Publications by authors named "Carolyn Mead-Harvey"

14 Publications

  • Page 1 of 1

Use of the Electronic Health Record During Clinical Encounters: An Experience Survey.

Ann Fam Med 2022 Jul-Aug;20(4):312-318

Office of Patient Experience, Mayo Clinic, Phoenix, Arizona.

Purpose: Use of the electronic health record (EHR) during face-to-face clinical encounters affects communication, and prior research has been inconclusive regarding its effect. This survey study assessed health care practitioner use of EHR-specific communication skills and patient and practitioner experiences and attitudes regarding EHR use during clinical encounters.

Methods: For this US-based study, we distributed previously validated surveys to practitioners and adult patients (aged >18 years) at academic primary care practices from July 1, 2018 through August 31, 2018. The electronic practitioner survey was completed first; a paper survey was administered to patients after appointments. Descriptive statistics were calculated, and the Cochran-Armitage test was used to assess for associations between key variables.

Results: The practitioner response was 72.9% (43/59); patient response, 45.2% (452/1,000). Practitioners reported maintaining less eye contact (79.1%), listening less carefully (53.5%), focusing less on patients (65.1%), and visits feeling less personal (62.8%). However, patients reported that practitioners provided sufficient eye contact (96.8%) and listened carefully (97.0%); they disagreed that practitioners focused less on them (86.7%) or that visits felt less personal (87.2%). Patients thought EHR use was positive (91.7%); only one-third of practitioners (37.2%) thought that patients would agree with that statement. Practitioners reported stress, burnout, and a lack of sufficient time for EHR documentation.

Conclusions: A discrepancy existed in this study between patient and practitioner experiences and attitudes about EHR use, which appeared to negatively affect the experience of health care practitioners but not patients. Organizations should adopt formal strategies to improve practitioner experiences with EHR use.
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http://dx.doi.org/10.1370/afm.2826DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9328709PMC
August 2021

An Exploratory Analysis of the "Was It Worth It?" Questionnaire as a Novel Metric to Capture Patient Perceptions of Cancer Treatment.

Value Health 2022 Jul 3;25(7):1081-1086. Epub 2022 Jan 3.

Department of Quantitative Health Sciences, Mayo Clinic, Scottsdale, AZ, USA.

Objectives: Asking "Was it worth it?" (WIWI) potentially captures the patient perception of a treatment's benefit weighed against its harms. This exploratory analysis evaluates the WIWI questionnaire as a metric of patients' perspectives on the worthwhileness of cancer treatment.

Methods: A 3-item WIWI questionnaire was assessed at end of treatment in patients with cancer on the COMET-2 trial (NCT01522443). WIWI items were evaluated to determine their association with quality of life (QOL), treatment duration, end-of-treatment reason, patient-reported adverse events (AEs), and disease response.

Results: A total of 65 patients completed the questionnaire; 40 (62%), 16 (25%), and 9 (14%) patients replied yes, uncertain, and no to "Was it worthwhile for you to receive the cancer treatment given in this study?" (item 1), respectively; 39 (60%), 12 (18%), and 14 (22%) to "If you had to do it over again, would you choose to have this cancer treatment?"; and 40 (62%), 14 (22%), and 11 (17%) to "Would you recommend this cancer treatment to others?" Patients responding yes to item 1 remained on treatment longer than those responding uncertain or no (mean 23.0 vs 11.3 weeks, P<.001). Patients responding uncertain/no to item 1 discontinued treatment because of AEs more frequently than those responding yes (36% vs 7.5%, P=.004) and demonstrated meaningful decline in QOL from baseline (-2.5 vs -0.2 mean change, P<.001). Associations between WIWI responses and most patient-reported AEs or treatment efficacy did not reach statistical significance.

Conclusions: Patients who responded affirmatively on WIWI items remained on therapy longer, were less likely to stop treatment because of AEs, and demonstrated superior QOL. The WIWI may inform clinical practice, oncology research, and value frameworks.
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http://dx.doi.org/10.1016/j.jval.2021.11.1368DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9250647PMC
July 2022

Nonmarinum, Nontuberculous Mycobacterial Infections of the Upper Extremity: A Multi-Institutional Descriptive Report.

J Hand Surg Am 2022 May 27. Epub 2022 May 27.

Division of Infectious Diseases, Mayo Clinic, Phoenix, AZ.

Purpose: We analyzed patient demographic factors involved in the development of nonmarinum, nontuberculous mycobacterial infections (NTMI) involving the upper extremity, and assessed diagnostic and prognostic values of commonly used preoperative laboratory and imaging studies, as well as factors related to recurrence of disease and patient outcomes.

Methods: Patients from 2 academic, tertiary facilities with culture-proven, nonmarinum NTMI involving the upper extremity were reviewed. Patient-related factors and clinical outcomes were extracted. The analysis was based on pathogen identification (rapid- vs slow-growing subspecies) and immune status.

Results: Our 76 patients had a mean age of 59 years, and 65% were male. Forty-eight percent reported an injury, and hands were frequently involved (58%). Forty-one percent were immunosuppressed (19% organ transplant recipients). The mean symptom duration prior to presentation was 203 days. The culture identification took a mean of 33 days, with 25 different species identified (subcategorized as rapid or slow growers). Seventy-seven percent had solitary lesions, with a cutaneous or subcutaneous location most common. Immunosuppressed patients were treated longer with antibiotics (243 vs 155 days in immunocompetent patients) and experienced higher rates of side effects, complications, and recurrence. All patients underwent debridement to control infection, including 4 individuals who required amputations. One-third experienced complications and/or recurrence, regardless of the organism type.

Conclusions: Upper-extremity nonmarinum NTMI is often misdiagnosed, causing management delays. Early consideration in differential diagnoses of chronic, painful swelling, nodular or inflammatory lesions, or septic arthritis is crucial. Tissue biopsy with specimens for histopathology and microbiological analysis (mycobacterial smear, cultures, and broad range polymerase chain reaction) and early involvement with an infectious disease specialist are recommended. Empiric antibiotic therapy is not standard. Debridement and prolonged, directed combination antimicrobial therapy is required; however, adverse reactions are commonly encountered. Type of study/level of evidence Prognostic IV.
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http://dx.doi.org/10.1016/j.jhsa.2022.03.019DOI Listing
May 2022

How Does Orthopaedic Surgeon Gender Representation Vary by Career Stage, Regional Distribution, and Practice Size? A Large-Database Medicare Study.

Clin Orthop Relat Res 2022 Mar 17. Epub 2022 Mar 17.

Department of Orthopaedic Surgery, Mayo Clinic, Phoenix, AZ, USA.

Background: Orthopaedic surgery has the lowest proportion of women surgeons in practice of any specialty in the United States. Preliminary studies suggest that patients who are treated by physicians of the same race, ethnicity, cultural background, or gender feel more comfortable with their care and may have better outcomes. Therefore, understanding the discrepancies in the diversity of the orthopaedic surgeon workforce is crucial to addressing system-wide healthcare inequities.

Questions/purposes: (1) Does a difference exist in gender representation among practicing orthopaedic surgeons across geographic distributions and years in practice? (2) Does a difference exist in gender representation among practicing orthopaedic surgeons with regard to rural-urban setting, group practice size, and years in practice?

Methods: Orthopaedic surgeons serving Medicare patients in 2017 were identified in the Medicare Physician and Other Supplier Public Use File and Physician Compare national databases. This dataset encompasses more than 64% of practicing orthopaedic surgeons, providing a low proportion of missing data compared with other survey techniques. Group practice size, location, and Rural-urban Commuting Area scores were compared across physician gender and years in practice. Linear and logistic regressions modeled gender and outcomes relationships adjusted by years in practice. Least-square means estimates for outcomes were calculated by gender at the median years in practice (19 years) via regression models.

Results: According to the combined Medicare databases used, 5% (1019 of 19,221) of orthopaedic surgeons serving Medicare patients were women; this proportion increased with decreasing years in practice (R2 0.97; p < 0.001). Compared by region, the West region demonstrated the highest proportion of women orthopaedic surgeons overall (7% [259 of 3811]). The Midwest and South regions were below the national mean for proportions of women orthopaedic surgeons, both overall (5% [305 of 6666] and 5% [209 of 4146], respectively) and in the first 5 years of practice (9% [54 of 574] and 9% [74 of 817], respectively). Women worked in larger group practices than men (median [interquartile range] 118 physicians [20 to 636] versus median 56 [12 to 338]; p < 0.001, respectively). Both genders were more likely to practice in an urban setting, and when controlling for years in practice, there was no difference between men and women orthopaedic surgeons practicing in rural or urban settings (respectively, R2 = 0.0004 and 0.07; p = 0.89 and 0.09).

Conclusion: Among orthopaedic surgeons, there is only one woman for every 20 men caring for Medicare patients in the United States. Although gender representation is increasing longitudinally for women, it trails behind other surgical subspecialties substantially. Longitudinal mentoring programs, among other evidenced initiatives, should focus on the more pronounced underrepresentation identified in Midwestern/Southern regions and smaller group practices. Gender-based equity, inclusion, and diversity efforts should focus on recruitment strategies, and further research is needed to study how inclusion and diversity efforts among orthopaedic surgeons improves patient-centered care.

Level Of Evidence: Level III, therapeutic study.
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http://dx.doi.org/10.1097/CORR.0000000000002176DOI Listing
March 2022

Impact of timing of preoperative gabapentin administration on postoperative somnolence.

J Osteopath Med 2022 Feb 22;122(6):303-311. Epub 2022 Feb 22.

Department of Medical and Surgical Gynecology, Mayo Clinic, Phoenix, AZ, USA.

Context: Enhanced Recovery After Surgery (ERAS) is a multimodal protocol aimed to improve quality of postoperative recovery, minimize complications, and optimize overall self-regulation. Preoperative gabapentin decreases postoperative pain but can be associated with prolonged postoperative somnolence and respiratory depression risk. Although it is known that gabapentin affects the postoperative course, it is unclear if the timing of preoperative administration affects this finding.

Objectives: This study aims to assess the optimal preoperative timing for gabapentin administration in patients undergoing gynecologic surgery to minimize postoperative somnolence risk.

Methods: A retrospective cohort study evaluated patients who underwent major gynecologic surgery and received preoperative gabapentin. Patients were grouped based on timing from gabapentin administration to surgical incision (<4 h group vs. ≥4 h group). Preoperative, intraoperative, and postoperative data were abstracted and compared. Univariate associations between the timing of gabapentin administration and the patient and surgical characteristics and outcomes were tested utilizing two-sample equal-variance t-tests, linear model ANOVA, or Fisher's exact tests. Associations between the timing of gabapentin administration and the time until the Richmond Agitation Sedation Scale (RASS) score of 0 were modeled utilizing linear regression, adjusted for age, initial postoperative anesthesia care unit (PACU), RASS score, and postoperative narcotics.

Results: Each group contained 127 patients. Demographics were similar except for age (<4 h group mean=44.2 years; ≥4 h group mean=40.5 years; p=0.021), chronic pain (<4 h group=17.6%; ≥4 h group=43.3%; p<0.001), and surgical indication (<4 h group=pelvic pain [29.1%]; ≥4 h group=pelvic pain [51.2%]; p=0.007). The <4 h group had a similar postoperative narcotic administration (<4 h group mean morphine milligram equivalents [MME]=3.667; ≥4 h group mean MME=4.833; p=0.185). The minutes from surgical closure until the patient received a RASS score of 0 and initial PACU pain score (Visual Analogue Scale [VAS]) were similar. The initial PACU oxygen administration volume, hours from surgical closure until the patient transitioned to room air, and initial PACU respiratory rate were similar. The PACU duration, admission secondary to somnolence, and initial PACU Glasgow Coma Scale (GCS) score showed no difference. Postoperative nausea/vomiting was decreased in the ≥4 h group (<4 h group=24.4%; ≥4 h group=13.4%; p-value=0.036), and urinary retention (<4 h group=14.2%; ≥4 h group=5.5%; p-value=0.033) was decreased in the ≥4 h group.

Conclusions: The timing of gabapentin administration less than or more than 4 h preoperatively in patients 18 years does not significantly affect postoperative somnolence or respiratory depression. Further, it does not have a significant effect on GCS scores or VAS scores.
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http://dx.doi.org/10.1515/jom-2021-0256DOI Listing
February 2022

Symptom burden and quality of life in patients with high-risk essential thrombocythaemia and polycythaemia vera receiving hydroxyurea or pegylated interferon alfa-2a: a post-hoc analysis of the MPN-RC 111 and 112 trials.

Lancet Haematol 2022 Jan;9(1):e38-e48

Mays Cancer Center at UT Health San Antonio MD Anderson, San Antonio, TX, USA.

Background: Patients with essential thrombocythaemia or polycythaemia vera have several symptoms that can worsen their quality of life. We aimed to assess how symptom burden changes over time with cytoreductive therapy.

Methods: We performed a post-hoc analysis of data from MPN-RC 111-a single-arm, open-label, phase 2, multicentre trial at 17 hospitals and cancer centres in Italy and the USA, evaluating the clinical-haematological response to pegylated interferon alfa-2a in patients who were resistant or intolerant to hydroxyurea (NCT01259817)-and MPN-RC 112-a randomised, open-label, phase 3, multicentre trial at 25 hospitals and cancer centres in France, Germany, Israel, Italy, the UK, and the USA, comparing the clinical-haematological response to pegylated interferon alfa-2a versus hydroxyurea in therapy-naive patients with either high-risk essential thrombocythaemia or polycythaemia vera (NCT01258856). Patients completed the Myeloproliferative Neoplasm Symptom Assessment Form (MPN-SAF) and the European Organisation for the Research and Treatment of Cancer Core Quality of Life Questionnaire through 12 months after initiation of treatment as secondary endpoints. In this post-hoc analysis, we examined the association of symptom burden with the clinical-haematological response at 12 months and the effect of baseline symptom burden (ie, high burden [total symptom score ≥20] vs low burden [total symptom score <20]) on subsequent changes in symptoms, estimated via mixed models. A clinically significant improvement in symptom burden was defined as 50% or greater improvement in the MPN-SAF total symptom score from baseline to 12 months in patients with a total symptom score greater than zero at baseline.

Findings: 135 patients were enrolled in MPN-RC 111 between Feb 15, 2012, and Dec 23, 2015, and 168 were enrolled in MPN-RC 112 between Sept 24, 2011, and June 30, 2016. For this analysis, we included data from 114 patients from MPN-RC 111 (64 [56%] with essential thrombocythaemia and 50 [44%] with polycythaemia vera; 56 [49%] were female, and 100 [91%] of 110 were white) and 166 patients from MPN-RC 112 (79 [48%] with essential thrombocythaemia and 87 [52%] with polycythaemia vera; 68 [41%] were female, and 145 [93%] of 156 were white). At 12 months, a clinically significant improvement in symptom burden was reported by 12 (32%) of 38 complete responders and seven (20%) of 35 partial responders treated with pegylated interferon alfa-2a in MPN-RC 111; five (19%) of 27 complete responders and six (18%) of 34 partial responders treated with pegylated interferon alfa-2a in MPN-112; and eight (27%) of 30 complete responders and six (22%) of 27 partial responders treated with hydroxyurea in MPN-112. More complete and partial responders reported a clinically significant improvement than did non-responders (44 [22%] of 191 complete and partial responders vs four [5%] of 76 non-responders; Fisher's exact p=0·0003). Symptom burden improved between 3 and 12 months in patients with high baseline symptom burden, both those treated with pegylated interferon alfa-2a (mean total symptom score change -10·2, 95% CI -13·2 to -7·2) and those treated with hydroxyurea (-6·8, -11·2 to -2·4). However, symptom burden worsened between 3 and 12 months in patients with low baseline symptom burden (patients treated with pegylated interferon alfa-2a: mean total symptom score change 3·2, 95% CI 0·9 to 5·4; patients treated with hydroxyurea: 3·4, 0·6 to 6·2).

Interpretation: Results can inform treatment decisions, including treatment timing and goals in managing essential thrombocythaemia and polycythaemia vera, because measuring symptom burden from the patient perspective is crucial to understanding treatment efficacy and tolerability.

Funding: US National Cancer Institute of the National Institutes of Health, and Roche Genentech.
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http://dx.doi.org/10.1016/S2352-3026(21)00343-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9098160PMC
January 2022

Sex Differences in Objective Measures of Adult Patients Presenting for Pectus Excavatum Repair.

Ann Thorac Surg 2021 Sep 30. Epub 2021 Sep 30.

Department of Cardiothoracic Surgery, Mayo Clinic Arizona, Phoenix, Arizona.

Background: Women have a reported incidence of pectus deformities four to five times less than men. Sex differences have not been well studied.

Methods: A retrospective review was performed of adult patients (aged 18 years or more) who underwent a pectus excavatum repair at Mayo Clinic in Arizona (January 1, 2010, to December 31, 2019).

Results: In total, 776 adults underwent pectus repair, with 30% being women. Women presented older (mean age 35 vs 32 years, P = .007) and more symptomatic. Despite this, women performed better on cardiopulmonary exercise testing (higher maximum oxygen consumption and oxygen pulse). Women had more severe deformities (Haller index 5.9 vs 4.3, P < .001). However, in 609 patients undergoing attempted primary minimally invasive pectus repair, intraoperative fractures/osteotomies occurred equally between men and women, with the majority occurring in patients 30 years of age or more (11.5% for age 30 or more, 1.7% for age less than 30; total 7%). Women were also less likely to require three bars for repair (12% vs 42%, P < .001). Hospital length of stay and postoperative complication rates were not significantly different. Postoperatively, women reported a greater daily intensity of pain, but only on the initial postoperative day did they use significantly more opioids than men. Cardiopulmonary exercise testing of 142 patients undergoing baseline and postoperative evaluation at bar removal showed equal and significant benefits in both sexes.

Conclusions: Women presented for pectus excavatum repair at an older age and with greater symptoms and more severe symptoms. Despite this, women required fewer bars, and there were no significant differences in length of stay or complications. Cardiopulmonary benefits of repair were significant and equal for both women and men.
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http://dx.doi.org/10.1016/j.athoracsur.2021.08.060DOI Listing
September 2021

Vaginal leukocyte counts for predicting sexually transmitted infections in the emergency department.

Am J Emerg Med 2021 Nov 3;49:373-377. Epub 2021 Jul 3.

Biostatistics, Mayo Clinic, Scottsdale, AZ, USA.

Background: The use of vaginal white blood cell (WBC) counts to predict sexually transmitted infections (STIs) in the emergency department (ED) is incompletely characterized.

Objectives: Our objective was to assess the relationship between vaginal wet preparation WBC counts and STIs and to determine whether WBC counts of at least 11 WBCs per high-power field (HPF) could be useful for identifying STIs in women in the ED.

Methods: Female ED patients 18 years or older who were evaluated in a single health system between April 18, 2014, and March 7, 2017, and had a genital wet preparation WBC result were retrospectively examined using univariable and multivariable analysis.

Results: Vaginal wet preparation WBC counts were examined for 17,180 patient encounters. Vaginal WBC counts of at least 11 WBCs/HPF were associated with increased odds of having gonorrhea, chlamydia, or trichomoniasis. When this threshold was used for the diagnosis of each STI, sensitivity ranged from 48.2% to 53.9%, and specificity ranged from 67.2% to 68.8%.

Conclusion: Women with STIs are more likely to have higher vaginal WBC counts. However, higher vaginal wet preparation WBC counts in isolation have limited diagnostic utility for gonorrhea, chlamydia, and trichomoniasis. Incorporation of age, urine leukocyte esterase results, and vaginal WBC counts provided a better predictor of an STI than vaginal WBC counts alone.
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http://dx.doi.org/10.1016/j.ajem.2021.06.070DOI Listing
November 2021

Brain dysfunction and thyroid antibodies: autoimmune diagnosis and misdiagnosis.

Brain Commun 2021 5;3(2):fcaa233. Epub 2021 Jan 5.

Department of Neurology, Mayo Clinic, Rochester, MN, USA.

Hashimoto encephalopathy, also known as steroid-responsive encephalopathy associated with autoimmune thyroiditis, has been defined by sub-acute onset encephalopathy, with elevated thyroid antibodies, and immunotherapy responsiveness, in the absence of specific neural autoantibodies. We aimed to retrospectively review 144 cases referred with suspected Hashimoto encephalopathy over a 13-year period, and to determine the clinical utility of thyroid antibodies in the course of evaluation of those patients. One hundred and forty-four patients (all thyroid antibody positive) were included; 72% were women. Median age of symptom onset was 44.5 years (range, 10-87). After evaluation of Mayo Clinic, 39 patients (27%) were diagnosed with an autoimmune CNS disorder [autoimmune encephalopathy (36), dementia (2) or epilepsy (1)]. Three of those 39 patients had neural-IgGs detected (high glutamic acid decarboxylase-65, α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid receptor-receptor and neural-restricted unclassified antibody), and 36 were seronegative. Diagnoses among the remaining 105 patients (73%) were functional neurological disorder ( = 20), neurodegenerative disorder ( = 18), subjective cognitive complaints ( = 14), chronic pain syndrome ( = 12), primary psychiatric ( = 11), sleep disorder ( = 10), genetic/developmental ( = 8), non-autoimmune seizure disorders ( = 2) and other ( = 10). More patients with autoimmune CNS disorders presented with sub-acute symptom onset ( < 0.001), seizures ( = 0.008), stroke-like episodes ( = 0.007), aphasia ( = 0.04) and ataxia ( = 0.02), and had a prior autoimmune history ( = 0.04). Abnormal brain MRI ( = 0.003), abnormal EEG ( = 0.007) and CSF inflammatory findings ( = 0.002) were also more frequent in the autoimmune CNS patients. Patients with an alternative diagnosis had more depressive symptoms ( = 0.008), anxiety ( = 0.003) and chronic pain ( = 0.002). Thyoperoxidase antibody titre was not different between the groups (median, 312.7 versus 259.4 IU/ml;  = 0.44; normal range, <9 IU/ml). None of the non-autoimmune group and all but three of the CNS autoimmune group (two with insidious dementia presentation, one with seizures only) fulfilled the autoimmune encephalopathy criteria proposed by Graus (A clinical approach to diagnosis of autoimmune encephalitis. 2016; 15: 391-404.) (sensitivity, 92%; specificity, 100%). Among patients who received an immunotherapy trial at our institution and had objective post-treatment evaluations, the 16 responders with autoimmune CNS disorders more frequently had inflammatory CSF, compared to 12 non-responders, all eventually given an alternative diagnosis ( = 0.02). In total, 73% of the patients referred with suspected Hashimoto encephalopathy had an alternative non-immune-mediated diagnosis, and more than half had no evidence of a primary neurological disorder. Thyroid antibody prevalence is high in the general population, and does not support a diagnosis of autoimmune encephalopathy in the absence of objective neurological and CNS-specific immunological abnormalities. Thyroid antibody testing is of little value in the contemporary evaluation and diagnosis of autoimmune encephalopathies.
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http://dx.doi.org/10.1093/braincomms/fcaa233DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8152924PMC
January 2021

Intensive glycemic control in gestational diabetes mellitus: a randomized controlled clinical feasibility trial.

Am J Obstet Gynecol MFM 2019 11 27;1(4):100050. Epub 2019 Sep 27.

Department of Biostatistics and Epidemiology, University of Oklahoma Hudson College of Public Health, Oklahoma City, OK.

Background: Overweight and obese women with gestational diabetes mellitus are at increased risk for adverse perinatal outcomes, and they are also more likely to have suboptimal glycemic control. However, there is a paucity of data evaluating whether lower glycemic targets could improve outcomes.

Objective: To evaluate the feasibility of intensive glycemic control in overweight and obese women with gestational diabetes mellitus.

Materials And Methods: We randomized 60 overweight or obese women with gestational diabetes mellitus, diagnosed between 12 and 32 weeks' gestation to either intensive (fasting <90 mg/dL, 1 hour postprandial <120 mg/dL) or standard (fasting <95 mg/dL, 1 ho postprandial <140 mg/dL) glycemic targets. Maternal glucose was assessed in 2 ways: blinded continuous glucose monitors, worn for 5 days at 2 time points (at 12-32 weeks and again at 32-36 weeks), and self-monitored glucose measurement 4 times per day. All women underwent standardized dietary counseling, and medical therapy was prescribed as needed to achieve glycemic control.

Results: Between December 2015 and December 2017, we randomized 60 women to either intensive (n = 30) or standard (n = 30) glycemic control. Baseline characteristics including maternal age, body mass index, and gestational age at diagnosis were similar between the intensive and standard groups. Medical therapy was more common in women in the intensive group than those in the standard group (83 vs 57%, P = .02). Women in the intensive glycemic control group had lower glucose values as assessed by continuous glucose monitors at including 24-hour mean (-8.1; 95% confidence interval, -12.0 to -4.3 mg/dL; P < .0001) and 1-h postprandial (-11.8; 95% confidence interval, -19.7 to -3.9 mg/dL, P = .004) values. Hypoglycemia <60 mg/dL was uncommon and did not differ between groups.

Conclusion: Intensive glycemic targets can be used in overweight and obese women with minimal hypoglycemia, and this approach results in improved glycemic control when compared to standard glycemic targets. Further studies are needed to determine whether intensive glycemic targets can improve maternal and neonatal outcomes in high-risk women with gestational diabetes mellitus.

Clinical Trial Identifier: NCT02530866; clinicaltrials.gov.
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http://dx.doi.org/10.1016/j.ajogmf.2019.100050DOI Listing
November 2019

Sexually transmitted infections in the emergency department are not associated with holidays or school breaks.

Am J Emerg Med 2021 07 13;45:642-644. Epub 2020 Nov 13.

Department of Emergency Medicine, Mayo Clinic, Jacksonville, FL, United States of America.

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http://dx.doi.org/10.1016/j.ajem.2020.11.020DOI Listing
July 2021

Survival outcomes in patients with cervical cancer treated with open versus robotic radical hysterectomy: Our surgical pathology interrogation.

Gynecol Oncol 2020 11 3;159(2):373-380. Epub 2020 Sep 3.

Department of Medical and Surgical Gynecology, Mayo Clinic, Phoenix, AZ, USA. Electronic address:

Objective: To compare the survival outcomes and surgical radicality between women who underwent open versus robotic radical hysterectomy (RH) for early cervical cancer.

Methods: In this institutional retrospective study, patients with clinical stage IA2- IIA (FIGO 2009) squamous cell, adenocarcinoma and adenosquamous carcinoma of the cervix who underwent either open or robotic RH between 2000 and 2017 were identified. Parametrial width and vaginal length were re-measured from pathology slides. An inverse propensity score weighting model was used to adjust selection bias.

Results: A total of 333 patients were included (181 open, 152 robotic). The median follow-up time was 130 months for the open group and 53 months for the robotic group. There were 31 (17.1%) recurrences in the open and 21 (13.8%) in the robotic group. The 5-year progression-free survival (PFS) for the robotic and open group were 79.0% and 90.5%, respectively (HR 2.37, 95% CI 1.40-4.02). Five-year overall survival (OS) were 85.8% and 95.3%, respectively (HR 3.17, 95% CI 1.76-5.70). The mean parametrial width was similar between the open and robotic groups (2.5 vs 2.4 cm, p = 0.99). Unique recurrences (38.1%, 8/21) were noted in the robotic group: 2 port-site, 4 peritoneal, and 2 carcinomatosis. The time to vaginal recurrence was shorter in the robotic group than the open group (p = 0.001).

Conclusion: Patients who underwent robotic RH had inferior PFS and OS compared to open surgery. Surgical radicality according to pathology measurements was similar between the two approaches.
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http://dx.doi.org/10.1016/j.ygyno.2020.08.031DOI Listing
November 2020

Racial/ethnic differences in patients with anemia and folate deficiency.

Int J Lab Hematol 2020 Aug 16;42(4):403-410. Epub 2020 Apr 16.

Division of Hematology and Medical Oncology, Mayo Clinic Hospital, Phoenix, Arizona.

Objective: To determine the presence of racial/ethnic differences in patients with anemia and serum folate deficiency.

Methods: We performed a retrospective analysis of data from patient samples collected from January 2010 to October 2018. Reference laboratory ranges were determined by Mayo Clinic Reference Laboratories. Race and ethnicity were classified according to National Institutes of Health categories.

Results: The analysis comprised 197 974 samples. Hemoglobin, hematocrit, and SF results were available for 173 337, 173 056, and 129 760 samples, respectively. Of the samples, 46 505 (26.8%) showed anemia, with a higher prevalence among American Indian/Alaskan Natives (AI/AN) 42.9% and African Americans (AA) 47.2% (P < .001). SF deficiency was present in 897 (0.7%), with a higher prevalence among AI/AN (9, [1.4%]) and AA (78, [1.2%]) and a lower prevalence in non-Hispanic whites (NHW) (758, [0.7%]), Hispanics (40, [0.6%]), and Asians (8, [0.3%]). In multivariable analysis, the prevalence of anemia was higher in all non-NHW racial/ethnic groups: AA (OR, 3.67, [95%CI: 3.47-3.88, P < .001]), AI/AN (OR, 3.25, [95%CI: 2.71-3.90, P < .001]), Asians (OR, 1.62, [95%CI: 1.47-1.77, P < .001]), and Hispanics (OR, 1.41, [95%CI: 1.32-1.50, P < .001]). SF deficiency was more common in AA (OR, 1.48, [95%CI: 1.17-1.88, P.001]) and less common in Asians (OR, 0.35, [95%CI: 0.17-0.70, P = .003]), compared with NHW.

Conclusions: We showed significant racial/ethnic differences in anemia and SF deficiency. Differences were observed especially among NHW, AA, and Asians. We believe that these differences may be explained by social determinants of health. More research is needed regarding the causes of these differences and their clinical implications at a population level.
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http://dx.doi.org/10.1111/ijlh.13205DOI Listing
August 2020

Pressing Issues Among Trainees and Early Career Physicians in Headache Medicine: Survey Results From the American Headache Society New Investigator and Trainee Section and International Headache Academy.

Headache 2020 04 7;60(4):745-751. Epub 2020 Feb 7.

Department of Neurology, Mayo Clinic, Scottsdale, AZ, USA.

Objective: We surveyed the American Headache Society (AHS) New Investigators and Trainees Section (NITS), and International Headache Academy (IHA) attendees to better understand what they perceive as the most pressing issues for themselves as new investigators and trainees in the field of headache medicine.

Background: The NITS and IHA are intended as platforms for mentorship, leadership training, and professional development in the field of headache medicine. Identifying and addressing pressing issues among new investigators and trainees based on their perceived needs is critical to encouraging their development and success as headache medicine clinicians and researchers.

Methods: Paper surveys were administered at the NITS meeting at the November 2018 Scottsdale Headache Symposium and the January 2019 IHA. Additionally an online version was sent to the NIT listserv in November of 2018. The survey queried demographic information (gender, race, age, profession, training status, and years in practice) and asked participants to identify their top 3 most pressing issues/questions among a list of options.

Results: Fifty-three responses were submitted (53/255; total response rate 20.7%). Among the surveys, 18 in-person responses were from the NITS meeting (18/20; response rate 90.0%), 23 in-person responses were from the IHA (23/45; response rate 51.1%), and 12 responses were from the online survey (12/190; response rate 6.3%). No duplicate responses were submitted based on comparison of demographics. One respondent identified as a researcher exclusively and was excluded from further analyses; the rest identified as clinicians at various levels of medical training. Fifteen respondents were not members of the NITS (28.8%); the most common reason for nonmembership was lack of awareness of the section (92.8%). Overall the most pressing issues/questions included (% of respondents who ranked issue/question among top 3): Career planning (51.9%), Logistics of running a headache clinic (40.4%), and Opportunities for involvement (38.5%). Most pressing issues/questions differed depending on level of training. Working with industry was the most pressing issue/question identified by early career physicians (55.0%). Career planning was the most pressing issue/question among fellows (72.2%) and residents (64.3%).

Conclusion: Many of the most pressing issues identified by respondents are topics that are not formally addressed in medical and research training.
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http://dx.doi.org/10.1111/head.13764DOI Listing
April 2020
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