who had 1 or more visits in either a UCMyRx (648 patients, 14 practices) or usual care practice (1944 patients, 14 practices). MEASURES: Our outcomes were ED and hospitalization rates as measured before and after the consultations between UCMyRx and usual care. Our predictor variable was the pharmacist consultation. Poisson generalized estimating equations model was used to estimate the adjusted predicted change in utilization before and after the pharmacist consultation. The Average Treatment Effect on the Treated was estimated. RESULTS: In models adjusted, the adjusted mean predicted number of emergency department visits/month during the year before the consultation was 0.09 among UCMyRx patients. During the year after initiating the care with the pharmacists, this rate decreased to an adjusted mean monthly rate of 0.07, with an Average Treatment Effect on the Treated=0.021 (P=0.035), a predicted reduction of 21% in emergency department visits associated with the clinical pharmacist consults. There was a nonsignificant predicted 3.2% reduction in hospitalizations over time for patients in the UCMyRx program. CONCLUSION: Clinical pharmacists are an important addition to clinical care teams in primary care practices and significantly decreased utilization of the ED among patients with poorly controlled diabetes.

A Collaboration Among Primary Care-Based Clinical Pharmacists and Community-Based Health Coaches.

BACKGROUND/OBJECTIVES: Medication discrepancies and adverse drug events are common following hospital discharge. This study evaluates whether a collaboration between community-based health coaches and primary care-based pharmacists was associated with a reduction in inpatient utilization following hospitalization. DESIGN: Retrospective cohort study using propensity score matching. SETTING: Urban academic medical center and surrounding community. PARTICIPANTS: Intervention patients (n = 494) were adults aged 65 and older admitted to the University of California, Los Angeles (UCLA) Ronald Reagan Medical Center during the study period and who met study inclusion criteria. A matched-control group was composed of patients with similar demographic and clinical characteristics who were admitted to the study site during the study period but who received usual care (n = 2,470). A greedy algorithm approach was used to conduct the propensity score match. INTERVENTION: Following acute hospitalization, a health coach conducted a home visit and transmitted all medication-related information to a pharmacist based in a primary care practice. The pharmacist compared this information with the patient's electronic medical record medication list and consulted with the patient's primary care provider to optimize medication management. MEASUREMENTS: Thirty-day readmissions (primary outcome), 60- and 90-day readmissions, and 30-day emergency department (ED) visits (secondary outcomes) to UCLA Health. RESULTS: Among 494 patients who received the intervention, 307 (62.1%) were female with a mean age of 83.0 years (interquartile range [IQR] = 76-90 years). Among 2,470 matched-control patients, 1,541 (62.4%) were female with a mean age of 82.7 years (IQR = 74.9-89.5 years). For the propensity score match, standardized mean differences were below .1 for 23 of 25 variables, indicating good balance. Patients who received this intervention had a significantly lower predicted probability of being readmitted within 30 days compared with matched-control patients (10.6%; 95% confidence interval [CI] = 7.9-13.2) vs 21.4%; 95% CI = 19.8-23.0; P value < .001). CONCLUSION: A home visit conducted by a health coach combined with a medication review by a primary care-based pharmacist may prevent subsequent inpatient utilization.

Intravenous versus oral cyclophosphamide for lung and/or skin fibrosis in systemic sclerosis: an indirect comparison from EUSTAR and randomised controlled trials.

OBJECTIVES: Both intravenous (IV) and oral (PO) cyclophosphamide (CYC) showed beneficial effects on skin and lung involvement in systemic sclerosis (SSc) in placebo-controlled randomised clinical trials and observational studies. Our goal was to compare the relative efficacy and safety of PO- versus IV-CYC for treating interstitial lung disease and/or skin involvement in SSc. METHODS: Patients were derived from the EUSTAR centres and the Scleroderma Lung Studies I and II. A minimum of 6 months of CYC treatment and 12 months follow-up were required. Serious (SAEs) and non-serious adverse events and efficacy data (change in FVC%, DLCO%, mRSS) were analysed at the end of CYC treatment (EoT) and at follow-up (FU). Analysis included descriptive statistics and linear regressions. RESULTS: Differences in ethnicity, previous DMARD exposure, previous and concomitant steroid exposure/dosage were observed in the PO (n=149) and IV (n=153) CYC groups. Adjusted and unadjusted changes in FVC%, DLCO% and mRSS were similar irrespective of mode of administration. PO patients had more leukopenia (p<0.001), haemorrhagic cystitis (p=0.011) and alopecia (p<0.001) at the EoT visit, while the IV group had more SAEs (p=0.025) and need for oxygen supplementation at FU (p=0.049). CONCLUSIONS: In a comparison of PO- to IV-CYC for SSc, we found no differences in lung function or cutaneous sclerosis after one year. Some differences in side effects were seen. The results need to be considered as preliminary; however, because we needed to use a combination of RCT and registry data, with some differences in demographics and concomitant medications, well-controlled studies are warranted.

Durable Survival Outcomes in Primary and Secondary Central Nervous System Lymphoma After High-dose Chemotherapy and Autologous Stem Cell Transplantation Using a Thiotepa, Busulfan, and Cyclophosphamide Conditioning Regimen.

BACKGROUND: High-dose chemotherapy (HDC) with autologous stem cell transplantation (ASCT) has been investigated in patients with primary central nervous system lymphoma (PCNSL) and non-Hodgkin lymphoma (NHL) with CNS involvement and has shown promising results. PATIENTS AND METHODS: A retrospective analysis was performed of 48 consecutive patients who had undergone HDC/ASCT with TBC (thiotepa, busulfan, cyclophosphamide) conditioning for PCNSL (27 patients), secondary CNS lymphoma (SCNSL) (8 patients), or relapsed disease with CNS involvement (13 patients) from July 2006 to December 2017. Of the 27 patients with PCNSL, 21 had undergone ASCT at first complete remission (CR1). RESULTS: The 2-year progression-free survival (PFS) rate was 80.5% (95% confidence interval [CI], 69.9-92.9) and the 2-year overall survival (OS) rate was 80.1% (95% CI, 69.2%-92.7%) among all patients. The 2-year PFS and OS rate for patients with PCNSL in CR1 was 95.2% (95% CI, 86.6%-100%) and 95.2% (95% CI, 86.6%-100%), respectively. On univariate analysis of the patients with PCNSL, ASCT in CR1 was the only variable statistically significant for outcome (P = .007 for PFS; P = .008 for OS). Among patients with SCNSL or CNS relapse, the 2-year PFS and OS rate were comparable at 75.9% (95% CI, 59.5%-96.8%) and 75.3% (95% CI, 58.6%-98.6%), respectively. The most common side effects were febrile neutropenia (89.6%; of which 66.7% had an infectious etiology identified), nausea/vomiting (85.4%), diarrhea (93.8%), mucositis (89.6%), and electrolyte abnormalities (89.6%). Four patients (8.3%) died of treatment-related overwhelming infection; of these patients, 3 had SCNSL. CONCLUSION: HDC and ASCT using TBC conditioning for both PCNSL and secondary CNS NHL appears to have encouraging long-term efficacy with manageable side effects.

Psychometric Properties of the Altarum Consumer Engagement (ACE) Measure of Activation in Patients with Prediabetes.

BACKGROUND: Patient activation is associated with better outcomes in chronic conditions. OBJECTIVE: We evaluated the psychometric properties of the 12-item Altarum Consumer Engagement™ Measure (ACE-12) in patients with prediabetes. PARTICIPANTS: ACE-12 was administered to patients in the Prediabetes Informed Decisions and Education Study. MAIN MEASURES: We conducted an exploratory factor analysis followed by confirmatory factor analytic models. We evaluated item response categories using item characteristic curves. Construct validity was assessed by examining correlations of the ACE-12 scales with education, depressive symptoms, self-rated health, hemoglobin A1c, body mass index, and weight loss. KEY RESULTS: Participants (n = 515) had a median age of 58; 56% were female; 17% Hispanic; 54% were non-White. The scree plot and Tucker and Lewis reliability coefficient (0.95) suggested three factors similar to the original scales. One item loaded on the navigation rather than the informed choice scale. Ordinal alpha coefficients for the original scales were commitment (0.75); informed choice (0.71); and navigation (0.54). ICCs indicated that one or more of the response categories for 5 of the 12 items were never most likely to be selected. Patients with lower education were less activated on the commitment (r = - 0.124, p = 0.004), choice (r = - 0.085, p = 0.009), and overall score (r = - 0.042, p = 0.011). Patients with depressive symptoms had lower commitment (r = - 0.313, p ≤ 0.001) and overall scores (r = - 0.172, p = 0.012). Patients with poorer health scored lower on the Commitment (r = - 0.308, p ≤ 0.001), Navigation (r = - 0.137, p ≤ 0.001), and overall score (r = - 0.279, p ≤ 0.001). CONCLUSION: The analyses provide some support for the psychometric properties of the ACE-12 in prediabetic patients. Future research evaluating this tool among patients with other chronic conditions are needed to determine whether Q1 (I spend a lot of time learning about health) should remain in the informed choice or be included in the navigation scale. Additional items may be needed to yield acceptable reliability for the navigation scale.

Diagnostic Utility and Impact on Clinical Decision Making of Focused Assessment With Sonography for HIV-Associated Tuberculosis in Malawi: A Prospective Cohort Study.

BACKGROUND: The focused assessment with sonography for HIV-associated tuberculosis (TB) (FASH) ultrasound protocol has been increasingly used to help clinicians diagnose TB. We sought to quantify the diagnostic utility of FASH for TB among individuals with HIV in Malawi. METHODS: Between March 2016 and August 2017, 210 adults with HIV who had 2 or more signs and symptoms that were concerning for TB (fever, cough, night sweats, weight loss) were enrolled from a public HIV clinic in Lilongwe, Malawi. The treating clinicians conducted a history, physical exam, FASH protocol, and additional TB evaluation (laboratory diagnostics and chest radiography) on all participants. The clinician made a final treatment decision based on all available information. At the 6-month follow-up visit, we categorized participants based on clinical outcomes and diagnostic tests as having probable/confirmed TB or unlikely TB; association of FASH with probable/confirmed TB was calculated using Fisher's exact tests. The impact of FASH on empiric TB treatment was determined by asking the clinicians prospectively about whether they would start treatment at 2 time points in the baseline visit: (1) after the initial history and physical exam; and (2) after history, physical exam, and FASH protocol. RESULTS: A total of 181 participants underwent final analysis, of whom 56 were categorized as probable/confirmed TB and 125 were categorized as unlikely TB. The FASH protocol was positive in 71% (40/56) of participants with probable/confirmed TB compared to 24% (30/125) of participants with unlikely TB (odds ratio=7.9, 95% confidence interval=3.9,16.1; P<.001). Among those classified as confirmed/probable TB, FASH increased the likelihood of empiric TB treatment before obtaining any other diagnostic studies from 9% (5/56) to 46% (26/56) at the point-of-care. For those classified as unlikely TB, FASH increased the likelihood of empiric treatment from 2% to 4%. CONCLUSION: In the setting of HIV coinfection in Malawi, FASH can be a helpful tool that augments the clinician's ability to make a timely diagnosis of TB.

Evaluation of General and Musculoskeletal Health Literacy Disparities in Pediatric Sports Injury Patient and Guardian Populations.

BACKGROUND: Increased participation of adolescents in organized sports has led to an increase in pediatric sports injury. Limited health literacy puts patients at risk for worse outcomes through decreased compliance. We aim to evaluate the extent of health literacy disparities in pediatric sports medicine populations. METHODS: Patients aged 10 to 17 years and their consenting guardians visiting clinic for treatment of a sports-related injury completed a unique questionnaire including self-reported health literacy measures and direct assessment of knowledge regarding care for musculoskeletal injuries. Statistical analysis based on socioeconomic factors and demographics was performed using t tests. RESULTS: A total of 268 patient surveys (14.37±1.94 y) and 251 guardian surveys (43.62±9.08 y) were collected. In self-reported general health literacy scores for guardians, all categories except ethnicity played a statistically significant role, with higher health literacy scores associated with higher education, use of English as the primary language at home, private insurance, and female guardians (P<0.001, <0.001, <0.001, 0.011). In contrast, age was the only factor affecting scores in the patient population (P=0.015). Among self-reported musculoskeletal health literacy and directly measured musculoskeletal literacy scores, there were significant differences in groups by age, primary language, and level of education (P=0.020, 0.003). CONCLUSIONS: Significant disparities in general and musculoskeletal health literacy exist within pediatric sports medicine populations, most notably between guardian groups. Improving disparities in health literacy for these populations may best be aimed at guardians, using medical education through verbal/written instruction in multiple languages. LEVEL OF EVIDENCE: Level IV.

Association of brain amyloidosis with the incidence and frequency of neuropsychiatric symptoms in ADNI: a multisite observational cohort study.

OBJECTIVE: To investigate the relationship between amyloid burden and frequency of existing and incidence of new neuropsychiatric symptoms (NPS) in elderly with and without cognitive decline. METHODS: 275 cognitively normal controls (NC), 100 subjective memory complaint (SMC), 559 mild cognitive impairment (MCI) and 143 Alzheimer's disease dementia subjects from the Alzheimer's Disease Neuroimaging Initiative received (18F)-florbetapir positron emission tomography (PET) scans. Yearly neuropsychiatric inventory (Neuropsychiatric Inventory (NPI)/NPI-Questionnaire) data were collected from the study partners at each visit. Mean standard uptake volume ratios (SUVR) normalised to whole cerebellum were obtained. Positive amyloid PET scan was defined as mean SUVR ≥1.17. Fisher's exact test was used to compare frequency and incidence between amyloid positive and amyloid negative subjects. Survival analyses were used to estimate of neuropsychiatric symptoms (NPS) between amyloid positive and amyloid negative subjects. Survival analyses were used to estimate hazard ratios for developing the most common NPS by amyloid status. RESULTS: No differences in NPS frequency were seen between amyloid positive and amyloid negative NC, SMC, MCI or dementia groups. MCI subjects with amyloid pathology however tended to have greater frequency x severity (FxS) of anxiety, hallucinations, delusions, apathy, disinhibition, irritability, aberrant motor behavior, and appetite, but not agitation, depression, night-time disturbances, or elation. MCI subjects with amyloid pathology were at greater risk for developing apathy, anxiety and agitation over time. Baseline presence of agitation and apathy and new onset agitation, irritability and apathy predicted faster conversion to dementia among MCI subjects. CONCLUSIONS: Amyloid pathology is associated with greater rate of development of new NPS in MCI. Anxiety and delusions are significant predictors of amyloid pathology. Agitation, irritability and apathy are significant predictors for conversion from MCI to dementia.

Racial disparities and the acute management of severe blunt traumatic brain injury.

BACKGROUND: Traumatic brain injury (TBI) is a significant source of morbidity and mortality. In patients with TBI, racial disparities have been shown to exist in patient outcomes. Identifying where disparities occur along the patient continuum of care will allow for targeted interventions. This study evaluated if racial disparity exists for neuromonitoring and neurointervention rates in patients with severe TBI due to blunt injury. METHODS: The National Trauma Data Bank was used to identify patients aged 18 to 55 years old from 2007 through 2016 with a blunt injury, an initial Glasgow Coma Scale score of 3 to 8, a head Abbreviated Injury Scale score of 3 to 5, and all other anatomic Abbreviated Injury Scale scores less than 3. Coarsened exact matching (CEM) was used to balance covariates between white and non-white patients. Rates of neuromonitoring and neurosurgical interventions were compared between groups. Secondary outcomes were days spent in the intensive care unit (ICU), total hospital length of stay (LOS), and mortality. RESULTS: A total of 3692 patients with severe isolated TBI due to blunt injury were identified. After applying CEM, 1064 patients were analyzed (644 white, 420 non-white). No differences were observed between white and non-white patient groups for neuromonitoring, neurointervention, mortality, or ICU LOS. White patients had a shorter hospital LOS (8 days vs. 9 days, p<0.05) than non-white patients. DISCUSSION: For severe isolated blunt TBI, neuromonitoring, neurointervention, and mortality rates were similar for white and non-white patients. Although racial disparities in patient outcomes exist, these differences do not seem to be due to neuromonitoring and neurointervention rates for management of TBI. LEVEL OF EVIDENCE: Level III.

Diabetes Prevention Program attendance is associated with improved patient activation: Results from the Prediabetes Informed Decisions and Education (PRIDE) study.

The Diabetes Prevention Program (DPP) is a 12-month behavior change program designed to increase physical activity and improve dietary patterns among patients at risk for Type 2 diabetes, in order to facilitate modest weight loss and improve cardio-metabolic profiles. It is unknown whether baseline patient activation is related to increased DPP uptake, and whether DPP attendance leads to subsequent improvement in patient activation. We analyzed data from 352 adult participants in the Prediabetes Informed Decisions and Education (PRIDE) trial of shared decision-making (SDM) in diabetes prevention, collected from November 2015 through September 2017. PRIDE participants completed baseline and 4-month follow-up surveys, including the Altarum Consumer Engagement (ACE) Measure™ of patient activation. We tracked DPP attendance over 8 months using data from partnering DPP providers. In multivariate models, we measured whether self-reported baseline activation was associated with DPP "uptake" (1+ session attended) or DPP "attendance" (9+ sessions). We also examined whether DPP attendance was associated with change in activation at 4-months follow-up. We did not find an association between baseline activation and DPP uptake or attendance. However, we did find that DPP attendance was associated with an increase in the overall ACE score (6.68 points, 95% CI 1.97-11.39, p = 0.005) and increased activation in 2 of the 3 ACE subscales (Commitment and Informed Choice). Our finding of increased patient activation with DPP attendance suggests a mechanism for the improved health outcomes seen in DPP real-world translational studies. This work has important implications for diabetes prevention and other behavior change programs.

Cytokine Profiles Associated With Angiotensin II Type 1 Receptor Antibodies.

INTRODUCTION: Angiotensin II type 1 receptor antibody (AT1R-Ab), is a non-human leukocyte antigen (HLA) antibody implicated in poor renal allograft outcomes, although its actions may be mediated through a different pathway than HLA donor-specific antibodies (DSAs). Our aim was to examine serum cytokine profiles associated with AT1R-Ab and distinguish them from those associated with HLA DSA in serially collected blood samples from a cohort of pediatric renal transplant recipients. METHODS: Blood samples from 65 pediatric renal transplant recipients drawn during the first 3 months posttransplant, at 6, 12, and 24 months posttransplant, and during suspected episodes of kidney transplant rejection were tested for AT1R-Ab, HLA DSA, and a panel of 6 cytokines (tumor necrosis factor [TNF]-α, interferon [IFN]-γ, interleukin [IL]-8, IL-1ß, IL-6, and IL-17). Associations between antibodies and cytokines were evaluated. RESULTS: AT1R-Ab, but not HLA DSA, was associated with elevations in TNF-α, IFN-γ, IL-8, IL-1ß, IL-6, and IL-17. This relationship remained significant even after controlling for relevant clinical factors and was consistent across all time points. In contrast to HLA DSA, AT1R-Ab was associated with elevations in vascular inflammatory cytokines in the first 2 years posttransplant. CONCLUSIONS: This profile of vascular cytokines may be informative for clinical monitoring and designing future studies to delineate the distinct pathophysiology of AT1R-Ab-mediated allograft injury in kidney transplantation.

Effect of theory-based contraception comics on subjective contraceptive knowledge: a pilot study.

OBJECTIVES: We assessed the effect on subjective knowledge of a pilot educational comic decision aid about contraceptive methods. STUDY DESIGN: We designed four comics (www.birthcontroltales.com), each about a different contraceptive method choice. The comics employ a theoretical framework, and the methods addressed were injection, intrauterine device, implant and combined hormonal contraceptives (including pill, patch and ring). The study population included young women presenting to a college student health clinic whose preferred language is English. Participants had not used the contraceptive method described in the comic and viewed the comics in color printed copy. We assessed contraception subjective knowledge using a pretest/posttest six-question survey with Likert scale responses before and after exposure to the comics. Surveys conducted during the participants' visit also measured participant satisfaction with the comic and participant sexual history. RESULTS: A total of 120 individual participants divided into groups of 30 each viewed one of four separate comics. Across the four groups, the difference in the pretest/posttest scores of the six-question subjective knowledge survey indicated a 72% average increase (p value<.001). CONCLUSION: Comics about contraceptive methods can be a communications tool that increases subjective knowledge of contraceptive methods. Comics that model contraceptive choice decision processes can increase individual subjective knowledge of the contraceptive method mechanism, effect, usage, side effects, feasibility and benefits. Possessing subjective knowledge of contraceptive methods can influence contraceptive initiation and use and therefore has potential implications for changing contraceptive attitudes and behavior. IMPLICATIONS: Contraceptive method comics should be further examined in other clinic settings with broader demographic populations to glean the effect on patient decision and contraceptive behavior. Integration of the comics into a contraceptive counseling practice can be assessed in an observational trial. Additionally, studies should also consider testing long-term patient behavior, and both patient and provider satisfaction.

Predictors of Outcomes After Thoracic Surgery in Orthotopic Liver Transplant Recipients With Pleural Disease.

Orthotopic liver transplant (OLT) recipients are at high risk for postoperative pulmonary complications. We aim to determine factors associated with morbidity and mortality in OLT recipients that required thoracic surgery for pleural space complications. A retrospective review was performed of 42 patients who underwent thoracic surgery after OLT between 2005 and 2015. Preoperative data and postoperative outcomes were reviewed. Time to mortality was summarized using Kaplan-Meier curves. Outcomes associated with 30-day morbidity and mortality as well as long-term mortality were analyzed with univariate analysis. Between 2005 and 2015, 1735 OLTs were performed at our institution. We identified 42 patients who required thoracic surgery. Of these 42 OLT recipients, 33 patients required thoracic surgery for pleural space complications. The median interval between OLT and thoracic surgery for pleural space complications was 5.7 months (interquartile range 2.2-14.1). The most common surgical indications were chronic pleural effusion (n = 12, 36.4%) and empyema (n = 10, 30.3%). The most common thoracic operations were decortication and empyema evacuation. The 30-day morbidity was 69.7%. Bilirubin and empyema were significantly associated with 30-day morbidity (odds ratio [OR] = 2.3, P = 0.023; OR = 16.3, P = 0.015). The 30-day, 1-year, and 5-year mortality rates were 15.2%, 57.6%, and 70.2%, respectively. Vasopressor requirement was significantly associated with 30-day mortality (OR = 10.2, P = 0.031). The development of pleural space complications requiring surgery in OLT recipients suggests a poor prognosis. Hyperbilirubinemia and pleural space infections were associated with high postoperative morbidity in OLT recipients requiring thoracic surgery for pleural space complications.

Inadequate Hepatocellular Carcinoma Screening in Patients With Nonalcoholic Steatohepatitis Cirrhosis.

BACKGROUND: Nonalcoholic steatohepatitis (NASH) is a common cause of liver disease which can progress to cirrhosis and hepatocellular carcinoma (HCC). American Association for the Study of Liver Diseases (AASLD) guidelines recommend abdominal ultrasound, with or without serum alpha-fetoprotein, every 6 months for HCC surveillance in cirrhotic patients. GOALS: Describe HCC surveillance rates in NASH cirrhosis compared with hepatitis C (HCV) cirrhosis and the impact of surveillance on tumor size, treatment, and mortality. STUDY: Adults with NASH and HCV cirrhosis diagnosed with HCC from 2009 to 2016 were retrospectively evaluated. Patients were categorized into 3 mutually exclusive disease screening groups based on abdominal imaging with or without serum alpha-fetoprotein testing before HCC diagnosis. RESULTS: In total, 99 patients with NASH cirrhosis and 162 patients with HCV cirrhosis were evaluated. In total, 51.5% of NASH cirrhosis patients and 25.9% of HCV cirrhosis patients had no screening before HCC diagnosis. Patients with HCV cirrhosis were significantly more likely to undergo surveillance compared with patients with NASH cirrhosis (P=0.002). NASH cirrhosis patients who underwent complete screening had smaller tumors compared with those with incomplete screening and no screening (P=0.006). There were no differences in number of tumors at diagnosis or mortality between screening groups in patients with NASH cirrhosis (P=0.281 and 0.468, respectively). CONCLUSIONS: There is suboptimal HCC surveillance in NASH and HCV cirrhotic patients, with a greater proportion of patients with NASH cirrhosis not undergoing surveillance. Patients with NASH cirrhosis who had complete surveillance had smaller tumors at diagnosis, but there were no differences in treatment outcomes or mortality.

Pretransplant Sarcopenia in Patients With NASH Cirrhosis Does Not Impact Rehospitalization or Mortality.

BACKGROUND: Malnutrition and muscle wasting are common in patients with end-stage liver disease (ESLD), yet go underdiagnosed. Frequently used indices of nutritional status, such as body mass index, are inflated in patients with ESLD due to a fluid overloaded state. Previous work has demonstrated a strong association between psoas muscle area, a surrogate for sarcopenia, and worse survival following liver transplantation; however, the impact of sarcopenia on post liver transplant outcomes in patients with nonalcoholic steatohepatitis (NASH) cirrhosis has not been evaluated. GOALS: Describe the impact of sarcopenia in patients with NASH cirrhosis on post liver transplantation outcomes, including initial hospital length of stay, rehospitalization, and survival. MATERIALS AND METHODS: A single-center, retrospective analysis was conducted of adult liver transplants performed for NASH cirrhosis between 2002 and 2015. Sarcopenia was defined by psoas area measured at the L3 vertebra from abdominal imaging within 6 months before orthotopic liver transplant (OLT). RESULTS: A total of 146 patients were evaluated. The mean Model for End-Stage Liver Disease score at transplant was 34.9±7.4. Sarcopenia was present in 62% of patients and was more likely in female and Hispanic patients. There were no significant differences in length of initial hospitalization following OLT, days hospitalized within the first year post-OLT, survival at 1 year, or overall survival between sarcopenic and nonsarcopenic patients. CONCLUSIONS: Sarcopenia in patients with NASH cirrhosis and high Model for End-Stage Liver Disease scores is not associated with an increase in mortality or rehospitalization following liver transplantation; however, the study findings were limited by a small sample size.

Preliminary Validation of the Digital Ulcer Clinical Assessment Score in Systemic Sclerosis.

OBJECTIVE: To date, "healed/non-healed" and clinical judgment are the only available assessment tools for digital ulcers (DU) in patients with systemic sclerosis (SSc). The aim of our study is to examine a preliminary composite DU clinical assessment score (DUCAS) for SSc for face, content, and construct validity. METHODS: Patients with SSc presenting at least 1 finger DU were enrolled and assessed with the Health Assessment Questionnaire-Disability Index, Cochin scale, visual analog scale (VAS) for DU-related pain, patient global DU status, and global assessment as patient-reported outcomes (PRO), and physician VAS for DU status (phyGDU) as an SSc-DU expert physician/nurse measure. The DUCAS included 7 DU-related variables selected by a committee of SSc DU experts and weighted on a clinical basis. Face validity was examined by consensus and partial construct validity was tested through convergent correlation with other measures of hand function, using Spearman's correlations. A range of patients with SSc was examined. A linear regression model with backward stepwise analysis was used to determine the relationship of individual variables with the primary clinical parameter, phyGDU. RESULTS: Forty-four patients with SSc (9 males, mean age 55 ± 15 yrs, mean disease duration 9.9 ± 5.8 yrs) were enrolled in the study. Overall DUCAS showed significant positive correlations with all abovementioned PRO (r > 0.4, p < 0.01). When all scores and scales were modeled, only DUCAS significantly predicted phyGDU (r = 0.59, R2 = 0.354, Akaike information criterion = 385.4). CONCLUSION: Preliminarily, we suggest that the DUCAS may be a new clinical score for SSc-related DU, having face and content validity and convergent/divergent correlations (construct validity). These early data suggest that this score deserves further evaluation.

Depression in Nonclassical Hypogonadism in Young Men.

The specific objective of this study was to test the clinically derived hypothesis associating a high prevalence of depression in young men with nonclassical hypogonadism. We studied the entire population of men aged 18 to 40 years who had an outpatient visit at an academic health system in the years 2013 to 2015. The study group comprised 186 patients with a diagnosis of eugonadotropic hypogonadism and a testosterone value below 10.4 nmol/L with no apparent cause. We compared their demographic factors, other diagnoses, and treatments with those of (i) the entire population, (ii) a matched population of 930 controls, and (iii) 404 controls with normal testosterone determinations, and no hypogonadism diagnosis. Depression, defined as either an International Classification of Diseases, Ninth Revision (ICD-9) diagnosis or treatment with an antidepressant medication, was found in 22.6% of cases vs 6.6% of population controls [P < 0.001; OR: 1.13 (1.09 to 1.17); 95% CI]. Obesity was also higher in the cases (P < 0.001). The matched controls had a depression rate of 13.4% compared with the case rate of 22.6% [P < 0.002; OR 1.14 (1.08 to 1.17)]. Controls with normal testosterone determinations had a depression rate of 16.8% [P = 0.121; OR: 1.04 (0.96 to 1.12)], suggesting that clinicians may have ordered a testosterone determination because of symptoms consistent with both depression and hypogonadism. The high incidence of depression in nonclassical hypogonadism in young men, although only associative, supports a depression evaluation and treatment as appropriate as well as investigation of the proximate causes of this form of hypogonadism.