Characteristics of Patients Who Return to the Emergency Department After an Observation Unit Assessment.

Introduction: Emergency Department observation units (EDOU) transition patients from the emergency department (ED) to dedicated areas where they can receive continuous monitoring. Understanding patient return visits after EDOU discharge is important for optimizing healthcare. The objective of this study was to investigate the correlation between demographic and clinical features and the likelihood of returning to the ED within 30 days following their initial assessment in the EDOU. Methods: This retrospective, observational cohort study of adult EDOU subjects was conducted between February 1, 2018 - January 31, 2023. Adult patients evaluated in the EDOU and returned to the ED within 30 days were identified. Subjects were compared to those assessed in the EDOU but did not return to the ED within 30 days. The analysis took into account multiple visits by the same subject and made adjustments for variables including gender, ethnicity, insurance status, primary diagnosis, and disposition, using a generalized linear mixed model. Results: A total of 14,910 EDOU encounters were analyzed and 2,252 (15%) patients returned to the ED within 30 days. The analysis took into account several variables demonstrated a significant association with the likelihood of returning to the ED within 30 days. These included gender (p=0.0002), ethnicity (p=0.005), race (p=0.0004), insurance status (p<0.0001), primary diagnosis (p<0.0001), and disposition (p<0.001). Emergency severity index and length of stay were not associated with returning. Conclusions: Understanding these factors may guide interventions, enhance EDOU care, and reduce resource strain. Further research should explore these associations and long-term intervention impacts for improved outcomes.

Presence and Size of Placental Lakes on 20-Week Fetal Anatomy Ultrasound and Obstetrical Outcomes.

Our objective was to determine if placental lake presence or size is associated with adverse pregnancy outcomes. This was a retrospective cohort of patients who had fetal anatomy ultrasounds at 18-22 weeks and delivered between 2018 and 2022. Placental lakes were classified as small (>2.0 to 3.9 cm) or large (≥4 cm). Multiple gestations, placenta previas, and placenta accretas were excluded. Outcomes included low birthweight, cesarean delivery, primary cesarean for non-reassuring fetal heart tracing, fetal growth restriction, preterm birth, and severe preeclampsia. A total of 1052 patients were included; 294 had placental lakes (204 small, 90 large). No differences in pregnancy outcomes were observed.

Does a Preoperative Bowel Regimen Change Time to Bowel Movement? A Randomized Clinical Trial.

IMPORTANCE: This study is important because it aimed to assess an intervention to decrease patient discomfort after a robotic sacral colpopexy. OBJECTIVE: Our primary outcome was to determine whether preoperative use of polyethylene glycol decreases time to first bowel movement postoperatively. Secondary outcomes include degree of pain with first bowel movement and stool consistency. STUDY DESIGN: This was a randomized controlled trial. The experimental group was assigned polyethylene glycol daily for 7 days before surgery and the control group was not. All patients received polyethylene glycol postoperatively. RESULTS: There was no statistically significant reduction in the time to first postoperative bowel movement when preoperative polyethylene glycol was used (mean [SD] in days for the control and experimental groups of 2.32 [0.99] and 1.96 [1.00], P = 0.21). There was a statistically significant reduction in pain levels with the first postoperative bowel movement in the experimental group (median [IQR] of 4 [2-5] vs 1 [0-2], P = 0.0007). Postoperative day 1 pain levels were also significantly lower in the experimental group (median [IQR] of 4 [3-6] vs 2 [0-4], P = 0.0484). In addition, patients had decreased average postoperative pain levels over 7 days with an estimated difference in the median pain levels of 1.88 units (95% confidence interval, 0.64-3.12; P = 0.0038). CONCLUSIONS: Preoperative administration of polyethylene glycol did not decrease time to first postoperative bowel movement. Patients in the experimental group exhibited less pain with their first postoperative bowel movement and had improved pain levels on postoperative day 1.

Radiation Therapy Practice Patterns for Treatment of Curative Breast Cancer in a Large Tertiary Health Care System.

Purpose: Disparities have been reported in women treated for breast cancer (BrCa). This study examines potential disparities in BrCa treatment offered based on race and age from a multicenter radiation department. Methods and Materials: We identified 901 patients with early stage BrCa who received curative intent radiation therapy (RT) between 2004 and 2018. Data extracted included age, race, disease stage, treatment technique, treatment dates, and fractionation. Patient race was recorded as Asian, Black, Hispanic, and White. RT technique delivered was classified as a type of external beam radiation therapy or brachytherapy/intraoperative radiation therapy. Fractionation schema were defined as 1) standard fractionation, 1.8-2 Gy; 2) hypofractionation, 2.5-2.67 Gy; 3) accelerated partial breast irradiation (APBI), 3.4 Gy - 4.25 Gy, and 4) intraoperative radiation therapy, single dose of 20 Gy. Stage was recorded using TNM staging. The χ2 test and a multivariable multinomial logistic regression model were used to assess whether patient characteristics, such as age, race, or stage influenced fractionation schemes. Results with 2-sided P values < .05 were considered statistically significant. Results: Racial composition of the study was 13.8% Asian, 22% Black, 29%, White, and 35.1% Hispanic. Mean age was 61 and was divided into 4 age range groups: 30 to 49 (n = 160), 50 to 59 (n = 231), 60 to 69 (n = 294), and ≥70 years (n = 216). In addition, 501 patients (56%) received hypofractionation, 342 (38.8%) received standard fractionation, and 58 (7.1%) received APBI, respectively. For all groups, hypofractionation became more common over time. Age ≥70 years was associated with 9 times higher odds of APBI and 14 times higher odds of hypofractionation, compared with age 30 to 49 years. After adjusting for the other predictors in a multivariable multinomial logistic regression model, the race distribution differed among the 3 groups (P = .03), with a smaller percentage of Hispanics and higher percentage of blacks in the standard group. Conclusions: This study of a diverse cohort of patients with breast cancer failed to identify treatment differences associated by race. The study found an association between age and hypofractionation.

A Real World Perspective of PARP Inhibitor Use in Gynecological Cancer Patients.

Introduction: Over the last few years, targeted therapy has become the mainstay maintenance treatment of patients with ovarian cancer including patients with BRCA1/BRCA2 mutations. Poly ADP ribose polymerase inhibitors (PARPi) are effective in the treatment of patients who are in complete or partial remission. PARPi are known to cause hematological adverse events (AEs), but have not been compared directly to each other. Objective: Primary objective was to compare the incidence of hematological and non-hematological AEs associated with the use of PARPi. Methods: This was a single institution, retrospective study evaluating patients who were treated with PARPi for ovarian cancer from January 2017 to October 2020. Patients were stratified according to which PARP inhibitor they received. Results: Ninety-two patients were included in final analysis. Thirty-one (33.7%) patients received niraparib and 61 (66.3%) patients received olaparib. Median age of patients were 64.3 (range, 33.8 to 92.3) years, 66 (71.7%) were white, and 84 (91.3%) had an ECOG PS of 0/1. Patients in the niraparib group experienced a higher rate of hematologic AEs, with 11 (35.5%), 20 (64.5%), and 18 (58.1%) experiencing neutropenia, anemia, and thrombocytopenia, respectively. Eight (13.1%), 24 (39.3%), and 16 (26.2%) patients in the olaparib group experienced neutropenia, anemia, and thrombocytopenia, respectively. Conclusion: This single institution retrospective study outlines the hematological toxicities observed between two PARPi. Our results suggested that niraparib tended to be associated with a higher risk for hematologic toxicities than olaparib. Anemia was the most common hematologic toxicity which was consistent with what has been widely documented in the literature.

Acceptance Rate and Reasons for Rejection of Long Acting Injectable Antiretrovirals.

In January 2021, cabotegravir/rilpivirine, the first extended-release injectable regimen for the treatment of Human Immunodeficiency Virus (HIV) was approved. Long-acting injections have the potential to improve adherence and viral suppression. We analyzed the acceptance rate of, and reasons for declining to switch to, the new regimen. During routine appointments, 102 people living with HIV (PLWH) were presented with information on the new medication and asked if they would like to switch from their current regimen. If they declined to switch, they were asked why. Sixty-nine percent of respondents declined to switch, with frequency of injections as the primary reason. Patients indicated they would be willing to switch if the interval between injections was longer. Forty percent of the patients accepting the injectable anti-retrovirals (ARVs) were not on any other medications. Barriers to switching to long-acting injectable ARVs include the need for more frequent provider visits, aversion to needles, and a perceived lack of evidence supporting the new medication.

Angiographic Treatment of Asymptomatic Cerebral Vasospasm Following Aneurysmal Subarachnoid Hemorrhage for the Prevention of Delayed Cerebral Ischemia.

OBJECTIVE: Angiographic treatment of asymptomatic cerebral vasospasm (CVS) in aneurysmal subarachnoid hemorrhage remains controversial. We sought to investigate its relationship with the development of delayed cerebral ischemia. METHODS: Consecutive patients admitted between July 2017 and June 2019, with a diagnosis of aneurysmal subarachnoid hemorrhage, were retrospectively analyzed. The rate of development of delayed cerebral ischemia was compared between a group of patients who underwent cerebral angiography for asymptomatic CVS and those who did not. The Mann-Whitney U test or χ2 test was used to compare the 2 groups. RESULTS: Thirty-seven of the 94 patients with aneurysmal subarachnoid hemorrhage were screened for CVS, of whom 16 (43%) had moderate-severe vasospasm. When patients who underwent therapeutic cerebral angiography were compared with those who did not and after adjusting for sex, age, and grade of subarachnoid hemorrhage, treatment was not found to be significantly associated with delayed cerebral ischemia (hazard ratio = 0.82, 95% confidence interval: 0.19-3.52, P = 0.79). We found that the median length of stay in the intensive care unit and hospital increased significantly with the severity of CVS (P < 0.001). CONCLUSIONS: Cerebral angiography has a low rate of detecting moderate-severe CVS in asymptomatic patients. Moreover, there was no statistically significant difference in the rate of delayed cerebral ischemia between asymptomatic patients treated versus those not treated for CVS. There was significant association between the severity of CVS and the intensive care unit and hospital length of stay. More studies are needed to evaluate the utility of treating asymptomatic CVS in high-grade aneurysmal subarachnoid hemorrhage.

Health care consequences of hospitalization with Clostrioides difficile infection: a propensity score matching study.

BACKGROUND: Clostridiodies difficile infection (CDI) has been characterized by the Center for Disease Control and Prevention (CDC) as an urgent public health threat and a major concern in hospital, outpatient and extended-care facilities worldwide. METHODS: A retrospective cohort study of patients aged ≥ 18 hospitalized with CDI in New York State (NYS) between January 1, 2014-December 31, 2016. Data were extracted from NY Statewide Planning and Research Cooperative (SPARCS) and propensity score matching was performed to achieve comparability of the CDI (exposure) and non-CDI (non-exposure) groups. Of the 3,714,486 hospitalizations, 28,874 incidence CDI cases were successfully matched to 28,874 non-exposures. RESULTS: The matched pairs comparison demonstrated that CDI cases were more likely to be readmitted to the hospital at 30 (28.26% vs. 19.46%), 60 (37.65% vs. 26.02%), 90 (42.93% vs. 30.43) and 120 days (46.47% vs. 33.74), had greater mortality rates at 7 (3.68% vs. 2.0%) and 180 days (20.54% vs. 11.96%), with significant increases in length of stay and total hospital charges (p < .001, respectively). CONCLUSIONS: CDI is associated with a large burden on patients and health care systems, significantly increasing hospital utilization, costs and mortality.

Repeated superselective intraarterial bevacizumab after blood brain barrier disruption for newly diagnosed glioblastoma: a phase I/II clinical trial.

PURPOSE: Pre-clinical evidence suggests bevacizumab (BV) depletes the GBM peri-vascular cancer-stem cell niche. This phase I/II study assesses the safety and efficacy of repeated doses of superselective intra-arterial cerebral infusion (SIACI) of BV after blood-brain barrier disruption (BBBD). METHODS: Date of surgery was day 0. Evaluated patients received repeated SIACI bevacizumab (15 mg/kg) with BBBD at days 30 ± 7, 120 ± 7, and 210 ± 7 along with 6 weeks of standard chemoradiation. Response assessment in neuro-oncology criteria and the Kaplan-Meier product-limit method was used to evaluate progression free and overall survival (PFS and OS, respectively). RESULTS: Twenty-three patients with a median age of 60.5 years (SD = 12.6; 24.7-78.3) were included. Isocitrate dehydrogenase mutation was found in 1/23 (4%) patients. MGMT status was available for 11/23 patients (7 unmethylated; 3 methylated; 1 inconclusive). Median tumor volume was 24.0 cm3 (SD = 31.1, 1.7-48.3 cm3). Median PFS was 11.5 months (95% CI 7.7-25.9) with 6, 12, 24 and 60 month PFS estimated to be 91.3% (95% CI 69.5-97.8), 47.4% (26.3-65.9), 32.5% (14.4-52.2) and 5.4% (0.4-21.8), respectively. Median OS was 23.1 months (95% CI 12.2-36.9) with 12, 24, and 36 month OS as 77.3% (95% CI 53.6-89.9), 45.0% (22.3-65.3) and 32.1% (12.5-53.8), respectively. CONCLUSIONS: Repeated dosing of IA BV after BBBD offers an encouraging outcome in terms of PFS and OS. Phase III trials are warranted to determine whether repeated IA BV combined with Stupp protocol is superior to Stupp protocol alone for newly diagnosed GBM.

Robot-assisted stereoelectroencephalography electrode placement in twenty-three pediatric patients: a high-resolution analysis of individual lead placement time and accuracy at a single institution.

PURPOSE: We describe a detailed evaluation of predictors associated with individual lead placement efficiency and accuracy for 261 stereoelectroencephalography (sEEG) electrodes placed for epilepsy monitoring in twenty-three children at our institution. METHODS: Intra- and post-operative data was used to generate a linear mixed model to investigate predictors associated with three outcomes (lead placement time, lead entry error, lead target error) while accounting for correlated observations from the same patients. Lead placement time was measured using electronic time-stamp records stored by the ROSA software for each individual electrode; entry and target site accuracy was measured using postoperative stereotactic CT images fused with preoperative electrode trajectory planning images on the ROSA computer software. Predictors were selected from a list of variables that included patient demographics, laterality of leads, anatomic location of lead, skull thickness, bolt cap device used, and lead sequence number. RESULTS: Twenty-three patients (11 female, 48%) of mean age 11.7 (± 6.1) years underwent placement of intracranial sEEG electrodes (median 11 electrodes) at our institution over a period of 1 year. There were no associated infections, hemorrhages, or other adverse events, and successful seizure capture was obtained in all monitored patients. The mean placement time for individual electrodes across all patients was 6.56 (± 3.5) min; mean target accuracy was 4.5 (± 3.5) mm. Lesional electrodes were associated with 25.7% (95% CI: 6.7-40.9%, p = 0.02) smaller target point errors. Larger skull thickness was associated with larger error: for every 1-mm increase in skull thickness, there was a 4.3% (95% CI: 1.2-7.5%, p = 0.007) increase in target error. Bilateral lead placement was associated with 26.0% (95% CI: 9.9-44.5%, p = 0.002) longer lead placement time. The relationship between placement time and lead sequence number was nonlinear: it decreased consistently for the first 4 electrodes, and became less pronounced thereafter. CONCLUSIONS: Variation in sEEG electrode placement efficiency and accuracy can be explained by phenomena both within and outside of operator control. It is important to keep in mind the factors that can lead to better or worse lead placement efficiency and/or accuracy in order to maximize patient safety while maintaining the standard of care.

Comparative Survival Analysis of Immunomodulatory Therapy for Coronavirus Disease 2019 Cytokine Storm.

BACKGROUND: Cytokine storm is a marker of coronavirus disease 2019 (COVID-19) illness severity and increased mortality. Immunomodulatory treatments have been repurposed to improve mortality outcomes. RESEARCH QUESTION: Do immunomodulatory therapies improve survival in patients with COVID-19 cytokine storm (CCS)? STUDY DESIGN AND METHODS: We conducted a retrospective analysis of electronic health records across the Northwell Health system. COVID-19 patients hospitalized between March 1, 2020, and April 24, 2020, were included. CCS was defined by inflammatory markers: ferritin, > 700 ng/mL; C-reactive protein (CRP), > 30 mg/dL; or lactate dehydrogenase (LDH), > 300 U/L. Patients were subdivided into six groups: no immunomodulatory treatment (standard of care) and five groups that received either corticosteroids, anti-IL-6 antibody (tocilizumab), or anti-IL-1 therapy (anakinra) alone or in combination with corticosteroids. The primary outcome was hospital mortality. RESULTS: Five thousand seven hundred seventy-six patients met the inclusion criteria. The most common comorbidities were hypertension (44%-59%), diabetes (32%-46%), and cardiovascular disease (5%-14%). Patients most frequently met criteria with high LDH (76.2%) alone or in combination, followed by ferritin (63.2%) and CRP (8.4%). More than 80% of patients showed an elevated D-dimer. Patients treated with corticosteroids and tocilizumab combination showed lower mortality compared with patients receiving standard-of-care (SoC) treatment (hazard ratio [HR], 0.44; 95% CI, 0.35-0.55; P < .0001) and with patients treated with corticosteroids alone (HR, 0.66; 95% CI, 0.53-0.83; P = .004) or in combination with anakinra (HR, 0.64; 95% CI, 0.50-0.81; P = .003). Corticosteroids when administered alone (HR, 0.66; 95% CI, 0.57-0.76; P < .0001) or in combination with tocilizumab (HR, 0.43; 95% CI, 0.35-0.55; P < .0001) or anakinra (HR, 0.68; 95% CI, 0.57-0.81; P < .0001) improved hospital survival compared with SoC treatment. INTERPRETATION: The combination of corticosteroids with tocilizumab showed superior survival outcome when compared with SoC treatment as well as treatment with corticosteroids alone or in combination with anakinra. Furthermore, corticosteroid use either alone or in combination with tocilizumab or anakinra was associated with reduced hospital mortality for patients with CCS compared with patients receiving SoC treatment.

Adapted Feeding Utensils for People With Parkinson's-Related or Essential Tremor.

OBJECTIVE: Our objective was to evaluate the effectiveness of four adapted feeding utensils with participants with essential tremor (ET) or tremor related to Parkinson's disease (PD). METHOD: Participants performed a simulated feeding task under five conditions: (1) standard spoon (control condition), (2) weighted spoon with standard handle, (3) weighted spoon with built-up handle, (4) swivel spoon, and (5) Liftware Steady™ spoon, a product using active tremor cancellation technology. Participants rated each adapted utensil in comparison with the standard spoon regarding performance, ease of use, speed, neatness, and aesthetics. RESULTS: Participants preferred the Liftware Steady spoon and weighted spoon with standard handle. Friedman's test did not reveal statistically significant differences in ratings between the two preferred utensils. CONCLUSION: Participants had varied reactions to the different adaptive utensils and gave different reasons for preferences. These findings support the need for people with tremor related to ET or PD to have access to trial use of all four devices assessed in this study.

Disparities in the Use of Intravenous t-PA among Ischemic Stroke Patients: Population-based Recent Temporal Trends.

OBJECTIVE: To explore a 5-year comparison of disparities in intravenous t-PA (IV t-PA) use among acute ischemic stroke (AIS) patients based on race, gender, age, ethnic origin, hospital status, and geographic location. METHODS: We extracted patients' demographic information and hospital characteristics for 2010 and 2014 from the New York Statewide Planning and Research Cooperative System (SPARCS). We compared disparities in IV t-PA use among AIS patients in 2010 to that in 2014 to estimate temporal trends. Multiple logistic regression was performed to compare disparities based on demographic variables, hospital designation, and geographic location. RESULTS: Overall, there was approximately a 2% increase in IV t-PA from 2010 to 2014. Blacks were 15% less likely to receive IV t-PA compared to Whites in 2014, but in 2010, there was no difference. Patients aged 62-73 had lower odds of receiving IV t-PA than age group ≤61 in both 2010 and 2014. Designated stroke centers in the Lower New York State region were associated with reduced odds of IV t-PA use in 2010 while those located in the Upper New York State region were associated with increased odds of IV t-PA use in both 2010 and 2014, compared to their respective nondesignated counterparts. Gender, ethnic origin, and insurance status were not associated with IV t-PA utilization in both 2010 and 2014. CONCLUSION: Overall IV t-PA utilization among AIS patients increased between 2010 and 2014. However, there are evident disparities in IV t-PA use based on patient's race, age, hospital geography, and stroke designation status.

A PROSPECTIVE STUDY OF COMMONLY UTILIZED REGIMENS OF VITAMIN D REPLACEMENT AND MAINTENANCE THERAPY IN ADULTS.

OBJECTIVE: To determine which vitamin D dose, formulation, and schedule most effectively and safely achieves a 25-hydroxyvitamin D (25[OH]D) level of >30 ng/mL (75 nmol/L). METHODS: In this prospective study, 100 subjects from the NY Harbor HCS Brooklyn Campus, ages 25 to 85 years, with 25(OH)D <30 ng/mL (<75 nmol/L), were randomized into four groups: cholecalciferol (D3) 2,000 international units (IU) daily; D3 3,000 IU daily; ergocalciferol (D2) 50,000 IU weekly; and D2 50,000 IU twice weekly. All were supplemented with 500 mg calcium carbonate daily. 25(OH)D, parathyroid hormone (PTH), urinary calcium, urinary creatinine, and other variables were measured during 7 visits over 12 months. RESULTS: All groups achieved a mean vitamin D level >30 ng/mL (>75 nmol/L) by visit 4 (5 months). Those receiving 50,000 IU D2 twice weekly displayed the most rapid and robust response, with 25(OH)D reaching >30 ng/mL (>75 nmol/L) after only 1 month and plateauing at 60 ng/mL (150 nmol/L) by 7 months. Although no statistically significant difference was seen in mean 25(OH)D levels between groups 1 through 3, subjects on 50,000 IU D2 weekly more consistently showed higher mean levels than either groups 1 or 2. No episodes of significant hypercalcemia occurred. There was a negative correlation in mean PTH levels and mean vitamin D levels in group 4 and all groups combined. CONCLUSION: All four schedules of vitamin D replacement were effective in safely achieving and maintaining 25(OH)D >30 ng/mL (>75 nmol/L). D2 50,000 IU twice weekly provided the most rapid attainment and highest mean levels of vitamin D. ABBREVIATIONS: 25(OH)D = 25-hydroxyvitamin D; BMI = body mass index; BUN = blood urea nitrogen; Ca/Cr = calcium/creatinine; D2 = ergocalciferol; D3 = cholecalciferol; IU = international units; PTH = parathyroid hormone.

Mortality in Living Kidney Donors With ESRD: A Propensity Score Analysis Using the United States Renal Data System.

INTRODUCTION: In recent years, data have emerged on the outcomes of living kidney donors who develop end-stage renal disease (ESRD). We aimed to evaluate mortality rates in kidney donors who had initiated dialysis compared with a propensity-matched cohort of dialysis patients without previous kidney donation. METHODS: We used the United States Renal Data System (USRDS) and abstracted 274 previous living kidney donors between 1995 and 2009. There were 609,398 individuals on dialysis without kidney donation. We used propensity score matching to identify 258 donors and 258 nondonors. The time-dependent Cox proportional hazards model was used to compare survival between the 2 matched cohorts. RESULTS: In the propensity score-matched cohort, mortality was lower in donors compared with nondonors (19% vs. 49%; P < 0.0001). The time-dependent Cox proportional hazards model demonstrated that donors had significantly lower mortality compared with nondonors 0 to 5 years since start of dialysis (hazard ratio [HR]: 0.17; 95% confidence interval [CI] 0.11-0.27; P < 0.0001) and with nondonors 5 to 10 years on dialysis (HR: 0.34; 95% CI: 0.19-0.63; P < 0.001). We were unable to estimate the difference between the 2 groups after 10 years on dialysis with any precision (HR: 0.51; 95% CI: 0.18-1.42; P = 0.20) due to the small sample size. CONCLUSION: We observed a lower mortality rate in living kidney donors with ESRD compared with matched nondonors. This data should guide clinicians in the informed consent process with prospective donors.

To Treat or Not to Treat?

Background and Purpose- The 2015 updated US Food and Drug Administration alteplase package insert altered several contraindications. We thus explored clinical factors influencing alteplase treatment decisions for patients with minor stroke. Methods- An expert panel selected 7 factors to build a series of survey vignettes: National Institutes of Health Stroke Scale (NIHSS), NIHSS area of primary deficit, baseline functional status, previous ischemic stroke, previous intracerebral hemorrhage, recent anticoagulation, and temporal pattern of symptoms in first hour of care. We used a fractional factorial design (150 vignettes) to provide unconfounded estimates of the effect of all 7 main factors, plus first-order interactions for NIHSS. Surveys were emailed to national organizations of neurologists, emergency physicians, and colleagues. Physicians were randomized to 1 of 10 sets of 15 vignettes, presented randomly. Physicians reported the subjective likelihood of giving alteplase on a 0 to 5 scale; scale categories were anchored to 6 probabilities from 0% to 100%. A conjoint statistical analysis was applied. Results- Responses from 194 US physicians yielded 156 with complete vignette data: 74% male, mean age 46, 80% neurologists. Treatment mean probabilities for individual vignettes ranged from 6% to 95%. Treatment probability increased from 24% for NIHSS score =1 to 41% for NIHSS score =5. The conjoint model accounted for 25% of total observed response variance. In contrast, a model accounting for all possible interactions accounted for 30% variance. Four of the 7 factors accounted jointly for 58% of total relative importance within the conjoint model: previous intracerebral hemorrhage (18%), recent anticoagulation (17%), NIHSS (13%), and previous ischemic stroke (10%). Conclusions- Four main variables jointly account for only a small fraction (<15%) of the total variance related to deciding to treat with intravenous alteplase, reflecting high variability and complexity. Future studies should consider other variables, including physician characteristics.

BC RNA Mislocalization in the Fragile X Premutation.

Fragile X premutation disorder is caused by CGG triplet repeat expansions in the 5' untranslated region of FMR1 mRNA. The question of how expanded CGG repeats cause disease is a subject of continuing debate. Our work indicates that CGG-repeat structures compete with regulatory BC1 RNA for access to RNA transport factor hnRNP A2. As a result, BC1 RNA is mislocalized in vivo, as its synapto-dendritic presence is severely diminished in brains of CGG-repeat knock-in animals (a premutation mouse model). Lack of BC1 RNA is known to cause seizure activity and cognitive dysfunction. Our working hypothesis thus predicted that absence, or significantly reduced presence, of BC1 RNA in synapto-dendritic domains of premutation animal neurons would engender cognate phenotypic alterations. Testing this prediction, we established epileptogenic susceptibility and cognitive impairments as major phenotypic abnormalities of CGG premutation mice. In CA3 hippocampal neurons of such animals, synaptic release of glutamate elicits neuronal hyperexcitability in the form of group I metabotropic glutamate receptor-dependent prolonged epileptiform discharges. CGG-repeat knock-in animals are susceptible to sound-induced seizures and are cognitively impaired as revealed in the Attentional Set Shift Task. These phenotypic disturbances occur in young-adult premutation animals, indicating that a neurodevelopmental deficit is an early-initial manifestation of the disorder. The data are consistent with the notion that RNA mislocalization can contribute to pathogenesis.

Gender disparity in fistula use at initiation of hemodialysis varies markedly across ESRD networks-Analysis of USRDS data.

BACKGROUND: Gender disparities had been noted in the care of women with end stage renal disease (ESRD) in the early 2000's, including less frequent initiation of hemodialysis utilizing a fistula but more recent data have not been examined and underlying factors have not been extensively studied. STUDY DESIGN: Data from the United States Renal Data System (USRDS) were examined, including 202,999 hemodialysis patients. Only those who had received prior nephrology care were included. Multiple logistic regression was used, adjusted for possible confounders, including age, race, cause of ESRD, BMI, height, history of alcohol or drug abuse, medical comorbidities, ability to ambulate, time of nephrology care, type of insurance, and ESRD network. RESULTS: The odds of arteriovenous fistula (AVF) use at initiation of hemodialysis were significantly lower in women compared to men (OR = 0.69, 95% CI 0.67-0.71, P < 0.0001). The gender gap in AVF use at initiation was highest in New York and the upper Midwest (networks 2 and12) and smallest for Southern California and the Pacific Northwest and Alaska (18 and 16). Gender disparity was more pronounced for black women, with odds ratios for AVF use at initiation of dialysis (OR = 0.66, 95% CI 0.62-0.69), P < 0.0001 as compared to non-black (OR 0.70, 95% CI 0.68-0.73), P ≤ 0.0001. LIMITATIONS: Limitations include use of USRDS data. Data misclassification or errors in data reporting may exist and certain comorbid conditions may be underreported. Data regarding rate of primary fistula non-function are also not available. CONCLUSION: Adjusted odds ratio for AVF use was significantly lower in women compared to men, independent of time of nephrology care and other predictors. The gender disparity was most pronounced for black women and also varied from 20% to 46% lower odds for AVF use in women for different ESRD networks, after controlling for possible confounding variables, suggesting that practice based factors may be of importance in explaining this important finding.