Levothyroxine for a high-normal TSH in unexplained infertility.

OBJECTIVE: Unexplained infertility affects nearly one-third of infertile couples. Women with unexplained infertility are more likely to have a high-normal thyroid-stimulating hormone level (TSH: 2.5-5 mIU/L) compared to women with severe male factor infertility. Practice guidelines vary on whether treatment should be initiated for TSH levels >2.5 mIU/L in women attempting conception because the effects of treating a high-normal TSH level with levothyroxine are not known. We evaluated conception and live birth rates in women with unexplained infertility and high-normal TSH levels. DESIGN, PATIENTS AND MEASUREMENTS: Retrospective study including 96 women evaluated for unexplained infertility at a large academic medical centre between 1 January 2000 and 30 June 2017 with high-normal TSH (TSH: 2.5-5 mIU/L and within the normal range of the assay) who were prescribed (n = 31) or not prescribed (n = 65) levothyroxine. Conception and live birth rates were assessed. RESULTS: The conception rate in the levothyroxine group was 100% compared to 90% in the untreated group (p = .086 unadjusted; p < .05 adjusted for age; p = .370 adjusted for TSH; p = .287 adjusted for age and TSH). The live birth rate was lower in the levothyroxine group (63%) compared to the untreated group (84%) (p = .05 unadjusted; p = .094 adjusted for age; p = .035 adjusted for TSH; p = .057 adjusted for age and TSH). CONCLUSIONS: Women with unexplained infertility and high-normal TSH levels treated with levothyroxine had a higher rate of conception but lower live birth rate compared to untreated women, with the limitation of a small sample size. These findings assert the need for prospective, randomized studies to determine whether treatment with levothyroxine in women with unexplained infertility and high-normal TSH is beneficial.

Polycystic ovary syndrome preceding the diagnosis of acromegaly: a retrospective study in 97 reproductive-aged women.

BACKGROUND: Acromegaly is a disease of growth hormone excess that results in enlargement of extremities, abnormal glucose and lipid metabolism, and gonadal disruption. Manifestations of the disease are insidious and typically lead to a diagnostic delay of 7-10 years. Classically the polycystic ovary syndrome (PCOS) phenotype is described in women with irregular menses, clinical or biochemical evidence of androgen excess, and/or multiple ovarian follicles on pelvic ultrasonography. Women with acromegaly may present with some or all of these symptoms. Our objective was to evaluate the prevalence of PCOS in patients with acromegaly and to determine if diagnosis of PCOS results in a delay in diagnosing acromegaly. METHODS: Using patient databases at two academic health centers, we identified 97 premenopausal women aged 18-49 years old presenting with acromegaly. Data were collected regarding pelvic sonography and reproductive history, including the diagnosis of PCOS. Patients carrying the diagnosis of PCOS before their diagnosis of acromegaly were identified and the remaining patients were screened using the Rotterdam criteria to identify additional patients meeting the criteria for PCOS prior to their diagnosis of acromegaly. RESULTS: Mean age of the population (n = 97) at the time of diagnosis of acromegaly was 33.4 ± 7.5 years (SD). Thirty-three percent of patients (n = 32) either carried a diagnosis of PCOS or met diagnostic criteria for PCOS before their diagnosis of acromegaly. In the subset of patients in whom data on symptom onset were available, those who met criteria for PCOS were diagnosed with acromegaly a median of 5 years [4, 9] after the onset of symptoms compared to 2 years [0.92, 3] (p = 0.006) in the patients who did not meet criteria for PCOS. CONCLUSIONS: Our data demonstrate a high prevalence of signs and symptoms of PCOS in reproductive-aged women with acromegaly and a longer time to diagnosis in women who meet the clinical criteria for PCOS. As screening for acromegaly is relatively simple and done with measurement of a random, non-fasting IGF-1 level that can be drawn at any time during the menstrual cycle, screening patients with PCOS for acromegaly may lessen the delay in diagnosis for reproductive-aged women with this disease.

Presentation and treatment of aggressive, Triple-Negative carcinosarcoma of the breast.

An extremely rare form of breast cancer, breast carcinosarcoma accounts for less than a percent of all breast malignancies and is highly aggressive. Composed of both cancerous epithelial and mesenchymal cell types, breast carcinosarcoma is associated with a poor prognosis compared to more common breast cancers, and typically lack the receptors typical of other breast carcinomas, which minimize potential targets for treatment. In this case report, we discuss a 56-year-old patient affected by carcinosarcoma of the breast at a T2N1 stage, and the decision-making process that factored into her treatment plan.

Assessing the Relationship between Socioeconomic Status, Race, and Psychological Distress in Cancer Survivors: A Population Based Study.

Psychological distress is more common in cancer survivors than the general population, and is associated with adverse outcomes. This cross-sectional study aimed to assess the relationship between socioeconomic status (SES), race and psychological distress, using data from a nationally representative sample of cancer survivors in the United States. Outcomes of interest were mild, moderate, and severe psychological distress as assessed by the Patient Health Questionnaire-4 (PHQ-4). In our univariate model, there was no statistically significant difference in the PHQ-4 scores of Caucasian and African American respondents. On the other hand, a lower SES correlated with a higher likelihood of psychological distress, and this persisted in our multivariate model. This study brings additional awareness to the negative impact of a lower socioeconomic status on mental health outcomes in cancer survivors, and further highlights the importance of the timely identification and screening of individuals at a high risk of psychological distress, in order to limit missed opportunities for relevant mental health interventions in this population.

Trends in HPV and HPV Vaccine Awareness among Gay and Bisexual Males in the U.S.

Human papillomavirus (HPV) is the most common sexually transmitted infection in the United States (US). It is often discussed within the context of women's sexual health due to its association with cervical cancer. However, HPV is also associated with other cancers and conditions which affect men. Gay and bisexual males (GBM) in the US have higher risks of HPV infection and a higher incidence of HPV-associated anal cancer than heterosexual males. In addition, GBM in the US have a higher prevalence of some high-risk strains of HPV than in other regions. HPV vaccination is highly effective at preventing HPV-associated cancers and genital warts. Several resources have been directed towards improving HPV awareness in the US over the past couple of years to improve vaccination rates. Given the low rates of HPV vaccination among GBM in the US, this study aimed to assess the trends in HPV and HPV vaccine awareness using a nationally representative sample of GBM. We found an overall increase in HPV and HPV vaccine awareness between 2017 and 2020. However, the sociodemographic differences in awareness levels highlight the need for more interventions to improve vaccination rates, especially in this high-risk population.

Radiation Recall Dermatitis following Radioactive Iodine Therapy: A New Observation.

A 47-year-old female, who had previously received adjuvant right breast radiation for ductal carcinoma in situ, presented with right breast edema, erythema, and pain. This developed about two and a half weeks following radioactive iodine therapy for thyroid carcinoma. A biopsy was performed to rule out malignancy, since inflammatory breast cancer can present with similar symptoms. This confirmed radiation recall dermatitis (RRD) as the most likely diagnosis. RRD is an inflammatory reaction occurring in a previously irradiated field and was first described in 1959. Subsequent reports in the literature have associated it with the administration of other drugs, mostly chemotherapy. To our knowledge, this is the first reported case of RRD following radioactive iodine therapy.

More Helmets Fewer Deaths: Motorcycle Helmet Legislation Impacts Traumatic Brain Injury-Related Mortality in Young Adults.

The aim of our study was to assess the impact of helmet legislations on the incidence and the mortality rate of motorcycle collision (MCC)-related traumatic brain injury (TBI) in young adult trauma patients. A 1-year (2011) retrospective analysis was performed of all patients under 21 years old with trauma-related hospitalization using the Nationwide Inpatient Sample database (representing 20% of all in-patient admissions). Patients with MCC were identified using E-codes. States were classified into three groups based on helmet legislations: universal age helmet legislation, <18 years helmet legislation, and <21 years helmet legislation. Outcome measures were the rates of TBI and mortality. Linear regression analysis was used to assess outcomes among the states. A total of 1,165,150 patients with trauma-related hospitalizations across 29 states were reviewed of which, 587 patients with MCC were included. Ten states had universal age legislation; 13 states had age <18 years legislation, and 6 states had age <21 years legislation. There was a lower incidence in the rate of TBI (P = 0.03) in states with universal helmet legislations compared with states with age-restricted helmet legislation. Universal helmet legislations lowered the rate of MCC-related TBI injures by a factor of 2.15 (ß coefficient: 2.15; 95% confidence interval: 0.91-10.18; P = 0.04). States with age-restricted helmet legislations have a higher rate of traumatic brain injury and mortality compared with states with universal helmet legislations. Establishing universal helmet legislations across the states may provide a potential preventive strategy against traumatic brain injury.

Ratio-based Resuscitation in Trauma Patients with Traumatic Brain Injury: Is There a Similar Effect?

The use of 1:1:1 (packed red blood cells: fresh frozen plasma: platelets) transfusion ratio has been shown to improve survival in severely injured trauma patients. The aim of this study was to assess the outcomes in patients with traumatic brain injury (TBI) receiving 1:1:1 ratio-based blood product transfusion (RBT). We hypothesized that RBT improves survival in patients with TBI as only major injury. We performed a 3-year retrospective analysis of all patients with TBI as only major injury presenting to our Level I trauma center. Patients receiving blood transfusion were included. Patients were stratified into two groups: those who received RBT and those who did not receive RBT (No-RBT). The outcome measure was inhospital mortality. Multivariate logistic regression analysis was performed. A total of 189 patients were included of which 29 per cent (n = 55) received RBT. The mean age was 48 ± 24 years, median (range) Glasgow Coma Scale score was 12 (3-15), and median head abbreviated injury severity scale was 3 (3-5). The overall mortality rate was 28.5 per cent. Patients in the RBT group had a higher survival rate compared with the patients in the No-RBT group (83.6% vs 66.5%, P = 0.02). In conclusion, the survival benefit of RBT exists even in patients with TBI as major injury. Guidelines for the initial management of TBI patients should focus on the use of RBT. The beneficial effect of platelets in RBT among TBI patients requires further evaluation.

Emergency General Surgery in the Elderly: Too Old or Too Frail?

BACKGROUND: Assessment of operative risk in geriatric patients undergoing emergency general surgery (EGS) is challenging. Frailty is an established measure for risk assessment in elective surgical cases. Emerging literature suggests the superiority of frailty measurements to chronological age in predicting outcomes. The aim of this study was to assess the outcomes in elderly patients undergoing EGS using an established Rockwood frailty index. STUDY DESIGN: We prospectively measured preadmission frailty in all geriatric (aged 65 years and older) patients undergoing EGS at our institution during a 2-year period. Frailty index (FI) was calculated using the modified 50-variable Rockwood Preadmission FI. Frail patients were defined by FI ≥ 0.25. Outcomes measures were in-hospital complications, development of major complications, and mortality. Multivariate regression analysis was performed. RESULTS: A total of 220 patients were enrolled, of which 82 (37%) were frail. Frailty index score did not correlate with age (R = 0.64; R(2) = 0.53; p = 0.1) and poorly correlated with American Society of Anesthesiologists score (R = 0.51; R(2) = 0.44; p = 0.045). Thirty-five percent (n = 77) of patients had postoperative complications and 19% (n = 42) had major complications. Frailty index was an independent predictor for development of in-hospital complications (odds ratio = 2.13; 95% CI, 1.09-4.16; p = 0.02) and major complications (odds ratio = 3.87; 95% CI, 1.69-8.84; p = 0.001). Age and American Society of Anesthesiologists score were not predictive of postoperative and major complications. Our FI model had 80% sensitivity, 72% specificity, and area under the curve of 0.75 in predicting complications in geriatric patients undergoing EGS. The overall mortality rate was 3.2% (n = 7) and all patients who died were frail. CONCLUSIONS: Frailty index independently predicts postoperative complications, major complications, and hospital length of stay in elderly patients undergoing emergency general surgery. Use of FI will provide insight into the hospital course of elderly patients, allowing for identification of patients in need and more efficient allocation of hospital resources.

Early feeds not force feeds: Enteral nutrition in traumatic brain injury.

BACKGROUND: Brain Trauma Foundation guidelines recommend the early use of enteral nutrition to optimize recovery following traumatic brain injury (TBI). Our aim was to examine the effect of early feeds (≤24 hours) on clinical outcomes after TBI. METHODS: We performed a 3-year retrospective study of patients with severe TBI (Glasgow Coma Scale score <8) who were intubated, admitted to the intensive care unit (ICU), and received tube feeds. Early tube feeds (early TF) were defined as initiation of tube feeds within 24 hours, whereas late tube feeds (late TF) were defined as initiation of tube feeds after 24 hours. Outcome measures included pneumonia rates, days on ventilator, hospital and ICU stay, and mortality rates. RESULTS: A total of 90 patients (early TF: 58, late TF: 32) were included, of which 73.3% were male, mean age was 42 (SD, 20) years, and median head Abbreviated Injury Scale score was 4 (range, 3-5). There was no difference in age (p = 0.1), head Abbreviated Injury Scale score (p = 0.5), or admission Glasgow Coma Scale score (p = 0.9) between the two groups. Patients with early TF were associated with higher number of ICU days (p = 0.03) and higher pneumonia rates (p = 0.04), but there was no significant difference in mortality (p = 0.44) as compared with those who underwent late TF. CONCLUSIONS: Although early tube feeds are known to improve outcomes in TBI patients, our data suggest that early feeds in TBI patients are associated with higher rates of pneumonia and greater hospital resource utilization. LEVEL OF EVIDENCE: Therapeutic study, level IV.

Antibiotics for appendicitis! Not so fast.

BACKGROUND: Emerging literature in acute appendicitis favors the nonoperative management of acute appendicitis. However, the actual use of this practice on a national level is not assessed. The aim of this study was to assess the changing trends in nonoperative management of acute appendicitis and its effects on patient outcomes. METHODS: We did an 8-year (2004-2011) retrospective analysis of the National Inpatient Sample database. We included all inpatients with the diagnosis of acute appendicitis. Patients with a diagnosis of appendiceal abscess or patients who underwent surgery for any other pathology were excluded from the analysis. Jonckheere-Terpstra trend analysis was performed for operative versus nonoperative management and outcomes. RESULTS: A total of 436,400 cases of acute appendicitis were identified. Mean age of the population was 33 ± 19.5 years, and 54.5% were male. There was no significant change in the number of acute appendicitis diagnosed over the study period (p = 0.2). During the study period, nonoperative management of acute appendicitis increased significantly from 4.5% in 2004 to 6% in 2011 (p < 0.001). When compared with operatively managed patients, conservatively managed patients had a significantly longer hospital length of stay (3 [2-6] vs. 2 [1-3] days, p < 0.001), and in-hospital complications (27.8% vs. 7%, p < 0.001). On comparison of open and laparoscopic appendectomy, both had shorter hospital length of stay and rate of in-hospital complications. Overall hospital charges were lower in patients managed conservatively (15,441 [8,070-31,688] vs. 20,062 [13,672-29,928] USD, p < 0.001). CONCLUSIONS: Nonoperative management of appendicitis has increased over time; however, outcomes of nonoperative management did not improve over the study period. A more in-depth analysis of patient and system demographics may reveal this disparity in trends. LEVEL OF EVIDENCE: Epidemiologic/prognostic study, level III.

Disparities in Mangement of Patients with Benign Colorectal Disease: Impact of Urbanization and Specialized Care.

Disparities in the management of patients with various medical conditions are well established. Colorectal diseases continue to remain one of the most common causes for surgical intervention. The aim of this study was to assess disparities (rural versus urban) in the surgical management of patients with noncancerous benign colorectal diseases. We hypothesized that there is no difference among rural versus urban centers (UC) in the surgical management for noncancerous benign colorectal diseases. The national estimates of surgical procedures for benign colorectal diseases from the National Inpatient Sample database 2011 representing 20 per cent of all in-patient admissions were abstracted. Patients undergoing procedures (abscess drainage, hemmoroidectomy, fistulectomy, and bowel resections) were included. Patients with colon cancer and those who underwent emergency surgery were excluded. The population was divided into two groups: urban and rural, based on the location of treatment. Outcome measures were in-hospital complications, mortality, and hospital costs. Subanalysis of UC was preformed: centers with colorectal surgeons and centers without colorectal surgeons. Regression analysis was performed. A total of 20,617 patients who underwent surgical intervention for benign colorectal diseases across 496 (urban: 342, rural: 154) centers, were included. Of the UC, 38.3 per cent centers had colorectal surgeons. Patients managed in UC had lower complication rate (7.6% vs 10.2%, P < 0.001), shorter hospital length of stay (4.7 ± 3.1 vs 5.9 ± 3.6 days, P < 0.001), and higher hospital costs ($56,820 ± $27,691 vs $49,341 ± $2,598, P < 0.001) compared with rural centers. On subanalysis, patients managed in UC with colorectal surgeons had 11 per cent lower incidence of in-hospital complications [odds ratio: 0.89 (95% confidence interval: 0.76-0.94)] and a shorter hospital length of stay [Beta: -0.72 (95% confidence interval: -0.81 to -0.65)] when compared with patients managed in UC without colorectal specialization. Disparities exit in outcomes of the patients with noncancerous benign colorectal diseases managed surgically in urban versus rural centers. Specialized care with colorectal surgeons at UC helps reduce adverse patient outcomes. Steps to provide effective and safe surgical care in a cost-effective manner across rural as well as UC are warranted. LEVEL OF EVIDENCE: Level III, retrospective cohort analysis.