Publications by authors named "Neel Shah"

197 Publications

Racial/Ethnic Inequities in Pregnancy-Related Social Support: Design Workshops With Community-Based Organizations in Greater Boston.

J Public Health Manag Pract 2022 Jan-Feb 01;28(Suppl 1):S66-S69

Ariadne Labs, Boston, Massachusetts (Drs Molina, Graham, and Shah and Mss DiMeo and Galvin); Department of Obstetrics & Gynecology, Beth Israel Deaconess Medical Center, Boston, Massachusetts (Drs Molina and Shah); and Women & Health Initiative, Harvard T. H. Chan School of Public Health, Boston, Massachusetts (Dr Langer).

Community-based organizations are uniquely positioned to address critical gaps in social support that contribute to inequities in maternal health. Using a human-centered design process, we held 3 design workshops with members of 15 organizations in Greater Boston, including community-based organizations, allied hospital systems, and public health departments, to assess proposed solutions for gaps in social support services during pregnancy and the first year after childbirth. The workshops focused on solutions to problems that emerged from a mixed-methods research study with community-based organizations that provide social support services; workshop attendees explored facilitators and barriers to implementing solutions. Key considerations included colocation of solutions, shared ownership of program and client data, decision making about triage and referrals, and strengthening coordination of existing programs. Collaborative design workshops surfaced potential solutions to improve coordination of services, which require addressing structural and interpersonal racism in Greater Boston.
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http://dx.doi.org/10.1097/PHH.0000000000001438DOI Listing
November 2021

Variation in guideline-based prenatal care in a commercially insured population.

Am J Obstet Gynecol 2021 Oct 3. Epub 2021 Oct 3.

Delivery Decisions Initiative, Ariadne Labs, Boston, MA; Beth Israel Deaconess Medical Center, Boston, MA; OptumLabs Visiting Fellow, Cambridge, MA; Maven Clinic, New York, NY.

Background: Despite the importance of prenatal care, quality measurement efforts have focused on the number of prenatal visits, or prenatal care adequacy, rather than the services received. It is unknown whether attending more prenatal visits is associated with receiving more guideline-based prenatal care services. The relationship between guideline-based prenatal care and patients' clinical and sociodemographic characteristics has also not been studied.

Objective: This study aimed to measure the receipt of guideline-based prenatal care among pregnant patients and to describe the association between guideline-based prenatal care and the number of prenatal visits and other patient characteristics.

Study Design: This was a retrospective descriptive cohort study of 176,092 pregnancy episodes between 2016 and 2019. We used de-identified administrative claims data on commercial enrollees across the United States from the OptumLabs Data Warehouse. We identified the following 8 components of prenatal care that are universally recommended by the American College of Obstetricians and Gynecologists and other guideline-issuing organizations: testing for sexually transmitted infections, obstetric laboratory test panel, urine culture, urinalysis, anatomy scan ultrasound, oral glucose tolerance test, tetanus, diphtheria, and pertussis vaccine, and group B Streptococcus test. We measured the proportion of pregnant patients who received each of these guideline-based services at the appropriate gestational age. We measured the association between guideline-based services and the number of prenatal visits and prenatal care adequacy. We described variation of guideline-based care according to patient age, comorbidities, high deductible health plan enrollment, and their county's rurality, health professional shortage area status, racial composition, median income, and educational attainment.

Results: The 176,092 pregnancy episodes were mostly among patients aged 25 to 34 years (63%) with few pregnancy comorbidities (81%) and living in urban areas (92%). Guideline-based care varied by service, from 51% receiving a timely urinalysis to 90% receiving an anatomy scan and 91% completing testing for sexually transmitted infections. Patients with at least 4 prenatal visits received, on average, 6 of the 8 guideline-based services. Guideline-based care did not increase with additional prenatal visits and varied by patient characteristics. Rates of tetanus, diphtheria, and pertussis vaccination were lower in counties with high proportions of minoritized populations, lower education, and lower income.

Conclusion: In this commercially insured population, receipt of guideline-based care was not universal, did not increase with the number of prenatal visits, and varied by patient- and area-level characteristics. Measuring guideline-based care is feasible and may capture quality of prenatal care better than visit count or adequacy alone.
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http://dx.doi.org/10.1016/j.ajog.2021.09.038DOI Listing
October 2021

Differences in the dynamics of the tandem-SH2 modules of the Syk and ZAP-70 tyrosine kinases.

Protein Sci 2021 Dec 23;30(12):2373-2384. Epub 2021 Oct 23.

Department of Chemistry, University of California, Berkeley, California, USA.

The catalytic activity of Syk-family tyrosine kinases is regulated by a tandem Src homology 2 module (tSH2 module). In the autoinhibited state, this module adopts a conformation that stabilizes an inactive conformation of the kinase domain. The binding of the tSH2 module to phosphorylated immunoreceptor tyrosine-based activation motifs necessitates a conformational change, thereby relieving kinase inhibition and promoting activation. We determined the crystal structure of the isolated tSH2 module of Syk and find, in contrast to ZAP-70, that its conformation more closely resembles that of the peptide-bound state, rather than the autoinhibited state. Hydrogen-deuterium exchange by mass spectrometry, as well as molecular dynamics simulations, reveal that the dynamics of the tSH2 modules of Syk and ZAP-70 differ, with most of these differences occurring in the C-terminal SH2 domain. Our data suggest that the conformational landscapes of the tSH2 modules in Syk and ZAP-70 have been tuned differently, such that the autoinhibited conformation of the Syk tSH2 module is less stable. This feature of Syk likely contributes to its ability to more readily escape autoinhibition when compared to ZAP-70, consistent with tighter control of downstream signaling pathways in T cells.
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http://dx.doi.org/10.1002/pro.4199DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8605373PMC
December 2021

Subtype heterogeneity and epigenetic convergence in neuroendocrine prostate cancer.

Nat Commun 2021 10 1;12(1):5775. Epub 2021 Oct 1.

Massachusetts General Hospital Cancer Center, Boston, MA, USA.

Neuroendocrine carcinomas (NEC) are tumors expressing markers of neuronal differentiation that can arise at different anatomic sites but have strong histological and clinical similarities. Here we report the chromatin landscapes of a range of human NECs and show convergence to the activation of a common epigenetic program. With a particular focus on treatment emergent neuroendocrine prostate cancer (NEPC), we analyze cell lines, patient-derived xenograft (PDX) models and human clinical samples to show the existence of two distinct NEPC subtypes based on the expression of the neuronal transcription factors ASCL1 and NEUROD1. While in cell lines and PDX models these subtypes are mutually exclusive, single-cell analysis of human clinical samples exhibits a more complex tumor structure with subtypes coexisting as separate sub-populations within the same tumor. These tumor sub-populations differ genetically and epigenetically contributing to intra- and inter-tumoral heterogeneity in human metastases. Overall, our results provide a deeper understanding of the shared clinicopathological characteristics shown by NECs. Furthermore, the intratumoral heterogeneity of human NEPCs suggests the requirement of simultaneous targeting of coexisting tumor populations as a therapeutic strategy.
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http://dx.doi.org/10.1038/s41467-021-26042-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8486778PMC
October 2021

Reversible Cerebral Vasoconstriction Syndrome in Patients with Coronavirus Disease: A Multicenter Case Series.

J Stroke Cerebrovasc Dis 2021 Dec 17;30(12):106118. Epub 2021 Sep 17.

Departments of Neurology, Boston University School of Medicine and Boston Medical Center, United States; Departments of Neurosurgery, Boston University School of Medicine and Boston Medical Center, United States; Departments of Medicine Infectious Diseases, Boston University School of Medicine and Boston Medical Center, United States. Electronic address:

Background And Objectives: RCVS (Reversible Cerebral Vasoconstrictive Syndrome) is a condition associated with vasoactive agents that alter endothelial function. There is growing evidence that endothelial inflammation contributes to cerebrovascular disease in patients with coronavirus disease 2019 (COVID-19). In our study, we describe the clinical features, risk factors, and outcomes of RCVS in a multicenter case series of patients with COVID-19.

Materials And Methods: Multicenter retrospective case series. We collected clinical characteristics, imaging, and outcomes of patients with RCVS and COVID-19 identified at each participating site.

Results: Ten patients were identified, 7 women, ages 21 - 62 years. Risk factors included use of vasoconstrictive agents in 7 and history of migraine in 2. Presenting symptoms included thunderclap headache in 5 patients with recurrent headaches in 4. Eight were hypertensive on arrival to the hospital. Symptoms of COVID-19 included fever in 2, respiratory symptoms in 8, and gastrointestinal symptoms in 1. One patient did not have systemic COVID-19 symptoms. MRI showed subarachnoid hemorrhage in 3 cases, intraparenchymal hemorrhage in 2, acute ischemic stroke in 4, FLAIR hyperintensities in 2, and no abnormalities in 1 case. Neurovascular imaging showed focal segment irregularity and narrowing concerning for vasospasm of the left MCA in 4 cases and diffuse, multifocal narrowing of the intracranial vasculature in 6 cases. Outcomes varied, with 2 deaths, 2 remaining in the ICU, and 6 surviving to discharge with modified Rankin scale (mRS) scores of 0 (n=3), 2 (n=2), and 3 (n=1).

Conclusions: Our series suggests that patients with COVID-19 may be at risk for RCVS, particularly in the setting of additional risk factors such as exposure to vasoactive agents. There was variability in the symptoms and severity of COVID-19, clinical characteristics, abnormalities on imaging, and mRS scores. However, a larger study is needed to validate a causal relationship between RCVS and COVID-19.
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http://dx.doi.org/10.1016/j.jstrokecerebrovasdis.2021.106118DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8445803PMC
December 2021

Comparing Methods of Identifying Outlying Nurses in Audits of Low-Risk Cesarean Delivery Rates.

J Nurs Care Qual 2021 Aug 24. Epub 2021 Aug 24.

Connell School of Nursing, Boston College, Chestnut Hill, Massachusetts (Dr Edmonds); Science and Technology, Ariadne Labs, Boston, Massachusetts (Mr Woodbury and Drs Lipsitz, Weiseth, and Shah); Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, and the Department of Obstetrics, Gynecology and Reproductive Biology, Harvard Medical School, Boston, Massachusetts (Dr Farrell); Division of Maternal Fetal Medicine (Dr Gregory), Department of Obstetrics and Gynecology, Cedars-Sinai Medical Center, Los Angeles, California (Dr Greene).

Background: The low-risk cesarean delivery (CD) rate is an established performance indicator for providers in maternity care for quality improvement purposes.

Purpose: Our objectives were to assess nurse performance using adjusted nurse-level CD rates and to compare methods of identifying nurse outliers.

Methods: We conducted a retrospective, cohort study of 6970 births attended by 181 registered nurses in one hospital's maternity unit. Adjusted and unadjusted nurse-level CD rates were compared and agreement between 3 definitions (statistical, top decile, over a benchmark) of outliers calculated.

Results: Adjusted nurse-level CD rates varied from 5.5% to 53.2%, and the unadjusted rates varied from 5% to 50%. Risk adjustment had little impact on the ranking of nurses, and outliers were consistently identified by 3 definitions.

Conclusions: Trade-offs between statistical certainty and feasibility need to be considered when classifying nurse outliers. Findings can help target interventions to improve nurse performance.
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http://dx.doi.org/10.1097/NCQ.0000000000000588DOI Listing
August 2021

Patterns of Use of a Price Transparency Tool for Childbirth Among Pregnant Individuals With Commercial Insurance.

JAMA Netw Open 2021 Aug 2;4(8):e2121410. Epub 2021 Aug 2.

Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts.

Importance: When introduced a decade ago, patient-facing price transparency tools had low use rates and were largely not associated with changes in spending. Little is known about how such tools are used by pregnant individuals in anticipation of childbirth, a shoppable service with increasing out-of-pocket spending.

Objective: To measure changes over time in the patterns and characteristics of use of a price transparency tool by pregnant individuals, and to identify the association between price transparency tool use, coinsurance, and childbirth spending.

Design, Setting, And Participants: This descriptive cross-sectional study of 2 cohorts used data from a US commercial health insurance company that launched a web-based price transparency tool in 2010. Data on all price transparency tool queries for 2 periods (January 1, 2011, to December 31, 2012, and January 1, 2015, to December 31, 2016) were obtained. The sample included enrollees aged 19 to 45 years who had a delivery episode during 2 periods (November 1, 2011, to December 31, 2012, or November 1, 2015, to December 31, 2016) and were continuously enrolled for the 10 months prior to delivery (N = 253 606).

Exposures: Access to a web-based price transparency tool that provided individualized out-of-pocket price estimates for vaginal and cesarean deliveries.

Main Outcomes And Measures: The primary outcomes were searches on the price transparency tool by delivery mode (vaginal or cesarean), timing (first, second, or third trimester), and individual characteristics (age at childbirth, rurality, pregnancy risk status, coinsurance exposure, area educational attainment, and area median household income). Another outcome was the association of out-of-pocket childbirth spending with price transparency tool use.

Results: The sample included 253 606 pregnant individuals, of whom 131 224 (51.7%) were in the 2011 to 2012 cohort and 122 382 (48.3%) were in the 2015 to 2016 cohort. In the 2015 to 2016 cohort, the mean (SD) age was 31 years (5.2 years) and most individuals had coinsurance for delivery (94 251 [77.0%]). Price searching increased from 5.9% in the 2011 to 2012 cohort to 13.0% in the 2015 to 2016 cohort. In the 2015 to 2016 cohort, 43.9% of searchers' first price query was in their first trimester. The adjusted probability of searching was lower for individuals with a high-risk pregnancy due to a previous cesarean delivery (11.5%; 95% CI, 11.0%-12.1%) vs individuals with low-risk pregnancy (13.4%; 95% CI, 12.9%-14.0%). Use increased monotonically with coinsurance, from 9.2% (95% CI, 8.7%-9.8%) among individuals with no coinsurance to 15.0% (95% CI, 14.4%-15.5%) among individuals with 11% or higher coinsurance. After adjusting for covariates, searching was positively associated with out-of-pocket delivery episode spending. Among patients with 11% coinsurance or higher, early and late searchers spent more out of pocket ($59.57 [95% CI, $33.44-$85.96] and $73.33 [95% CI, $32.04-$115.29], respectively), compared with never searchers.

Conclusions And Relevance: The results of this cross-sectional study indicate that the proportion of pregnant individuals who sought price information before childbirth more than doubled within the first 6 years of availability of a price transparency tool. These findings suggest that price information may help individuals anticipate their out-of-pocket childbirth costs.
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http://dx.doi.org/10.1001/jamanetworkopen.2021.21410DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8374613PMC
August 2021

Extracorporeal Support Prognostication-Time to Move the Goal Posts?

Membranes (Basel) 2021 Jul 15;11(7). Epub 2021 Jul 15.

Division of Pediatric Critical Care, Department of Pediatrics, School of Medicine, Washington University in St. Louis, St. Louis, MO 63130, USA.

Advances in extracorporeal membrane oxygenation (ECMO) technology are associated with expanded indications, increased utilization and improved outcome. There is growing interest in developing ECMO prognostication scores to aid in bedside decision making. To date, the majority of available scores have been limited to mostly registry-based data and with mortality as the main outcome of interest. There continues to be a gap in clinically applicable decision support tools to aid in the timing of ECMO cannulation to improve patients' long-term outcomes. We present a brief review of the commonly available adult and pediatric ECMO prognostication tools, their limitations, and future directions.
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http://dx.doi.org/10.3390/membranes11070537DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8304743PMC
July 2021

Methylprednisolone and 60 Days in Hospital Survival in Coronavirus Disease 2019 Pneumonia.

Crit Care Explor 2021 Jul 19;3(7):e0493. Epub 2021 Jul 19.

Hackensack Meridian School of Medicine, Nutley, NJ.

Objectives: To determine methylprednisolone's dose, duration, and administration from onset of symptoms and association with 60 days in hospital survival of coronavirus disease 2019 pneumonia.

Design: Cohort study.

Setting: Thirteen hospitals in New Jersey, United States during March to June 2020.

Patients: Seven-hundred fifty-nine hospitalized coronavirus disease 2019 patients.

Interventions: We performed a propensity matched cohort study between patients who received methylprednisolone and no methylprednisolone. Patients in the methylprednisolone group were further differentiated into dose (high dose and low dose), duration, and administration from onset of symptoms.

Measurements And Main Results: In the propensity matched sample, 99 out of 380 (26%) in no methylprednisolone, 69 out of 215 (31.9%) in low-dose methylprednisolone, and 74 out of 164 (55.2%) high-dose methylprednisolone expired. Overall median survival for no methylprednisolone (25.0 d), low-dose methylprednisolone (39.0 d), high-dose methylprednisolone (20.0 d), less than or equal to 7 days duration (19.0 d), 7-14 days duration (30.0 d), greater than 14 days duration (44.0 d), onset of symptoms less than or equal to 7 days (20.0 d), and onset of symptoms 7-14 days (27.0 d) were statistically significant (log-rank ≤ 0.001). Multivariate Cox regression showed nursing home residents, coronary artery disease, and invasive mechanical ventilation were independently associated with mortality. Methylprednisolone was associated with reduced mortality compared with no methylprednisolone (hazard ratio, 0.40; 95% CI, 0.27-0.59; < 0.001) but no added benefit with high dose. Low-dose methylprednisolone for 7-14 days was associated with reduced mortality compared with less than or equal to 7 days (hazard ratio, 0.45; 95% CI, 0.22-0.91; = 0.0273), and no additional benefit if greater than 14 days (hazard ratio, 1.27; 95% CI, 0.60-2.69; = 0.5434). Combination therapy with tocilizumab was associated with reduced mortality over monotherapy ( < 0.0116).

Conclusions: Low-dose methylprednisolone was associated with reduced mortality if given greater than 7 days from onset of symptoms, and no additional benefit greater than 14 days. High dose was associated with higher mortality.
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http://dx.doi.org/10.1097/CCE.0000000000000493DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8291358PMC
July 2021

The design of "TeamBirth": A care process to improve communication and teamwork during labor.

Birth 2021 Dec 9;48(4):534-540. Epub 2021 Jul 9.

Guy's and St Thomas' NHS Foundation Trust, London, UK.

Background: Despite evidence that communication and teamwork are critical to patient safety, few care processes have been intentionally designed for this purpose in labor and delivery. The purpose of this project was to design an intrapartum care process that aims to improve communication and teamwork between clinicians and patients.

Methods: We followed the "Double-Diamond" design method with four sequential steps: Discover, Define, Develop, and Deliver. In Discover, we searched professional guidelines and peer-reviewed literature to delineate the challenges to quality of intrapartum care and to uncover options for solutions. In Define, we convened an interdisciplinary group of experts to focus the problem scope and prioritize solution features. In Develop, we created initial prototype solutions. In Deliver, we engaged clinicians and patients in rapid cycle testing to iteratively produce a care process called "TeamBirth" that aims to improve team communication.

Results: We designed TeamBirth, an intrapartum care process composed of brief team meetings ("huddles") between clinicians and patients. Huddles are navigated by a shared planning board placed in the labor and delivery room in view of the patient and their care team. The board promotes transparent and reliable communication and contains four areas to be acknowledged or discussed: (a) the names of the team members, starting with the patient; (b) the patient's preferences; (c) the care plan for the patient, baby, and labor progress; and (d) when the next team huddle is anticipated.

Discussion: We identified an opportunity to improve the safety and dignity of childbirth care through an intrapartum care process that promotes reliable and structured communication and teamwork. Future work should evaluate the acceptability and feasibility of implementation and potential impact on safety and experience of care.
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http://dx.doi.org/10.1111/birt.12566DOI Listing
December 2021

Ensuring Racial Equity in Pregnancy Care During the COVID-19 Pandemic and Beyond.

Matern Child Health J 2021 Jun 28. Epub 2021 Jun 28.

Harvard Medical School, 25 Shattuck Street, Boston, MA, 02115, USA.

Background: The COVID-19 pandemic provoked sweeping changes in practice to care for pregnant and birthing people, and highlighted inequities that threaten to exacerbate racial disparities in maternal outcomes. Moreover, social distancing measures have made it harder for pregnant people to access support.

Assessment: Prioritizing widespread access to COVID-19 testing and vaccination for pregnant people is critical to ensuring they receive safe and equitable care. Transparency in reporting outcomes including race and pregnancy status is key. Expanding telemedicine services to provide mental healthcare and labor support is necessary to maintain access to critical social networks. Additionally, resources must be allocated to pregnant people with complex social needs and are the most vulnerable.

Conclusion: Policy centered on maintaining equity and agency in the care of pregnant people is imperative now and should continue as the standard moving forward to narrow racial disparities in maternal health outcomes.
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http://dx.doi.org/10.1007/s10995-021-03194-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8236566PMC
June 2021

Hemodynamic Profiles of Shock in Patients With COVID-19.

Am J Cardiol 2021 08 26;153:135-139. Epub 2021 May 26.

Heart and Vascular Hospital, Hackensack Meridian Health/Hackensack University Medical Center, Hackensack, New Jersey; Hackensack Meridian School of Medicine, Nutley, New Jersey.

Patients with serious COVID infections develop shock frequently. To characterize the hemodynamic profile of this cohort, 156 patients with COVID pneumonia and shock requiring vasopressors had interpretable echocardiography with measurement of ejection fraction (EF) by Simpson's rule and stroke volume (SV) by Doppler. RV systolic pressure (RVSP) was estimated from the tricuspid regurgitation peak velocity. Patients were divided into groups with low or preserved EF (EF or EF, cutoff ≤45%), and low or normal cardiac index (CI or CI cutoff ≤2.2 L/min/m). Mean age was 67 ± 12.0, EF 59.5 ± 12.9, and CI 2.40 ± 0.86. A minority of patients had depressed EF (EFCI, n = 15, EFCI, n = 8); of those with preserved EF, less than half had low CI (EFCI, n = 55, EFCI, n = 73). Overall hospital mortality was 73%. Mortality was highest in the EFCI group (87%), but the difference between groups was not significant (p = 0.68 by ANOVA). High PEEP correlated with low CI in the EFCI group (r = 0.44, p = 0.04). In conclusion, this study reports the prevalence of shock characterized by EF and CI in patients with COVID-19. COVID-induced shock had a cardiogenic profile (EFCI) in 9.6% of patients, reflecting the impact of COVID-19 on myocardial function. Low CI despite preservation of EF and the correlation with PEEP suggests underfilling of the LV in this subset; these patients might benefit from additional volume. Hemodynamic assessment of COVID patients with shock with definition of subgroups may allow therapy to be tailored to the underlying causes of the hemodynamic abnormalities.
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http://dx.doi.org/10.1016/j.amjcard.2021.05.029DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8149198PMC
August 2021

Exopolysaccharide anchoring creates an extreme resistance to sedimentation.

J Bacteriol 2021 Mar 22. Epub 2021 Mar 22.

Burnett School of Biomedical Sciences, University of Central Florida, Orlando, Florida, USA

By evolving strains of that hyper-resist sedimentation, we discovered an uncharacterized mechanism that bacteria can use to remain in suspension indefinitely without expending energy. This unusual phenotype was traced to the anchoring of long colanic acid polymers (CAP) that project from the cell surface. Although each characterized mutant activated this same mechanism, the genes responsible and the strengths of the phenotypes varied. Mutations in , , operon were sufficient to stimulate sedimentation resistance, while mutations altering the promoter, or provided phenotypic enhancements. The sedimentation resistances changed in response to temperature, growth phase, and carbon source and each mutant exhibited significantly reduced biofilm formation. We discovered that the degree of colony mucoidy exhibited by these mutants was not related to the degree of Rcs pathways activation or to the amount of CAP that was produced; rather, it was related to the fraction of CAP that was shed as a true exopolysaccharide. Therefore, these and other mutations that activate this phenotype are likely to be absent from genetic screens that relied on centrifugation to harvest bacteria. We also found that this anchored CAP form is not linked to LPS cores and may not be attached to the outer membrane.Bacteria can partition in aqueous environments between surface-dwelling, planktonic, sedimentary, and biofilm forms. Residence in each location provides an advantage depending on nutritional and environmental stresses and a community of a single species is often observed to be distributed throughout two or more of these niches. Another adaptive strategy is to produce an extracellular capsule, which provides an environmental shield for the microbe and can allow escape from predators and immune systems. We discovered that bacteria can either shed or stably anchor capsules to dramatically alter their propensity to sediment. The degree to which the bacteria anchor their capsule is controlled by a stress sensing system, suggesting that anchoring may be used as an adaptive response to severe environmental challenges.
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http://dx.doi.org/10.1128/JB.00023-21DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8117528PMC
March 2021

Local insulin application has a dose-dependent effect on lumbar fusion in a rabbit model.

J Tissue Eng Regen Med 2021 05 12;15(5):442-452. Epub 2021 Mar 12.

Department of Orthopaedics, Rutgers-New Jersey Medical School, Newark, NJ, USA.

The purpose of this study was to determine if locally applied insulin has a dose-responsive effect on posterolateral lumbar fusion. Adult male New Zealand White rabbits underwent posterolateral intertransverse spinal fusions (PLFs) at L5-L6 using suboptimal amounts of autograft. Fusion sites were treated with collagen sponge soaked in saline (control, n = 11), or with insulin at low (5 or 10 units, n = 13), mid (20 units, n = 11), and high (40 units, n = 11) doses. Rabbits were euthanized at 6 weeks. The L5-L6 spine segment underwent manual palpation and radiographic evaluation performed by two fellowship trained spine surgeons blinded to treatment. Differences between groups were evaluated by analysis of variance on ranks followed by post-hoc Dunn's tests. Forty-three rabbits were euthanized at the planned 6 weeks endpoint, while three died or were euthanized prior to the endpoint. Radiographic evaluation found bilateral solid fusion in 10%, 31%, 60%, and 60% of the rabbits from the control and low, mid, and high-dose insulin-treated groups, respectively (p < 0.05). As per manual palpation, 7 of 10 rabbits in the mid-dose insulin group were fused as compared to 1 of 10 rabbits in the control group (p < 0.05). This study demonstrates that insulin enhanced the effectiveness of autograft to increase fusion success in the rabbit PLF model. The study indicates that insulin or insulin-mimetic compounds can be used to promote bone regeneration.
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http://dx.doi.org/10.1002/term.3182DOI Listing
May 2021

Understanding the migraine treatment landscape prior to the introduction of calcitonin gene-related peptide inhibitors: Results from the Assessment of TolerabiliTy and Effectiveness in MigrAINe Patients using Preventive Treatment (ATTAIN) study.

Headache 2021 Mar 16;61(3):438-454. Epub 2021 Feb 16.

Albert Einstein College of Medicine and Montefiore Headache Center, Bronx, NY, USA.

Background: Calcitonin gene-related peptide (CGRP) inhibitors were introduced in the United States (US) in 2018. To understand the changing patterns of preventive treatment following the introduction of these new agents, we must first characterize the patterns which preceded their introduction.

Objective: To characterize the burden, unmet need, and treatment patterns in patients with migraine initiating preventive migraine medications before the introduction of CGRP inhibitors in the US.

Methods: Between March 2016 and October 2017, we enrolled episodic (EM) and chronic migraine (CM) patients initiating or changing preventive treatment at primary care or neurology clinic visits in the US, in a real-world observational study using a prospective cohort design. At baseline and monthly thereafter for 6 months, we collected data from study sites and patients on migraine frequency, treatment modifications, migraine impact on functioning, and work productivity for a descriptive analysis of migraine patient experience and treatment patterns.

Results: From the sample of 234 completers, 118 had EM (50.4%) and 116 had CM (49.6%). Mean age at enrollment was 41 years (SD = 12) and mean age at first migraine diagnosis was 22 years (SD = 11). Most participants were females (n = 204/234; 87.2%) and white (n = 178/234; 76.1%). The majority (n = 164/234; 70.1%) had not used preventive migraine treatment in the 5 years prior to enrollment (treatment naïve). At baseline, mean monthly migraine days were 9.6 days (SD = 5.0) for the preventive treatment naïve group and 12.4 days (SD = 7.0) for treatment experienced patients. The majority had severe Migraine Disability Assessment (Grade IV, total score ≥21), including 67.1% (n = 110/164) of the preventive treatment naïve and 77.1% (n = 54/70) of the preventive treatment experienced patients. Headache Impact Test total scores indicating severe impairment (score >59) occurred in 88.4% (n = 145/164) of the treatment naïve and 88.6% (n = 62/70) of treatment experienced patients. Mean work productivity loss as measured by the Work Productivity and Activity Impairment questionnaire in the subsample of employed patients was 53.3% loss. The most used acute medications at baseline were nonsteroidal anti-inflammatory agents (n = 124/234; 53.0%), acetaminophen-based products (n = 112/234; 47.9%), and triptans (n = 105/234; 44.9%). The most commonly initiated preventive treatments were topiramate (n = 100/234; 42.7%), tricyclic antidepressants (n = 39/234; 16.7%), beta-blockers (n = 26/234; 11.1%), and onabotulinumtoxinA (n = 24/234; 10.3%). Over the 6-month follow-up period, almost half of patients (n = 116/234, 49.6%) modified their preventive treatment and discontinued treatment (n = 88/312 total modifications; 28.2%) or modified their pattern of use by increasing, decreasing, or skipping doses (n = 224/312 total modifications; 71.8%), often without seeking medical advice. Avoiding side effects was the main reason reported among patients who discontinued (n = 52/88; 59.1%), decreased frequency or dose (n = 37/89; 41.6%), and skipped doses (n = 29/86; 33.7%). Perceived lack of efficacy was another frequent reason reported among those who discontinued (n = 20/88; 22.7%), decreased frequency or dose (n = 15/89; 16.9%), and skipped doses (n = 18/86; 20.9%). Despite initiation of preventive treatment and improvements observed in number of headache and migraine days, migraine patients continued to experience substantial disability, headache impact, and reduced productivity throughout the 6-month follow-up period.

Conclusions: Prior to 2018, the burden of migraine was high for patients initiating preventive treatments. Despite having more than 9 days of migraine per month on average, the majority (70.1%) of patients initiating prevention had been treatment naïve, indicating underuse of preventive treatments. The preventive treatments used in this study were poorly tolerated and were reported by patients to lack efficacy, resulting in suboptimal adherence. The high discontinuation rates suggest that the preventive medications being offered during the period of the study did not meet the treatment needs of patients. In addition, the decisions by about half of patients to alter their prescribed treatment plan without consulting their provider can pose substantial health risks. These findings pertain to the broad set of preventive treatments initiated in this study and do not support inferences about individual preventive treatments, due to limitations in sample size. These findings suggest the need for more effective and better tolerated preventive treatment options.
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http://dx.doi.org/10.1111/head.14053DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8048891PMC
March 2021

Risk Factors, Screening, and Treatment Challenges in Native Septic Arthritis.

Open Forum Infect Dis 2021 Jan 18;8(1):ofaa593. Epub 2020 Dec 18.

Division of Infectious Disease, Department of Internal Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.

Background: is the most common cause of native septic arthritis. Few studies have characterized this disease during the US opioid epidemic. The role of methicillin-resistant (MRSA) nasal screening in this disease has not been elucidated. We sought to identify risk factors and outcomes for native septic arthritis and to evaluate MRSA screening in this disease.

Methods: A retrospective cohort study of native septic arthritis patients (2012-2016) was performed. Demographics, risk factors, and outcomes were compared between and other native septic arthritis infections. Sensitivity, specificity, and predictive values of MRSA screening were assessed.

Results: Two hundred fifteen cases of native septic arthritis were included. s was cultured in 64% (138/215). MRSA was cultured in 23% (50/215). was associated with injection drug use (odds ratio [OR], 4.33; 95% CI, 1.74-10.81; = .002) and switching antibiotics (OR, 3.92; 95% CI, 1.01-21.38; = .032). For every 10-year increase in age, the odds of decreased (OR, 0.72; 95% CI, 0.60-0.87; = .001). For 1-unit increases in Charlson comorbidity index score, the odds of decreased (OR, 0.82; 95% CI, 0.73-0.91; = .0004). MRSA screening during admission demonstrated a sensitivity of 0.59, specificity of 0.96, positive predictive value of 0.85, and negative predictive value of 0.84 for MRSA native septic arthritis.

Conclusions: The opioid epidemic may be contributing to a demographic shift in native septic arthritis to younger, healthier individuals. native septic arthritis has unique risks, including injection drug use. MRSA screening may be useful to rule in MRSA native septic arthritis.
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http://dx.doi.org/10.1093/ofid/ofaa593DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7813160PMC
January 2021

Patient Experience of Obstetric Care During the COVID-19 Pandemic: Preliminary Results From a Recurring National Survey.

J Patient Exp 2020 Oct 6;7(5):653-656. Epub 2020 Oct 6.

Ovia Health, Cambridge Hospital, Cambridge, MA, USA.

The experience of pregnant and postpartum patients continues to evolve during the COVID-19 pandemic. Limited clinical data and the unknown nature of the virus' impact and transmission routes have forced constant changes to traditional care delivery. Dependence on telehealth technology such as telephonic and videoconferencing has surged, and patients' willingness to visit traditional health care facilities has plummeted. We set out to create an ongoing surveillance system to monitor changes to prenatal and obstetric care and the patient experience during the COVID-19 pandemic.
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http://dx.doi.org/10.1177/2374373520964045DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7705828PMC
October 2020

An Atypical Case of Acute Q Fever Presenting with Inflammatory Polyarthritis.

Am J Med 2021 04 19;134(4):e275-e276. Epub 2020 Nov 19.

University of Pittsburgh Medical Center, Pittsburgh, PA.

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http://dx.doi.org/10.1016/j.amjmed.2020.09.062DOI Listing
April 2021

Early Medical Complications and Delayed Discharge after Spinopelvic Fusion: A Comparative Analysis of 887 NSQIP Cases from 2006 to 2016.

Spine Surg Relat Res 2020 31;4(4):314-319. Epub 2020 Mar 31.

Department of Orthopedic Surgery, Montefiore Hospital Medical Center And Albert Einstein College of Medicine, Bronx, New York, USA.

Introduction: The effect of pelvic fixation on postoperative medical complications, blood transfusion, length of hospital stay, and discharge disposition is poorly understood. Determining factors that predispose patients to increased complications after spinopelvic fusion will help surgeons to plan these complex procedures and optimize patients preoperatively.

Methods: We conducted a retrospective cohort study using data from the ACS-NSQIP database between 2006 and 2016 of patients who underwent lumbar fusion with and without spinopelvic fixation. Data regarding demographics, complications, hospital stay, and discharge disposition were collected.

Results: A total of 57,417 (98.5%) cases of lumbar fusion without spinopelvic fixation (LF) and 887 (1.5%) cases of lumbar fusion with spinopelvic fixation (SPF) were analyzed. The transfusion rate in the SPF group was 59.3% vs 13% in the LF group ( < 0.001). The mean length of stay (LOS) and discharge to skilled nursing facility (SNF) were significantly different (LOS: SPF 6.5 days vs LF 3.5 days < 0.001; SNF: SPF 21.3% vs LF 10.4% < 0.001). After controlling for demographic differences, the overall complication rates were not significantly different between the groups ( = 0.531). The odds ratio for transfusion in the SPF group was 2.9 ( < 0.001). The odds ratio for increased LOS and increased care discharge disposition were elevated in the SPF group (LOS OR: 1.3, < 0.012, Discharge disposition OR: 1.8, < 0.001).

Conclusions: Patients who underwent SPF had increased complications, transfusion rate, LOS, and discharge to SNF or subacute rehab facilities as compared with patients who underwent LF. SPF remains an effective technique for achieving lumbosacral arthrodesis. Surgeons should consider the implications of the associated complication profile for SPF and the value of preoperative optimization in a select cohort of patients.
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http://dx.doi.org/10.22603/ssrr.2019-0122DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7661021PMC
March 2020

Biofilms Have a High Tolerance to Antibiotics in Periprosthetic Joint Infection.

Life (Basel) 2020 Oct 24;10(11). Epub 2020 Oct 24.

Arthritis and Arthroplasty Design Group, Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, PA 15260, USA.

Both and are commonly associated with periprosthetic joint infections (PJIs). The treatment of PJI can be challenging because biofilms are assumed to have an increased intolerance to antibiotics. This makes the treatment of PJI challenging from a clinical perspective. Although has been previously demonstrated to have increased biofilm antibiotic tolerance, this has not been well established with . A prospective registry of PJI isolates was developed. The efficacy of clinically relevant antibiotics was quantified against these isolates. planktonic minimum inhibitory concentration (MIC) and minimum bactericidal concentration (MBC) were collected using clinical laboratory standard index (CLSI) assays for eight antibiotics (doxycycline, vancomycin, daptomycin, clindamycin, rifampin, nafcillin, and trimethoprim/sulfamethoxazole). Mature biofilms were grown in vitro, after which minimum biofilm inhibitory concentration (MBIC) and minimum biofilm bactericidal concentration (MBBC) were quantified. Only rifampin and doxycycline had a measurable MBIC across all tested isolates. Based on MBBC, 64% of biofilms could be eliminated by rifampin, whereas only 18% by doxycycline. biofilm was observed to have a high tolerance to antibiotics as compared to planktonic culture. Isolate biofilm antibiotic tolerance varied to a larger degree than was seen in planktonic cultures.
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http://dx.doi.org/10.3390/life10110253DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7693748PMC
October 2020

The COVID-19 Pandemic as a Catalyst for More Integrated Maternity Care.

Am J Public Health 2020 11;110(11):1663-1665

Jochen Profit is with the Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA, and the California Perinatal Quality Care Collaborative, Stanford. Brownsyne Tucker Edmonds is with the Department of Obstetrics and Gynecology, Indiana University School of Medicine, Indianapolis. Neel Shah is with the Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, and Harvard Medical School, Boston, MA. Melissa Cheyney is with the School of Language, Culture and Society, Oregon State University, Corvallis, and the Oregon Maternal Mortality Review Commission, Portland.

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http://dx.doi.org/10.2105/AJPH.2020.305935DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7542276PMC
November 2020

Robots join the care team: Making healthcare decisions safer with machine learning and robotics.

Healthc (Amst) 2020 Dec 6;8(4):100465. Epub 2020 Sep 6.

Harvard Medical School, Boston, MA, USA.

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http://dx.doi.org/10.1016/j.hjdsi.2020.100465DOI Listing
December 2020

Physician and Nurse Practitioner Attitudes on Generic Prescribing of Oral Contraceptive Pills and Antidepressants.

J Gen Intern Med 2020 12 28;35(12):3478-3484. Epub 2020 Sep 28.

Department of Medicine, University of Chicago Medicine, Chicago, IL, USA.

Importance: As prescription drug costs rise, it is important to understand attitudes among primary care physicians and nurse practitioners (NPs) towards generic drugs.

Objective: We aimed to examine the generic skepticism index (GSI) among primary care clinicians, and their willingness to discuss and prescribe generic antidepressants (ADs) and generic oral contraceptives (OCPs).

Design: We used a factorial vignette design survey to test 4 factors: message source, message, brand preference, and drug class. Participants were randomized to different combinations of factors.

Setting: This was a cross-sectional study.

Participants: Physicians registered with the American College of Physicians (ACP) and NPs registered with the American Association of Nurse Practitioners (AANP) participated in the study.

Main Measures: The primary outcomes were generic skepticism as measured using the generic skepticism index (GSI), and clinician willingness to discuss and prescribe generics.

Results: Surveys were completed by 56% of physicians (n = 369/661) and 60% of NPs (n = 493/819). Compared with physicians, NPs were younger (p < 0.001), predominantly female (p < 0.001), and differed in the race (p < 0.001). According to the GSI, 16% (n = 138/862) were identified as generic skeptics (18.5% of NPs and 12.7% of physicians, p = 0.023). Generic skeptics had lower odds of willingness to discuss switching (OR 0.22, 95% CI (0.14-0.35), p < 0.001) or prescribe (OR 0.18, 95% CI (0.11-0.28), p < 0.001) generic OCPs. Participants had lower odds of willingness to prescribe generic drugs to patients with brand preference compared with brand-neutral patients (OR 0.64, 95% CI 0.50-0.82, p < 0.001).

Conclusions And Relevance: Generic skepticism was associated with lower willingness to discuss or prescribe generic drugs. Clinicians reported lower willingness to discuss switching or prescribe generics for OCPs than for ADs. Patient brand preference hindered generic prescribing. Message source and message type were not significantly associated with outcomes.
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http://dx.doi.org/10.1007/s11606-020-06239-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7728859PMC
December 2020

ERG-Mediated Coregulator Complex Formation Maintains Androgen Receptor Signaling in Prostate Cancer.

Cancer Res 2020 11 15;80(21):4612-4619. Epub 2020 Sep 15.

Department of Medical Oncology, Dana-Farber Cancer Institute and Harvard Medical School, Boston, Massachusetts.

The TMPRSS2-ERG fusion is the most common genomic rearrangement in human prostate cancer. However, in established adenocarcinoma, it is unknown how the ERG oncogene promotes a cancerous phenotype and maintains downstream androgen receptor (AR) signaling pathways. In this study, we utilized a murine prostate organoid system to explore the effects of ERG on tumorigenesis and determined the mechanism underlying prostate cancer dependence on ERG. Prostate organoids lacking PTEN and overexpressing ERG () faithfully recapitulated distinct stages of prostate cancer disease progression. In this model, deletion of ERG significantly dampened AR-dependent gene expression. While ERG was able to reprogram the AR cistrome in the process of prostate carcinogenesis, ERG knockout in established prostate cancer organoids did not drastically alter AR binding, H3K27ac enhancer, or open chromatin profiles at these reprogrammed sites. Proteomic analysis of DNA-bound AR complexes demonstrated that ERG deletion causes a loss of recruitment of critical AR coregulators and basal transcriptional machinery, including NCOA3 and RNA polymerase II, but does not alter AR binding itself. Together, these data reveal a novel mechanism of ERG oncogene addiction in prostate cancer, whereby ERG facilitates AR signaling by maintaining coregulator complexes at AR bound sites across the genome. SIGNIFICANCE: These findings exploit murine organoid models to uncover the mechanism of ERG-mediated tumorigenesis and subsequent oncogenic dependencies in prostate cancer.
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http://dx.doi.org/10.1158/0008-5472.CAN-20-2044DOI Listing
November 2020

Risk of chemotherapy-induced febrile neutropenia in patients with metastatic cancer not receiving granulocyte colony-stimulating factor prophylaxis in US clinical practice.

Support Care Cancer 2021 Apr 3;29(4):2179-2186. Epub 2020 Sep 3.

Policy Analysis Inc. (PAI), Four Davis Court, Brookline, MA, 02445, USA.

Objectives: To evaluate the use of granulocyte colony-stimulating factor (G-CSF) prophylaxis in US patients with selected metastatic cancers and chemotherapy-induced febrile neutropenia (FN) incidence and associated outcomes among the subgroup who did not receive prophylaxis.

Methods: This retrospective cohort study was conducted at four US health systems and included adults with metastatic cancer (breast, colorectal, lung, non-Hodgkin lymphoma [NHL]) who received myelosuppressive chemotherapy (2009-2017). Patients were stratified by FN risk level based on risk factors and chemotherapy (low/unclassified risk, intermediate risk without any risk factors, intermediate risk with ≥ 1 risk factor [IR + 1], high risk [HR]). G-CSF use was evaluated among all patients stratified by FN risk, and FN/FN-related outcomes were evaluated among patients who did not receive first-cycle G-CSF prophylaxis.

Results: Among 1457 metastatic cancer patients, 20.5% and 28.1% were classified as HR and IR + 1, respectively. First-cycle G-CSF prophylaxis use was 48.5% among HR patients and 13.9% among IR + 1 patients. In the subgroup not receiving first-cycle G-CSF prophylaxis, FN incidence in cycle 1 was 7.8% for HR patients and 4.8% for IR + 1 patients; during the course, corresponding values were 16.9% and 15.9%. Most (> 90%) FN episodes required hospitalization, and mortality risk ranged from 7.1 to 26.9% across subgroups.

Conclusion: In this retrospective study, the majority of metastatic cancer chemotherapy patients for whom G-CSF prophylaxis is recommended did not receive it; FN incidence in this subgroup was notably high. Patients with elevated FN risk should be carefully identified and managed to ensure appropriate use of supportive care.
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http://dx.doi.org/10.1007/s00520-020-05715-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7892737PMC
April 2021

Variability in cesarean delivery rates among individual labor and delivery nurses compared to physicians at three attribution time points.

Health Serv Res 2021 04 26;56(2):204-213. Epub 2020 Aug 26.

Delivery Decisions Initiative, Ariadne Labs, Boston, Massachusetts, USA.

Objective: To examine the variability in the cesarean delivery (CD) rates of individual labor and delivery nurses compared with physicians at three attribution time points.

Data Sources: Medical record data from nine hospitals in Washington State from January 2016 through September 2018.

Study Design: Retrospective, observational cohort design using an aggregated database of birth records.

Data Collection/extraction Methods: Chart-abstracted clinical data from a subset of nulliparous, term, singleton, vertex births attributed at admission, labor management, and delivery to nurses and physicians. Two classification methods were used to categorize nurse- and physician-level CD rates at three attribution time points and the reliability of these methods compared.

Principal Findings: The sample included 12 556 births, 319 nurses, and 126 physicians. Overall, variation in nurse-level CD rates did not differ significantly across the three attribution time points, and the extent of variation was similar to that observed in physicians. However, agreement between attribution time points varied between 35 percent and 65 percent when classifying individual nurses into the top and bottom deciles. The average reliability of nurse-level CD rates was 32 percent at admission (IQR 22.0 percent to 38.7 percent), 32.6 percent at labor (IQR 23.1 percent to 40.9 percent), and 29.3 percent (IQR 20.9 percent to 35.8 percent) at delivery. The average reliability of physician-level CD rates was higher: 54.2 percent (IQR 38.7 percent to 71.4 percent) at admission, 62.5 percent (IQR 49.0 percent to 79.6 percent) at labor management, and 66.1 percent (IQR 53.7 percent to 81.2 percent) at delivery.

Conclusion: Feedback on nurse-level CD rates as part of routine clinical quality audits can provide insight into nurse performance in the context of other individual-level and unit-level information. To reliably distinguish individual nurse performance, larger sample sizes are needed.
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http://dx.doi.org/10.1111/1475-6773.13546DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7969205PMC
April 2021

Neural Networks to Predict Radiographic Brain Injury in Pediatric Patients Treated with Extracorporeal Membrane Oxygenation.

J Clin Med 2020 Aug 22;9(9). Epub 2020 Aug 22.

Children's Health Dallas, Dallas, TX 75201, USA.

Brain injury is a significant source of morbidity and mortality for pediatric patients treated with Extracorporeal Membrane Oxygenation (ECMO). Our objective was to utilize neural networks to predict radiographic evidence of brain injury in pediatric ECMO-supported patients and identify specific variables that can be explored for future research. Data from 174 ECMO-supported patients were collected up to 24 h prior to, and for the duration of, the ECMO course. Thirty-five variables were collected, including physiological data, markers of end-organ perfusion, acid-base homeostasis, vasoactive infusions, markers of coagulation, and ECMO-machine factors. The primary outcome was the presence of radiologic evidence of moderate to severe brain injury as established by brain CT or MRI. This information was analyzed by a neural network, and results were compared to a logistic regression model as well as clinician judgement. The neural network model was able to predict brain injury with an Area Under the Curve (AUC) of 0.76, 73% sensitivity, and 80% specificity. Logistic regression had 62% sensitivity and 61% specificity. Clinician judgment had 39% sensitivity and 69% specificity. Sequential feature group masking demonstrated a relatively greater contribution of physiological data and minor contribution of coagulation factors to the model's performance. These findings lay the foundation for further areas of research directions.
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http://dx.doi.org/10.3390/jcm9092718DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7565544PMC
August 2020

A Review of Smart Technologies Embedded in Shoes.

J Med Syst 2020 Jul 29;44(9):150. Epub 2020 Jul 29.

K. J. Somaiya College of Engineering, Mumbai, India.

Technological advancements in wearable devices have revolutionized smart shoes. Smart shoes are sometimes referred to as intelligent shoes or computer-based shoes. They are capable of recognizing and recording data from day-to-day activities by the user. Such smart shoes are designed with sensors, vibrating motors, GPS, wireless systems, and various other sensors/actuators for the comfort and benefit of the wearer. In the current manuscript, we are reviewing various technologies that are implemented in smart shoes.
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http://dx.doi.org/10.1007/s10916-020-01613-7DOI Listing
July 2020

Severe anaplasmosis represents a treatable cause of secondary hemophagocytic lymphohistiocytosis: Two cases and review of literature.

Ticks Tick Borne Dis 2020 09 23;11(5):101468. Epub 2020 May 23.

Division of Infectious Disease, University of Pittsburgh School of Medicine, Falk Medical Building, 3601 Fifth Ave., Suite 3A, Pittsburgh, PA, 15213, USA. Electronic address:

Anaplasmosis is an emerging infection in the United States and remains under-recognized in many areas including Pennsylvania. Presenting signs and symptoms are often nonspecific, but fulminant infection can occur in vulnerable populations. We present two cases of severe anaplasmosis that progressed to secondary hemophagocytic lymphohistiocytosis (HLH). This severe immune dysregulation syndrome has an extremely high mortality, but anaplasmosis represents one of the few treatable underlying etiologies. It is imperative for physicians to recognize this complication and start empiric doxycycline, as early treatment improves mortality. We also present a case of anaplasmosis-induced HLH successfully treated with a combination of doxycycline, steroids, and anakinra (an IL-1 receptor antagonist), highlighting that this primarily immune-mediated complication is amenable to treatment with both antibiotics and immune suppression.
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http://dx.doi.org/10.1016/j.ttbdis.2020.101468DOI Listing
September 2020

Reply to Courjon and Del Giudice.

Clin Infect Dis 2021 01;72(1):177-178

Arthritis and Arthroplasty Design Group, the Bone and Joint Center, Magee Womens Hospital of the University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.

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http://dx.doi.org/10.1093/cid/ciaa392DOI Listing
January 2021
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