Publications by authors named "Patrick Ten Eyck"

50 Publications

Geriatric clinical screening tool for cervical spine injury after ground-level falls.

Emerg Med J 2021 Jun 9. Epub 2021 Jun 9.

Department of Surgery, Carver College of Medicine, The University of Iowa, Iowa City, Iowa, USA.

Background: A consistent approach to cervical spine injury (CSI) clearance for patients 65 and older remains a challenge. Clinical clearance algorithms like the National Emergency X-Radiography Utilisation Study (NEXUS) criteria have variable accuracy and the Canadian C-spine rule excludes older patients. Routine CT of the cervical spine is performed to rule out CSI but at an increased cost and low yield. Herein, we aimed to identify predictive clinical variables to selectively screen older patients for CSI.

Methods: The University of Iowa's trauma registry was interrogated to retrospectively identify all patients 65 years and older who presented with trauma from a ground-level fall from January 2012 to July 2017. The relationship between predictive variables (demographics, NEXUS criteria and distracting injuries) and presence of CSI was examined using the generalised linear modelling (GLM) framework. A training set was used to build the statistical models to identify clinical variables that can be used to predict CSI and a validation set was used to assess the reliability and consistency of the model coefficients estimated from the training set.

Results: Overall, 2312 patients ≥65 admitted for ground-level falls were identified; 253 (10.9%) patients had a CSI. Using the GLM framework, the best predictive model for CSI included midline tenderness, focal neurological deficit and signs of trauma to the head/face, with midline tenderness highly predictive of CSI (OR=22.961 (15.178-34.737); p<0.001). The negative predictive value (NPV) for this model was 95.1% (93.9%-96.3%). In the absence of midline tenderness, the best model included focal neurological deficit (OR=2.601 (1.340-5.049); p=0.005) and signs of trauma to the head/face (OR=3.024 (1.898-4.815); p<0.001). The NPV was 94.3% (93.1%-95.5%).

Conclusion: Midline tenderness, focal neurological deficit and signs of trauma to the head/face were significant in this older population. The absence of all three variables indicates lower likelihood of CSI for patients≥65. Future observational studies are warranted to prospectively validate this model.
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http://dx.doi.org/10.1136/emermed-2020-210693DOI Listing
June 2021

Generic Health-Related Quality of Life in Patients Seeking Care for Pelvic Organ Prolapse.

Female Pelvic Med Reconstr Surg 2021 Jun;27(6):337-343

Magee Women's Hospital of the University of Pittsburgh, Magee Women's Research Institute, Pittsburgh, PA.

Objective: Using the American Urogynecologic Society multicenter Pelvic Floor Disorder Registry for Research, we (1) compared generic quality of life (QOL) in women planning pelvic organ prolapse (POP) treatment (surgery vs pessary), (2) correlated generic and condition-specific QOL scores, and (3) identified associations between generic QOL and other factors.

Methods: This cross-sectional analysis assessed generic physical and mental QOL using the Patient-Reported Outcomes Measurement Information System Global Health Scale at baseline. Global Physical and Mental T-scores center on a representative US population sample (mean [SD], 50 [10]; higher scores, better health). Condition-specific QOL was assessed with Pelvic Floor Distress Inventory, Pelvic Floor Impact Questionnaire, and POP/Urinary Incontinence Sexual Function Questionnaire. Linear regression models identified associations between clinical factors and Global Physical/Mental scores.

Results: Five hundred sixty-eight women (419 surgery, 149 pessary) were included. Surgery patients were younger, heavier, and more often sexually active (all P's ≤ 0.01). Global Physical scores were lower in the surgery versus pessary group, but not likely clinically meaningful (mean [SD], 48.8 [8.1] vs 50.4 [8.5]; P = 0.035); Global Mental scores were similar (51.4 [8.4] vs 51.9 [9.5], P = 0.56). Global Health scores correlated with Pelvic Floor Distress Inventory, Pelvic Floor Impact Questionnaire, and POP/Urinary Incontinence Sexual Function Questionnaire scores (all P's < 0.0001). In multivariable models, menopause was associated with better physical QOL, and constipation, coronary artery disease, pelvic pain, and increased body mass index with worse physical QOL. Age was associated with better mental QOL, and constipation, fecal incontinence, pelvic pain, and coronary artery disease with worse mental QOL.

Conclusions: Women choosing POP surgery versus pessary had similar physical and mental generic QOL.
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http://dx.doi.org/10.1097/SPV.0000000000001069DOI Listing
June 2021

Racial And Socioeconomic Differences Affect Outcomes in Elderly Burn Patients.

Burns 2020 Nov 10. Epub 2020 Nov 10.

Acute Care Surgery Division, Department of Surgery, University of Iowa, Iowa City, Iowa, United States.

Background: Race and socioeconomic status influence outcomes for adult and pediatric burn patients, yet the impact of these factors on elderly patients (Medicare eligible, 65 years of age) remains unknown.

Methods: Data pooled from three verified burn centers from 2004 to 2014 were reviewed retrospectively. Age, race, gender, percent total body surface area (%TBSA) burn, mortality, length of stay (LOS), LOS per %TBSA burn, and zip code which provided Census data on race, poverty, and education levels within a community were collected. Data were analyzed using logistic and generalized linear models in SAS version 9.4 (SAS Institute, Cary, NC, USA).

Results: Our population was mainly Caucasian (63%), African American (18%), Hispanic (7.6%), and Asian (3.5%). Mean age was 76.3 ± 8.3 years, 52.5% were male. Mean %TBSA was 9 ± 13.8%; 15% of the patients sustained an inhalation injury. The mortality rate was 14.4%. Inhalation injury was significantly associated with mortality and discharge to a skilled nursing facility (SNF) (p < 0.05). Race was significantly associated with socioeconomic disparities and affected LOS/TBSA, but not discharge to SNF or mortality on univariate analysis. Poverty level, education level, and insurance status (others vs. public) independently predicted SNF discharge, while median income and insurance type independently predicted LOS/TBSA.

Conclusion: In this elderly cohort, race did not predict standard markers of burn outcome (mortality and discharge to SNF). Socioeconomic status independently predicted LOS and discharge to SNF, suggesting a relationship between socioeconomic status and recovery from a burn injury. Better understanding of racial and socioeconomic disparities is necessary to provide equitable treatment of all patients.
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http://dx.doi.org/10.1016/j.burns.2020.10.025DOI Listing
November 2020

Detection of pro angiogenic and inflammatory biomarkers in patients with CKD.

Sci Rep 2021 Apr 22;11(1):8786. Epub 2021 Apr 22.

Renal Division, University of Colorado Anschutz Medical Center, Aurora, CO, 80045, USA.

Cardiovascular disease (CVD) is the most common cause of death in patients with native and post-transplant chronic kidney disease (CKD). To identify new biomarkers of vascular injury and inflammation, we analyzed the proteome of plasma and circulating extracellular vesicles (EVs) in native and post-transplant CKD patients utilizing an aptamer-based assay. Proteins of angiogenesis were significantly higher in native and post-transplant CKD patients versus healthy controls. Ingenuity pathway analysis (IPA) indicated Ephrin receptor signaling, serine biosynthesis, and transforming growth factor-β as the top pathways activated in both CKD groups. Pro-inflammatory proteins were significantly higher only in the EVs of native CKD patients. IPA indicated acute phase response signaling, insulin-like growth factor-1, tumor necrosis factor-α, and interleukin-6 pathway activation. These data indicate that pathways of angiogenesis and inflammation are activated in CKD patients' plasma and EVs, respectively. The pathways common in both native and post-transplant CKD may signal similar mechanisms of CVD.
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http://dx.doi.org/10.1038/s41598-021-87710-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8062467PMC
April 2021

Symptoms of Anxiety, Burnout, and PTSD and the Mitigation Effect of Serologic Testing in Emergency Department Personnel During the COVID-19 Pandemic.

Ann Emerg Med 2021 Feb 5. Epub 2021 Feb 5.

Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, IA.

Study Objective: Among a comprehensive range of frontline emergency department health care personnel, we assessed symptoms of anxiety and burnout, specific coronavirus disease 2019 (COVID-19) work-related stressors, and risk for post-traumatic stress disorder (PTSD). We also determined whether COVID-19 serologic testing of HCP decreased their self-reported anxiety.

Methods: In a prospective cohort study from May 13, 2020, to July 8, 2020, we used electronic surveys to capture participant self-reported symptoms before and after serologic testing for anti-SARS-CoV-2 immunoglobulin G antibodies. Participants were physicians, nurses, advanced practice providers, and nonclinical ED personnel at 20 geographically diverse United States EDs. We evaluated these domains: 1) the effects of the COVID-19 pandemic on overall stress and anxiety; 2) COVID-19-related work stressors; 3) burnout; and 4) PTSD risk (measured using the Primary Care-PTSD Screen for DSM-5, a 5-item screening instrument in which a score of ≥3 signifies high risk for PTSD). We also assessed perceptions of whether results of COVID-19 antibody testing decreased participants' self-reported anxiety.

Results: Of 1,606 participants, 100% and 88% responded to the baseline and follow-up surveys, respectively. At baseline, approximately half (46%) reported symptoms of emotional exhaustion and burnout from their work, and 308 (19.2%, 95% confidence interval [CI] 17.3% to 21.1%) respondents screened positive for increased PTSD risk. Female respondents were more likely than males to screen positive (odds ratio [OR] 2.03, 95% CI 1.49 to 2.78). Common concerns included exposing their family and the health of coworkers diagnosed with COVID-19. After receiving antibody test results, 54% (95% CI 51.8 to 56.7) somewhat agreed, agreed, or strongly agreed that knowledge of their immune status had decreased their anxiety. A positive serology result indicating prior SARS-CoV-2 infection was associated with a higher likelihood of reporting decreased anxiety (2.83, 95% CI 1.37 to 5.83).

Conclusion: Symptoms of anxiety and burnout were prevalent across the spectrum of ED staff during the COVID-19 pandemic. One-fifth of ED personnel appeared to be at risk for PTSD. Increased provision of serologic testing may help to mitigate anxiety.
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http://dx.doi.org/10.1016/j.annemergmed.2021.01.028DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7862892PMC
February 2021

More than the oocyte source, egg donors as patients: a national picture of United States egg donors.

J Assist Reprod Genet 2021 May 1;38(5):1171-1175. Epub 2021 Apr 1.

Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology and Infertility, University of Iowa Carver College of Medicine, 200 Hawkins Drive, Iowa City, IA, 52242, USA.

Purpose: To characterize national oocyte donation practice patterns from the perspective of individual donors rather than of recipients.

Methods: Retrospective cohort including all donor oocyte retrievals and transfers reported to SARTCORS in 2016 and 2017 in the USA. Primary outcomes include characteristics of oocyte donors and of donor oocyte cycles. Secondary outcomes include overall pregnancy rates, elective single embryo transfer (eSET) rates, and perinatal outcomes among donor oocyte recipient transfers.

Results: During the study period, 49,193 donor oocyte retrievals were performed, of which the largest proportion were in the Western US. For all reported retrievals, there were 17,099 unique donors, each of whom underwent an average of 2.4 retrievals (range 1-22). Average donor age was 26.3 years (range 18-48). On average, 24.6 oocytes (SD 12.4) were retrieved each cycle, ranging from 0 to 102. Among 37,657 donor oocyte recipient transfers, 20,159 (53.5%) involved eSET, and 17,725 (47.1%) resulted in live birth. Miscarriage rates were 17.5%, and good perinatal outcome (GPO), defined as full-term normal birthweight delivery, was more likely among singleton (75.7%) than multiple (23.8%) pregnancies.

Conclusion: The average number of retrievals that donors underwent and oocyte yield mirrored national guidelines; however outliers, exist that may unnecessarily increase donor risk. Additionally, among resultant donor transfers, 46.5% transferred more than one embryo despite national recommendations for eSET. The significantly higher likelihood of GPO among singleton pregnancies points to the need to further increase donor recipient eSET rates.
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http://dx.doi.org/10.1007/s10815-021-02178-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8190211PMC
May 2021

The Articulated Oral Airway as an aid to mask ventilation: a prospective, randomized, interventional, non-inferiority study.

BMC Anesthesiol 2021 Mar 29;21(1):94. Epub 2021 Mar 29.

Resident in Anesthesiology, Department of Anesthesia, University of Iowa Carver College of Medicine, Iowa City, IA, USA.

Background: Oropharyngeal airways are used both to facilitate airway patency during mask ventilation as well as conduits for flexible scope intubation, though none excel at both. A novel device, the Articulated Oral Airway (AOA), is designed to facilitate flexible scope intubation by active displacement of the tongue. Whether this active tongue displacement also facilitates mask ventilation, thus adding dual functionality, is unknown. This study compared the AOA to the Guedel Oral Airway (GOA) in regards to efficacy of mask ventilation of patients with factors predictive of difficult mask ventilation. The hypothesis was that the AOA would be non-inferior to the GOA in terms of expiratory tidal volumes by a margin of 1 ml/kg, thus demonstrating dual functionality.

Methods: In this randomized controlled clinical trial, fifty-eight patients with factors predictive of difficult mask ventilation were mask ventilated with both the GOA and the AOA. Video of the anesthetic monitors were evaluated by a blinded member of the research team, noting inspiratory and expiratory tidal volumes and expiratory CO2 waveforms.

Results: The AOA was found to be non-inferior to the GOA at a margin of 1 ml/kg with a mean weight-standardized expiratory tidal measurement 0.45 ml/kg lower (CI: 0.34-0.57) and inspiratory tidal measurement 0.109 lower (CI: - 0.26-0.04). There was no significant difference in expiratory waveforms (p = 0.2639).

Conclusions: The AOA was non-inferior to the GOA for mask ventilation of patients with predictors of difficult mask ventilation and there was no significant difference in EtCO2 waveforms between the groups. These results were consistent in the subset of patients who were initially difficult to mask ventilate.

Trial Registration: ClinicalTrials.gov, NCT03144089 , May 2017.
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http://dx.doi.org/10.1186/s12871-021-01315-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8006343PMC
March 2021

Diagnosed and Undiagnosed COVID-19 in US Emergency Department Health Care Personnel: A Cross-sectional Analysis.

Ann Emerg Med 2020 Dec 17. Epub 2020 Dec 17.

Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, IA; Olive View-UCLA Education and Research Institute, Los Angeles, CA; Department of Emergency Medicine, University of California-Los Angeles Ronald Reagan Medical Center, Los Angeles.

Study Objective: We determine the percentage of diagnosed and undiagnosed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection among a sample of US emergency department (ED) health care personnel before July 2020.

Methods: This was a cross-sectional analysis of ED health care personnel in 20 geographically diverse university-affiliated EDs from May 13, to July 8, 2020, including case counts of prior laboratory-confirmed coronavirus disease 2019 (COVID-19) diagnoses among all ED health care personnel, and then point-in-time serology (with confirmatory testing) and reverse transcriptase-polymerase chain reaction testing in a sample of volunteers without a previous COVID-19 diagnosis. Health care staff were categorized as clinical (physicians, advanced practice providers, and nurses) and nonclinical (clerks, social workers, and case managers). Previously undiagnosed infection was based on positive SARS-CoV-2 serology or reverse transcriptase-polymerase chain reaction result among health care personnel without prior diagnosis.

Results: Diagnosed COVID-19 occurred in 2.8% of health care personnel (193/6,788), and the prevalence was similar for nonclinical and clinical staff (3.8% versus 2.7%; odds ratio 1.5; 95% confidence interval 0.7 to 3.2). Among 1,606 health care personnel without previously diagnosed COVID-19, 29 (1.8%) had evidence of current or past SARS-CoV-2 infection. Most (62%; 18/29) who were seropositive did not think they had been infected, 76% (19/25) recalled COVID-19-compatible symptoms, and 89% (17/19) continued to work while symptomatic. Accounting for both diagnosed and undiagnosed infections, 4.6% (95% confidence interval 2.8% to 7.5%) of ED health care personnel were estimated to have been infected with SARS-CoV-2, with 38% of those infections undiagnosed.

Conclusion: In late spring and early summer 2020, the estimated prevalence of severe acute respiratory syndrome coronavirus 2 infection was 4.6%, and greater than one third of infections were undiagnosed. Undiagnosed SARS-CoV-2 infection may pose substantial risk for transmission to other staff and patients.
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http://dx.doi.org/10.1016/j.annemergmed.2020.12.007DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7746085PMC
December 2020

Palliative care consultation in patients with bacteremia.

Palliat Med 2021 04 24;35(4):785-792. Epub 2021 Mar 24.

Division of Infectious Diseases, Department of Internal Medicine, University of Iowa, Iowa City, IA, USA.

Background: Palliative care consultation has shown benefits across a wide spectrum of diseases, but the utility in patients with bacteremia remains unclear despite its high mortality.

Aim: To examine the frequency of palliative care consultation and factors associated with palliative care consult in bacteremia patients in the United States.

Design: A population-based retrospective analysis using the Nationwide Inpatient Sample database in 2014, compiled by the Healthcare Costs and Utilization Project of the Agency for Healthcare Research and Quality.

Setting/subjects: All inpatients with a discharge diagnosis of bacteremia (ICD-9-CM codes; 038.11 and 038.12).

Measurements: Palliative care consultation was identified using ICD-9-CM code V66.7. Patients' baseline characteristics and outcomes were compared between those with and without palliative care consult.

Results: A total of 111,320 bacteremia admissions were identified in 2014. Palliative care consult was observed in 8140 admissions (7.3%). Palliative care consultation was associated with advanced age, white race, comorbidities, higher income, teaching/urban hospitals, Midwest region, Methicillin-resistant bacteremia and the lack of echocardiogram. Palliative care consult was also associated with shorter but more expensive hospitalizations. Crude mortality was 53% (4314/8140) among admissions with palliative care consult and 8% (8357/10,3180) among those without palliative care consult ( < 0.001).

Conclusions: Palliative care consultation was infrequent during the management of bacteremia, and a substantial number of patients died during their hospitalizations without palliative care consult. Given the reported benefit in other medical conditions, palliative care consultation may have a role in bacteremia. Selecting patients who may benefit the most should be explored.
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http://dx.doi.org/10.1177/0269216321999574DOI Listing
April 2021

International, multicenter retrospective trial comparing the efficacy and safety of bi-flanged versus lumen-apposing metal stents for endoscopic drainage of walled-off pancreatic necrosis.

Ann Gastroenterol 2021 4;34(2):273-281. Epub 2021 Jan 4.

University of Utah, Salt Lake City, UT, USA (Douglas G. Adler).

Background: To compare fully covered bi-flanged metal stents (BFMS) and lumen-apposing metal stents (LAMS) for endoscopic ultrasound (EUS)-guided drainage/debridement of pancreatic walled-off necrosis (WON).

Methods: Patients with WON managed by EUS-guided therapy were divided into those who underwent: 1) drainage using BFMS; and 2) drainage using LAMS and scheduled direct endoscopic necrosectomy (DEN). Clinical success (resolution of the WON), technical success (successful stent placement), and adverse events (AEs) were evaluated.

Results: 387 patients underwent WON endoscopic drainage, 205 using BFMS and 182 using LAMS. The clinical success in the BFMS or LAMS groups were similar (197 [96.1%] vs. 174 [95.6%]; P=0.81). Median number of procedures required for WON resolution was significantly lower in BFMS compared to LAMS (2 vs. 3, P<0.001). Technical success for stent placement was similar in BFMS and LAMS groups (203 [99%] vs. 180 [99%], P=0.90). Procedure-related AEs were similar in the BFMS and LAMS groups (19 [9.3%] vs. 20 [10.9%], P=0.61). Stent dysfunction with occluding debris was higher in the BFMS group compared to LAMS group (21 [10.2 %] vs. 11 [5.9%], P=0.04). The migration rate was higher in the BFMS group than in the LAMS group (15 [7.3%] vs. 3 [1.6%]; P<0.001). DEN was required in 23 [11.2%] patients in the BFMS group after lack of WON resolution by conservative means.

Conclusion: BFMS with a "step-up approach" and LAMS with scheduled DEN are both safe and effective for EUS-guided drainage/debridement of WON.
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http://dx.doi.org/10.20524/aog.2021.0570DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7903561PMC
January 2021

SARS-CoV-2 Infection during Pregnancy in a Rural Midwest All-delivery Cohort and Associated Maternal and Neonatal Outcomes.

Am J Perinatol 2021 05 21;38(6):614-621. Epub 2021 Feb 21.

Department of Obstetrics and Gynecology, University of Iowa, Iowa City, Iowa.

Objective: This study aimed to estimate the prevalence of severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) among pregnant patients at the time of delivery in a rural Midwest tertiary care hospital and to examine demographics, clinical factors, and maternal and neonatal outcomes associated with SARS-CoV-2 infection during pregnancy.

Study Design: This prospective cohort study included all delivering patients between May 1 and September 22, 2020 at the University of Iowa Hospitals and Clinics. Plasma SARS-CoV-2 antibody testing was performed. SARS-CoV-2 viral reverse-transcription polymerase chain reaction (RT-PCR) results and maternal and neonatal outcomes were collected from the electronic medical record. Data were analyzed using univariate statistical methods with clustering for multiple births.

Results: In total, 1,000 patients delivered between May 1 and September 22, 2020. Fifty-eight (5.8%) were SARS-CoV-2 antibody positive. Twenty-three also tested viral positive during pregnancy. Three of 1,000 (0.3%) were viral positive on admission but antibody negative. The median age was 30 years (interquartile range [IQR]: 26-33 years) and body mass index was 31.75 kg/m (IQR 27.7-37.5 kg/m). The cesarean delivery rate was 34.0%. The study population was primarily white (71.6%); however, 41.0% of SARS-CoV-2 infected patients identified as Black, 18.0% as Hispanic/Latino, 3.3% as Native Hawaiian/Pacific Islander, and only 27.9% as White ( < 0.0001). SARS-CoV-2 infection was more likely in patients without private insurance ( = 0.0243). Adverse maternal and/or neonatal outcomes were not more likely in patients with evidence of infection during pregnancy. Two SARS-CoV-2 infected patients were admitted to the intensive care unit. There were no maternal deaths during the study period.

Conclusion: In this largely rural Midwest population, 6.1% of delivering patients had evidence of past or current SARS-CoV-2 infection. Rates of SARS-CoV-2 during pregnancy were higher among racial and ethnic minorities and patients without private insurance. The SARS-CoV-2 infected patients and their neonates were not found to be at increased risk for adverse outcomes.

Key Points: · SARS-CoV-2 seroprevalence rate in pregnant population in Iowa is 5.8%.. · Infections are higher among minorities, non-English speakers, and patients without private insurance.. · No increased adverse maternal/neonatal outcomes observed for SARS-CoV-2 infected mothers..
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http://dx.doi.org/10.1055/s-0041-1723938DOI Listing
May 2021

Postpartum Nipple Symptoms: Risk Factors and Dermatologic Characterization.

Breastfeed Med 2021 Mar 18;16(3):215-221. Epub 2020 Dec 18.

Department of Dermatology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA.

Nipple discomfort inhibits breastfeeding goals, particularly between 0 and 8 weeks postpartum (PP), and yet the specific dermatologic entities that contribute to nipple soreness have not been clearly delineated. Moreover, there remains a lack of evidence-based guidelines for nipple symptoms and skin diseases. A survey was distributed to 6-8-week PP women, 18-50 years of age, with an intent to exclusively or partially breastfeed ("at the breast" or "pump"). The study aimed to characterize nipple skin symptoms (pain and itching) and lesions (eczema, redness, cuts, or wounds) and any association between these nipple problems and past dermatologic history, breastfeeding outcomes, and the ability to meet her breastfeeding goals. Findings paralleled Centers for Disease Control and Prevention (CDC) statistics with a 25% decline in breastfeeding rates between birth, 86.3% (189), and 6-8 weeks PP, 64.5% (145). By 6-8 weeks PP, exclusive "formula" and "exclusive feeding at the breast" showed the largest increase (+16.4%) and decrease (-22.9%), respectively. Although no significant difference was found in comparison of nipple problems to feeding methods or skin history, women who reported pumping or PP redness/eczema had higher odds ratios of a change in feeding practice, history of eczema, and sensitive skin. Strong pumping intentions were also associated with the highest risk of unmet breastfeeding goals. Regardless of feeding method, product, or provider use, PP nipple problems predominantly arose between 1 and 3 weeks PP. Clinical Trial Registration number 201901737.
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http://dx.doi.org/10.1089/bfm.2020.0030DOI Listing
March 2021

The Bucket Test Improves Detection of Stroke in Patients With Acute Dizziness.

J Emerg Med 2021 Apr 8;60(4):485-494. Epub 2020 Dec 8.

Department of Neurology, The University of Iowa, Iowa City, Iowa; The Veteran's Administration Medical Center, Iowa City, Iowa.

Background: It is challenging to detect posterior circulation strokes in patients presenting to the emergency department (ED) with acute dizziness. The current approach uses a combinatorial head-impulse, nystagmus, and test-of-skew method and is sensitive enough to differentiate central causes from peripheral ones. However, it is difficult to perform and underused. Further, magnetic resonance imaging (MRI) of the brain is not always available and can have low sensitivity for detecting posterior circulation strokes.

Objectives: We evaluated the feasibility and utility of the bucket test (BT), which measures the difference between patient's subjective perception of the visual vertical and the true vertical, as a screening tool for stroke in patients presenting to the ED with acute dizziness.

Methods: In this work, we prospectively enrolled 81 patients that presented to our academic medical center ED with dizziness as their chief complaint. The BT was performed 3 times for every patient.

Results: Seventy-one patients met the study criteria and were included in the analysis. Ten patients were excluded because of a history of drug-seeking behavior. There were no reported difficulties performing the BT. Six patients (8%) were diagnosed with ischemic stroke on MRI and 1 additional patient was diagnosed with transient ischemic attack and found to have a stroke on subsequent MRI. All 7 patients with dizziness attributed to cerebrovascular etiology had an abnormal BT, resulting in a sensitivity of 100% (95% confidence interval [CI] 59-100%). The specificity of the BT was 38% (95% CI 24-52%). The positive predictive value of the BT for detecting stroke was 18% (95% CI 15-21%).

Conclusions: The BT is an easy, cheap, safe, and quick test that is feasible and sensitive to screen acutely dizzy patients for stroke in the ED.
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http://dx.doi.org/10.1016/j.jemermed.2020.10.052DOI Listing
April 2021

Impact of Shared Plans of Care on Healthcare Utilization by Children with Special Healthcare Needs and Mental Health Diagnoses.

Matern Child Health J 2021 Apr 27;25(4):584-589. Epub 2020 Nov 27.

Department of Pediatrics, Child and Community Health, 247 CDD, 100 Hawkins Drive, Iowa City, IA, 52242, USA.

Objectives: We assessed how shared plans of care (SPoC), a care coordination tool, impact healthcare utilization of a cohort of children with special healthcare needs (CSHCN) and mental health conditions.

Methods: Data, including emergency department (ED) visits, hospitalizations, and primary care visits, were collected through chart review of CSHCN. A Poisson generalized linear mixed model was used to analyze healthcare utilization data for CSHCN.

Results: Our results showed a decrease in primary care visits, hospitalizations, and ED visits for CSHCN after SPoC implementation, though only primary care visits reached significance. Mental health care visits were specifically found to decrease by 39% following employment of SPoC.

Conclusions For Practice: The use of SPoCs in CSHCN had a positive impact on healthcare utilization suggesting widespread use of this tool improved care coordination in this population.
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http://dx.doi.org/10.1007/s10995-020-03101-3DOI Listing
April 2021

Current evidence supporting a goal of singletons: a review of maternal and perinatal outcomes associated with twin versus singleton pregnancies after in vitro fertilization and intracytoplasmic sperm injection.

Fertil Steril 2020 10;114(4):690-714

Department of Obstetrics and Gynecology, University of Iowa, Iowa City, Iowa.

With increasing use of in vitro fertilization and intracytoplasmic sperm injection (IVF-ICSI) almost 2% of all babies born in the United States each year are now conceived with these technologies, making outcomes of IVF-ICSI extremely important not only to patients and families but to public health. Twin pregnancy rates after IVF-ICSI in the United States have declined since their peak in 2013 but remain at approximately 1 in 10 to 1 in 20 pregnancies. A review of the current international literature on twin versus singleton pregnancy outcomes after IVF-ICSI treatment confirms statistically significantly higher risks to maternal and perinatal health and statistically significantly higher health care costs. The field of infertility care should continue to work to develop practices that lower twin pregnancy rates to an absolute minimum to maximize the safety of these medical treatments.
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http://dx.doi.org/10.1016/j.fertnstert.2020.08.1423DOI Listing
October 2020

Uric Acid Lowering and Biomarkers of Kidney Damage in CKD Stage 3: A Post Hoc Analysis of a Randomized Clinical Trial.

Kidney Med 2020 Mar-Apr;2(2):155-161. Epub 2020 Feb 26.

Division of Nephrology, Department of Internal Medicine, Carver College of Medicine, Iowa City, IA.

Rationale & Objective: Hyperuricemia is associated with chronic kidney disease (CKD) progression. We evaluated whether lowering serum uric acid levels improves levels of biomarkers of kidney damage.

Study Design: Post hoc analysis of clinical trial participants.

Setting & Participants: A double-blind randomized placebo-controlled study designed to lower serum uric acid levels. 80 patients with stage 3 CKD and asymptomatic hyperuricemia were randomly assigned to allopurinol treatment or placebo (300 mg/d) for 12 weeks.

Exposure/predictor: Allopurinol treatment versus placebo.

Outcomes & Measures: We evaluated the change from baseline for the following urinary biomarkers of kidney damage: albumin-creatinine ratio (ACR), neutrophil gelatinase-associated lipocalin (NGAL), kidney injury molecule 1 (KIM-1), and transforming growth factor β1 (TGF-β1). Additionally, we evaluated CKD Epidemiology Collaboration (CKD-EPI)-estimated glomerular filtration rate (eGFR) and cystatin C eGFR.

Analytical Approach: Generalized linear mixed modeling was used.

Results: After 12 weeks, allopurinol (compared to placebo) significantly lowered serum uric acid levels with an estimate of -3.3 mg/dL (95% CI, -4.1 to -2.5 mg/dL;  < 0.001). Estimates for the change for allopurinol versus placebo over time were 1.09 (95% CI, 0.77-1.54) for ACR, 0.77 (95% CI, 0.36-1.63) for NGAL, and 2.36 (95% CI, 0.97-5.70) for TGF-β1. The model did not converge for KIM-1, but Wilcoxon signed rank test showed no significant difference in change from baseline between study groups. There was no significant change observed in CKD-EPI eGFR or cystatin C eGFR.

Limitations: Post hoc analysis and short duration of the study.

Conclusions: Uric acid-lowering with allopurinol is not associated with improvement in levels of biomarkers of kidney damage in patients with asymptomatic hyperuricemia and stage 3 CKD.

Funding: The study was funded by the National Institutes of Health through a career development award, K23DK088833, and the Clinical and Translational Science Award UL1TR002537.

Trial Registration: NCT01228903.
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http://dx.doi.org/10.1016/j.xkme.2019.11.007DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7487946PMC
February 2020

Impact of Infectious Disease Consultation in Patients With Candidemia: A Retrospective Study, Systematic Literature Review, and Meta-analysis.

Open Forum Infect Dis 2020 Sep 3;7(9):ofaa270. Epub 2020 Aug 3.

Division of Infectious Diseases, Department of Internal Medicine, University of Iowa, Iowa City, Iowa, USA.

Background: Morbidity and mortality from candidemia remain unacceptably high. While infectious disease consultation (IDC) is known to lower the mortality from bacteremia, little is known about the impact of IDC in candidemia.

Methods: We conducted a retrospective observational cohort study of candidemia patients at a large tertiary care hospital between 2015 and 2019. The crude mortality rate was compared between those with IDC and without IDC. Then, we systematically searched 5 databases through February 2020 and performed a meta-analysis of the impact of IDC on the mortality of patients with candidemia.

Results: A total of 151 patients met the inclusion criteria, 129 (85%) of whom received IDC. Thirty-day and 90-day mortality rates were significantly lower in the IDC group (18% vs 50%; = .002; 23% vs 50%; = .0022, respectively). A systematic literature review returned 216 reports, of which 13 studies including the present report fulfilled the inclusion criteria. Among the 13 studies with a total of 3582 patients, IDC was performed in 50% of patients. Overall mortality was 38.2% with a significant difference in favor of the IDC group (28.4% vs 47.6%), with a pooled relative risk of 0.41 (95% CI, 0.35-0.49). Ophthalmology referral, echocardiogram, and central line removal were performed more frequently among patients receiving IDC.

Conclusions: This study is the first systematic literature review and meta-analysis to evaluate the association between IDC and candidemia mortality. IDC was associated with significantly lower mortality and should be considered in all patients with candidemia.
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http://dx.doi.org/10.1093/ofid/ofaa270DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7462368PMC
September 2020

Frailty measures can be used to predict the outcome of kidney transplant evaluation.

Surgery 2021 03 26;169(3):686-693. Epub 2020 Aug 26.

Department of Surgery, Organ Transplant Center, University of Iowa Hospitals and Clinics, Iowa City, IA; Veterans Affairs Medical Center, Iowa City, IA. Electronic address:

Background: Experience incorporating frailty and functional metrics in the transplant evaluation process is limited. We hypothesized that simple tests correlate with kidney transplant listing outcomes.

Methods: Frailty metrics, treadmill ability, pedometer data, troponin T, and brain natriuretic peptide were collected on 375 consecutive kidney transplant evaluations between July 2015 and December 2018. Patients initially denied were compared with those listed or deferred. Frailty metrics included handgrip, chair sit-stand, up-and-go, chair sit-reach, and questions related to exhaustion.

Results: A total of 95 (25%) patients were initially denied. Those denied were older, diabetic, or had higher body mass indexes. Frailty metrics including chair sit-stand, up-and-go, chair sit-reach, grip strength, and exhaustion; biochemical markers troponin and brain natriuretic peptide; and pedometer and treadmill ability were all significantly associated with denial (P < .001). The best order three model combining parsimony and predictiveness included treadmill ability, exhaustion, and troponin. The most predictive pedometer model also included exhaustion and up-and-go. The best order three model excluding biochemical markers, pedometer, and treadmill results included up-and-go, exhaustion, and chair sit-reach.

Conclusion: Outcomes after on-site kidney transplant evaluation strongly correlated with the results of common clinical and functional frailty metrics.
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http://dx.doi.org/10.1016/j.surg.2020.07.016DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7870463PMC
March 2021

Effects of patient-level noise abatement orders on sound levels experienced by critically ill subarachnoid hemorrhage patients: an observational study.

Hosp Pract (1995) 2020 Dec 22;48(5):258-265. Epub 2020 Aug 22.

Department of Anesthesia, University of Iowa , Iowa City, IA, USA.

Background/objective: Patients with aneurysmal subarachnoid hemorrhage (aSAH) may be at risk for complications related to excessive environmental noise. Our ICU utilizes a variety of universal interventions to minimize ambient noise levels, but patients with aSAH additionally have specific orders intended to further minimize physiologic stress and noise exposure. It is unknown whether such orders can have a supplementary reductive effect on noise exposure.

Methods: Sound levels were measured for at least three consecutive days in the rooms of 17 patients with aSAH and implemented 'subarachnoid precautions' orders. Sound levels were similarly recorded in the rooms of 11 geographically-proximate, critically-ill control patients without aSAH.

Results: Linear mixed models were used to assess the difference in measurements between groups. Observations were combined into fifteen-minute windows, then group means and their differences were calculated and plotted to help identify what times of the day had significant differences. aSAH patients consistently experienced lower sound levels than control patients, with a statistically significant difference (p < 0.05) in mean sound levels at 62 of 96 intervals throughout the day. Overall, the mean sound level for aSAH patients was always between 62-63dBA, while the mean sound level experienced by control patients ranged between 64-66dBA.

Conclusions: Implementation of patient-specific orders can have a supplementary reductive effect on noise exposure for aSAH patients in an intensive care unit that already utilizes universal noise abatement interventions.
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http://dx.doi.org/10.1080/21548331.2020.1801008DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7805414PMC
December 2020

Patients With Vestibular Migraine are More Likely to Have Occipital Headaches than those With Migraine Without Vestibular Symptoms.

Headache 2020 Sep 25;60(8):1581-1591. Epub 2020 Jul 25.

Department of Neurology, University of Iowa, Iowa City, IA, USA.

Objective: To determine whether patients with vestibular migraine are more likely to suffer from an occipital headache than patients with migraine without vestibular symptoms.

Background: Vestibular migraine is an underdiagnosed disorder in which migraine is associated with vestibular symptoms. Anatomical evidence and symptomatology hint at the involvement of brain structures in the posterior fossa (back of the head location). We hypothesized that vestibular migraine patients are more likely than migraineurs without vestibular symptoms to experience headaches located in the back of the head, that is, occipital headaches.

Methods: A retrospective cross-sectional study was conducted at the University of Iowa Hospital and Clinics. Chart analysis of 169 patients was performed. The primary outcome was the location of the headache in vestibular migraine patients and migraineurs without vestibular symptoms. The secondary outcomes included the association of vestibular migraine with gender, age at onset of headache, age at onset of vestibular symptoms (such as vertigo, head motion-induced dizziness), aura, motion sickness, other associated symptoms, family history of headaches, and family history of motion sickness.

Results: In vestibular migraine group, 45/103 (44%) had occipital location for their headaches vs 12/66 (18%) in migraine patients without vestibular symptoms, for an odd's ratio of 3.5 (95% CI = 1.7-7.2, P < .001). Additionally, the age at onset of headache was greater in the vestibular migraine group (28 ± 12 vs 18 ± 9 years, P < .001) and motion sickness was more common (41/98 (42%) in the vestibular migraine group, 1/64 (2%) in the migraine without vestibular symptoms group, P < .001).

Conclusions: This study suggests that patients with vestibular migraine are more likely to have occipital headaches than patients with migraine without vestibular symptoms. Our data support the initiation of a prospective study to determine whether a patient presenting with occipital headaches, with late onset of age of headache, and with a history of motion sickness is at an increased risk for the possible development of vestibular migraine.
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http://dx.doi.org/10.1111/head.13898DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7771256PMC
September 2020

NIH funding trends to US medical schools from 2009 to 2018.

PLoS One 2020 1;15(6):e0233367. Epub 2020 Jun 1.

Department of Pathology, Carver College of Medicine at the University of Iowa, Iowa City, Iowa, United States of America.

Total NIH funding dollars have increased from 2009-2018. We questioned whether this growth has occurred proportionately around the country and throughout allopathic medical schools. Therefore, we compared the trend in NIH grant funding from 2009 to 2018 for United States allopathic medical schools among historically top-funded schools, private and public schools, and by region of the country. Changes in both unadjusted and real funding dollars over time revealed a significant difference. Region was the only significant factor for mean percent change in funding from 2009-2018, with the Western region showing a 33.79% increase in purchasing power. The Northeastern region showed a -6.64% decrease in purchasing power while the Central and Southern regions reported changes of 2.46% and -6.08%, respectively. The mean percent increases were more proportional and nonsignificant in the public vs. private institutions comparison, at -3.41% and 4.75%, respectively. Likewise, the top-funded institutions vs. other institutions comparisons demonstrated modest, nonsignificant differences. However, although the relative changes might be proportional, the absolute increases evidence a pattern of growing cumulative advantage that favor the highest-funded institutions and private institutions. The potential consequences of this disproportionate increase include health science education, biomedical research, and patient access disparities in large parts of the country. The NIH and the scientific community should explore potential solutions in its funding models.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0233367PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7263845PMC
August 2020

Characterization of serum biomarkers during anaphylaxis in emergency department patients.

J Allergy Clin Immunol Pract 2020 10 19;8(9):3213-3215.e1. Epub 2020 May 19.

Department of Emergency Medicine, University of Iowa Hospitals and Clinics, Iowa City, Iowa. Electronic address:

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http://dx.doi.org/10.1016/j.jaip.2020.05.010DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7757750PMC
October 2020

Local cortical overexpression of human wild-type alpha-synuclein leads to increased dendritic spine density in mouse.

Neurosci Lett 2020 08 14;733:135051. Epub 2020 May 14.

University of Iowa, Iowa City, Iowa 52242, USA. Electronic address:

Lewy body dementias are characterized by deposition of alpha-synuclein (α-syn) protein aggregates known as Lewy bodies and Lewy neurites in cortical regions, in addition to brainstem. These aggregates are thought to cause the death of dopaminergic neurons in the substantia nigra and other vulnerable cell types in patients, leading to parkinsonism. There is evidence from mice that localized overexpression of wild-type α-syn leads to dopaminergic cell death in the substantia nigra. However, it is not known how cortical neurons are affected by α-syn. In this study, we used viral overexpression of α-syn to investigate whether localized overexpression within the cortex affects the density, length, and morphology of dendritic spines, which serve as a measure of synaptic connectivity. An AAV2/6 viral vector coding for wild-type human α-syn was used to target overexpression bilaterally to the medial prefrontal cortex within adult mice. After ten weeks the brain was stained using the Golgi-Cox method. Density of dendritic spines in the injected region was increased in layer V pyramidal neurons compared with animals injected with control virus. Immunohistochemistry in separate animals showed human α-syn expression throughout the region of interest, especially in presynaptic terminals. However, phosphorylated α-syn was seen in a discrete number of cells at the region of highest overexpression, localized mainly to the soma and nucleus. These findings demonstrate that at early timepoints, α-syn overexpression may alter connectivity in the cortex, which may be relevant to early stages of the disease. In addition, these findings contribute to the understanding of α-syn, which when overexpressed in the wildtype, non-aggregated state may promote spine formation. Loss of spines secondary to α-syn in cortex may require higher expression, longer incubation, cellular damage, concomitant dopaminergic dysfunction or other two-hit factors to lead to synaptic degeneration.
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http://dx.doi.org/10.1016/j.neulet.2020.135051DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7769708PMC
August 2020

Carotid Artery Stiffness is Associated With Cognitive Performance in Former Smokers With and Without Chronic Obstructive Pulmonary Disease.

J Am Heart Assoc 2020 05 26;9(9):e014862. Epub 2020 Apr 26.

Medicine National Jewish Health Denver CO.

Background Heavy smokers perform worse on neuropsychological assessment than age-matched peers. However, traditional pulmonary measures of airflow limitation and hypoxemia explain only a modest amount of variance in cognition. The current objective was to determine whether carotid artery stiffness is associated with cognition in former smokers beyond the effects of amount of smoking and pulmonary function. Methods and Results Eighty-four former smokers including individuals across a spectrum of airflow limitation severity were included: 30 without chronic obstructive pulmonary disease (Global Initiative for Chronic Obstructive Lung Disease [GOLD] 0 with normal spirometry and lung computed tomography), 31 with mild-moderate chronic obstructive pulmonary disease (GOLD 1-2), and 23 with severe-very severe chronic obstructive pulmonary disease (GOLD 3-4). Participants completed questionnaires, spirometry, carotid ultrasonography, and neuropsychological testing. Multiple linear regression was used to determine whether carotid artery stiffness is associated with neuropsychological performance in 4 cognitive domains after adjusting for age, sex, pack-years of smoking, estimated premorbid intellectual functioning, and airflow limitation. Higher carotid artery β-stiffness index was associated with reduced executive functioning-processing speed in the fully adjusted model (β=-0.49, SE=0.14; =0.001). Lower premorbid intellectual function, male sex, and presence of airflow limitation (GOLD 1 or 2 and GOLD 3 or 4) were also associated with worse executive functioning-processing speed. β-Stiffness index was not significantly associated with performance in other cognitive domains. Conclusions Carotid artery stiffness is associated with worse performance on executive functioning-processing speed in former smokers beyond the effects of aging, amount of past smoking, severity of airflow limitation, and hypoxemia. Future research should examine whether carotid stiffness can be used to identify former smokers at risk for subsequent cognitive impairment.
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http://dx.doi.org/10.1161/JAHA.119.014862DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7428572PMC
May 2020

Mental health disorders in haemophilia: Systematic literature review and meta-analysis.

Haemophilia 2020 May 19;26(3):431-442. Epub 2020 Apr 19.

Stead Family Department of Pediatrics, Carver College of Medicine, University of Iowa, Iowa City, IA, USA.

Aim: Despite significant advances in morbidity and mortality outcomes, quality of life for people with haemophilia (PWH) remains compromised. Underrecognized and undertreated mental health disorders decrease quality of life; however, reports are inconsistent regarding the true prevalence of mental health disorders in PWH.

Methods: We conducted a systematic literature search of Ovid MEDLINE, EMBASE, Psychinfo and the Cochrane Library, and hand searched the journal Haemophilia to identify records and subsequently conducted a meta-analysis to determine the prevalence of depression, anxiety and attention deficit hyperactivity disorder (ADHD) in patients with congenital haemophilia.

Results: Our search strategy identified 2315 records, and 28 studies met eligibility criteria. Meta-analysis demonstrated that PWH are at increased risk of depression (odds ratio (OR) 2.45; 95% confidence interval (CI) 1.64-3.68), anxiety (OR 1.74, 95% CI 1.01-3.00), anxiety/depression (OR 2.60, 95% CI 2.35-2.87) and ADHD (OR 3.48, 95% CI 1.74-6.96). We found considerable heterogeneity among the studies likely due to differences in assessment tools, populations studied and year of publication. This suggests that standardized tools to diagnose mental health disorders in PWH are needed. Additionally, high-quality studies investigating mental health disorders in PWH are necessary to adequately document the prevalence of these disorders.

Conclusion: Overall, our meta-analysis suggests that the prevalence of depression, anxiety and ADHD across decades is significantly increased in PWH compared to the general population.
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http://dx.doi.org/10.1111/hae.13960DOI Listing
May 2020

Reliability of targeting methods in TMS for depression: Beam F3 vs. 5.5 cm.

Brain Stimul 2020 May - Jun;13(3):578-581. Epub 2020 Jan 14.

Department of Psychiatry, University of Iowa, Iowa City, IA, United States; Department of Neurology, University of Iowa, Iowa City, IA, United States; Department of Pediatrics, University of Iowa, Iowa City, IA, United States.

Background: No consensus exists in the clinical transcranial magnetic stimulation (TMS) field as to the best method for targeting the left dorsolateral prefrontal cortex (DLPFC) for depression treatment. Two common targeting methods are the Beam F3 method and the 5.5 cm rule.

Objective: Evaluate the anatomical reliability of technician-identified DLPFC targets and obtain consensus average brain and scalp MNI152 coordinates.

Methods: Three trained TMS technicians performed repeated targeting using both the Beam F3 method and 5.5 cm rule in ten healthy subjects (n = 162). Average target locations were plotted on 7T structural MRIs to compare inter- and intra-rater reliability, respectively.

Results: (1) Beam F3 inter- and intra-rater reliability was superior to 5.5 cm targeting (p = 0.0005 and 0.0035). (2) The average Beam F3 location was 2.6±1.0 cm anterolateral to the 5.5 cm method.

Conclusions: Beam F3 targeting demonstrates greater precision and reliability than the 5.5 cm method and identifies a different anatomical target.
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http://dx.doi.org/10.1016/j.brs.2020.01.010DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7507589PMC
November 2020

The Influence of an Electronic Medical Record Embedded Best Practice Alert on Rate of Hospital Acquired Catheter Associated Urinary Tract Infections: Do Best Practice Alerts Reduce CAUTIs?

Urology 2020 Jul 5;141:71-76. Epub 2020 Apr 5.

University of Iowa Hospitals and Clinics, Department of Urology, Iowa City, IA. Electronic address:

Objective: To understand if an electronic medical record embedded best practice alert decreased our hospital's Catheter-associated urinary tract infections (CAUTIs) and catheter utilization (CU) rates.

Methods: Data from our inpatient prospective CAUTI database, spanning 2011 to 2016, were utilized for our analysis with the Best Practice Alert (BPA) starting in 2013. Using generalized linear models we compared the CU and CAUTI rates between pre- and post-BPA periods in different patient subpopulations.

Results: We identified no decrease in the CU rate and no effect on the CAUTI rates as a result of the BPA. However, there was an increase in CAUTI rates in our adult intensive care unit (ICU) population from 0.2 to 1.8 CAUTIs per 1,000 catheter days (P <.01) despite a significant decrease in CU rate within this population after the BPA (pre-BPA odds ratio [OR] 0.93 vs post-BPA OR 0.89; P <0.01). In contrast, our non-ICU adult population had a decrease in CAUTI rate from 2.8 to 1.7 CAUTIs per 1,000 catheter days (P <.01) despite no significant decrease after the BPA (pre-BPA OR 0.90 vs post-BPA OR 0.95; P <.1).

Conclusion: CAUTI rates are exceedingly low, with or without the use of a BPA. Such an alert appears to have limited success in lowering CU rates in populations where catheter use is already low and may not always lead to an improvement in CAUTI rates as there appears to be some populations that may be more prone to CAUTI development secondary to possible intrinsic or co-morbid conditions.
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http://dx.doi.org/10.1016/j.urology.2020.02.028DOI Listing
July 2020

An estimate of missed pediatric sepsis in the emergency department.

Diagnosis (Berl) 2021 May 19;8(2):193-198. Epub 2020 Mar 19.

University of Iowa Carver College of Medicine, Iowa City, USA.

Background: Timely diagnosis of pediatric sepsis remains elusive. We estimated the risk of potentially missed pediatric sepsis in US emergency departments (EDs) and determined factors associated with its occurrence.

Methods: In a retrospective study of linked inpatient and ED records from four states using administrative data (excluding 40% with missing identifiers), we identified children admitted with severe sepsis and/or septic shock who had at least one ED treat-and-release visit in the 7 days prior to sepsis admission. An expert panel rated the likelihood of each ED visit being related to subsequent sepsis admission. We used multivariable regression to identify associations with potentially missed sepsis.

Results: Of 1945 patients admitted with severe sepsis/septic shock, 158 [8.1%; 95% confidence interval (CI), 6.9%-9.4%] had potentially missed sepsis during an antecedent treat-and-release ED visit. The odds of potentially missed sepsis were lower for each additional comorbid chronic condition [odds ratio (OR), 0.86; 95% CI, 0.80-0.92] and higher in California (OR, 2.26; 95% CI, 1.34-3.82), Florida (OR, 3.33; 95% CI, 1.95-5.70), and Massachusetts (OR, 2.87; 95% CI, 1.35-6.09), compared to New York.

Conclusions: Administrative data can be used to screen large populations for potentially missed sepsis and identify cases that warrant detailed record review.
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http://dx.doi.org/10.1515/dx-2020-0023DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7732517PMC
May 2021

Predictive Factors and Time to Development of Hepatic Decompensation in Patients with Non-alcoholic Fatty Liver Disease.

J Gen Intern Med 2020 05 10;35(5):1523-1529. Epub 2020 Mar 10.

Department of Internal Medicine, University of Iowa Hospitals and Clinics, Iowa City, IA, USA.

Background: Non-alcoholic fatty liver disease (NAFLD) is one of the most common causes of cirrhosis in the USA.

Objectives: We aimed to determine the time to develop hepatic events in patients with NAFLD and develop a simple model to identify patients at risk for hepatic decompensation.

Design: Retrospective cohort study.

Patients: Seven hundred patients with NAFLD met inclusion criteria for the study. Patients were divided into model construction (n = 450) and validation (n = 250) cohorts.

Main Measures: Demographic, clinical, and laboratory variables were gathered at the time of diagnosis of NAFLD. Kaplan-Meier analysis determined the time to development of hepatic events from initial diagnosis. A time-to-event prediction model was established in the model construction cohort using the multivariate Cox proportional hazards model and was then internally validated.

Key Results: Forty-nine (7%) patients developed hepatic events at a mean duration of 6.2 ± 4.2 years from initial diagnosis. Kaplan-Meier probability of developing a hepatic event at 5-, 10-, and 12-year intervals was 4.8%, 10.6%, and 11.3%, respectively. Age, presence of diabetes, and platelet count were identified as significant variables to predict hepatic events. NAFLD decompensation risk score was developed as "age × 0.06335 + presence of diabetes (yes = 1, no = 0) × 0.92221 - platelet count × 0.01522" to predict the probability of hepatic decompensation. Risk score model had an area under the curve of 0.89 (95% CI = 0.92, 0.86) and it performed well in both the validation (0.91, 0.87-0.94) and the overall cohort (0.89, 0.87-0.91).

Conclusions: A significant proportion of patients with NAFLD developed hepatic decompensation. We have provided a simple, objective model to help identify "at-risk" patients.
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http://dx.doi.org/10.1007/s11606-020-05725-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7210346PMC
May 2020

Epstein-Barr virus infection status among first year undergraduate university students.

J Am Coll Health 2020 Feb 26:1-4. Epub 2020 Feb 26.

Department of Pathology, Roy J. and Lucille A. Carver College of Medicine, University of Iowa, Iowa City, Iowa, USA.

Epstein-Barr virus (EBV) is the cause of infectious mononucleosis, which disproportionately affects university students. This population has the potential to benefit from a prophylactic EBV vaccine trial. Our objectives were to determine EBV infection status and associated demographic/lifestyle factors among first year undergraduate university students at the beginning and end of first year. EBV infection status was assessed by testing for circulating IgG class antibodies against EBV viral capsid antigen. Of 198 starting students; 56.1% were positive for EBV antibodies with a higher rate in women (64.8%) than male (41.1%); p = 0.002. A history of deep kissing was associated with a higher rate of EBV antibody positivity. On follow-up 8 months later at the end of freshman year, 22.4% had acquired EBV antibodies for a primary infection incidence of 33.6/100 person years. These findings indicate that our first year undergraduate population contains sufficient EBV-naïve subjects for a prophylactic vaccine trial.
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http://dx.doi.org/10.1080/07448481.2020.1726927DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7832088PMC
February 2020