Citations

Introduction: The current literature regarding both specific interventions and the current level of nutrition education in the United States is scarce. The purpose of this paper is to provide medical student perspectives on both the degree and necessity of nutrition education during medical school. Methods: Medicine in Motion (MM) is a non-profit student-run organization founded in 2018 that aims to address burnout in medicine through physical activity, community service, and philanthropy. MM issued a survey to nine of its chapters in January 2021 to assess a range of topics including burnout, physical activity, and nutrition education. Results: Of 5500 invited students, 1182 (21.5%) responded. An average of 1.2 hours of formal nutrition education per year was reported across all participants. Students who received any degree of nutritional education reported 2.9 hours per year. Most students (57.6%) had not participated in a medical school course that provided formal education in nutrition. Of those that did participate in a nutrition course (42.4%), the course was required for 84.7% of students and the majority (80.1%) received 0-10 hours of nutrition education. Most respondents (88.7%) reported that requiring formal nutrition education should be a graduation requirement and a similar number of students (89.3%) believe medical students should receive formal training on nutrition counseling for patients. The majority (93.3%) of students either somewhat or strongly agreed that understanding the effects of nutrition/eating decisions on the human body is critical to maximizing patient care. Conclusion: Based on prior studies, physicians feel underprepared to provide nutrition counseling to their patients despite the large role poor diet plays in the burden of disease. Most medical students in this cohort believe that understanding nutrition is vital to maximize patient care. Funding and curricular changes should be allocated towards expanding the nutrition curriculum across U.S. medical schools.

Background: Sleep disorders are common in Parkinson’s disease (PD) and include alterations in sleep-related EEG oscillations. Objective: This case-control study tested the hypothesis that patients with PD would have a lower density of Scalp-Slow Wave (SW) oscillations and higher slow-to-fast frequencies ratio in rapid eye movement (REM) sleep than non-PD controls. Other sleep-related quantitative EEG (qEEG) features were also examined, including SW morphology, sleep spindles, and Scalp-SW spindle phase-amplitude coupling. Methods: Polysomnography (PSG)-derived sleep EEG was compared between PD participants ( n = 56) and non-PD controls ( n = 30). Following artifact rejection, sleep qEEG analysis was performed in frontal and central leads. Measures included SW density and morphological features of SW and sleep spindles, SW-spindle phase-amplitude coupling, and spectral power analysis in Non-REM (NREM) and REM. Differences in qEEG features between PD and non-PD controls were compared using two-tailed Welch’s t-tests, and correction for multiple comparisons was performed per the Benjamini-Hochberg method. Results: SW density was lower in PD than in non-PD controls (F = 13.5, p’ = 0.003). The PD group also exhibited higher ratio of slow REM EEG frequencies (F = 4.23, p’ = 0.013), higher slow spindle peak frequency (F = 24.7, p’ < 0.002), and greater SW-spindle coupling angle distribution non-uniformity (strength) (F = 7.30, p’ = 0.034). Conclusion: This study comprehensively evaluates sleep qEEG including SW-spindle phase amplitude coupling in PD compared to non-PD controls. These findings provide novel insights into how neurodegenerative disease disrupts electrophysiological sleep rhythms. Considering the role of sleep oscillatory activity on neural plasticity, future studies should investigate the influence of these qEEG markers on cognition in PD.

Objectives: Osteochondritis dissecans (OCD) of the humeral capitellum is an often painful condition that typically affects the adolescent athlete. There is little consensus on treatment and a scarcity of long-term outcomes data. The purpose of this study was to (1) report the long-term outcomes associated with both operative and non-operative management of capitellar OCD, (2) identify factors associated with failure of non-operative management, and (3) determine whether delay in surgery affects final outcomes. Methods: All patients diagnosed with OCD of the capitellum from 1995-2020 within a defined geographic cohort were included. Medical records, imaging studies, and operative reports were manually reviewed to record demographic data, treatment strategies, and outcomes. Surgical treatment was considered delayed if it occurred more than 6 months after symptom onset. Results: A total of 50 elbows with a mean follow-up of 9.4 years were included. Of these, 7 (14%) were treated non-operatively and never underwent surgery during follow-up, while 43 (86%) underwent surgical intervention: 27 had early surgery and 16 underwent delayed surgery after ≥ 6 months of non-operative treatment. When compared to non-operative management, surgical management resulted in superior MEPI scores (90 vs 83, p=0.05), decreased persistence of mechanical symptoms (9% vs 50%, p<0.01), and better elbow flexion (141° vs 131°, p=0.01) at long-term follow up. Older patients had a trend toward increased failure of non-operative management (p=0.06). The presence of an intra-articular loose body strongly predicted failure of non-operative management (p=0.01; OR 13). Plain radiography and MRI had poor sensitivities for identifying loose bodies (27% and 40%, respectively). Differences in outcomes following early versus delayed surgical management were not demonstrated. Conclusions: Patients with capitellar OCD initially treated nonoperatively failed nonoperative management 70% of the time. Elbows that did not undergo surgery had slightly increased symptoms and decreased functional outcomes compared to those treated surgically. In this cohort, the greatest predictors for failure of non-operative treatment were older age and presence of a loose body; however, an initial trial of non-operative treatment did not adversely impact the success of future surgery at long term follow-up. [Table: see text][Table: see text][Table: see text][Table: see text]

AbstractBackground and ObjectivesConvalescent COVID‐19 plasma (CCP) was developed and used worldwide as a treatment option by supplying passive immunity. Adult studies suggest administering high‐titer CCP early in the disease course of patients who are expected to be antibody‐negative; however, pediatric experience is limited. We created a multi‐institutional registry to characterize pediatric patients (<18 years) who received CCP and to assess the safety of this intervention.MethodsA REDCap survey was distributed. The registry collected de‐identified data including demographic information (age, gender, and underlying conditions), COVID‐19 disease features and concurrent treatments, CCP transfusion and safety events, and therapy response.ResultsNinety‐five children received CCP: 90 inpatients and 5 outpatients, with a median age of 10.2 years (range 0–17.9). They were predominantly Latino/Hispanic and White. The most frequent underlying medical conditions were chronic respiratory disease, immunosuppression, obesity, and genetic syndromes. CCP was primarily given as a treatment (95%) rather than prophylaxis (5%). Median total plasma dose administered and transfusion rates were 5.0 ml/kg and 2.6 ml/kg/h, respectively. The transfusions were well‐tolerated, with 3 in 115 transfusions reporting mild reactions. No serious adverse events were reported. Severity scores decreased significantly 7 days after CCP transfusion or at discharge. Eighty‐five patients (94.4%) survived to hospital discharge. All five outpatients survived to 60 days.ConclusionsCCP was found to be safe and well‐tolerated in children. CCP was frequently given concurrently with other COVID‐19‐directed treatments with improvement in clinical severity scores ≥7 days after CCP, but efficacy could not be evaluated in this study.

Abstract The CD8 + T-cell response is prognostic for survival outcomes in several tumor types. However, whether this extends to tumors in the brain, an organ with barriers to T cell entry, remains unclear. Here, we analyzed immune infiltration in 67 brain metastasis (BrM) and found high frequencies of PD1 + TCF1 + stem-like CD8 + T-cells and TCF1- effector-like cells. Importantly, the stem-like cells aggregate with antigen presenting cells in immune niches, and niches were prognostic for local disease control. Standard of care for BrM is resection followed by stereotactic radiosurgery (SRS), so to determine SRS’s impact on the BrM immune response, we examined 76 BrM treated with pre-operative SRS (pSRS). pSRS acutely reduced CD8 + T cells at 3 days. However, CD8 + T cells rebounded by day 6, driven by increased frequency of effector-like cells. This suggests that the immune response in BrM can be regenerated rapidly, likely by the local TCF1 + stem-like population.

Background: Medicare reimbursement is rapidly declining in many specialties. An in-depth analysis of Medicare reimbursement for routinely performed diagnostic imaging procedures in the United States is warranted. Purpose/Hypothesis: The purpose of this study was to evaluate Medicare reimbursement trends for the 20 most common lower extremity imaging procedures performed between 2005 and 2020, including radiographs, computed tomography (CT), and magnetic resonance imaging (MRI). We hypothesized that Medicare reimbursement for imaging procedures would decline substantially over the studied period. Study Design: Cohort study. Methods: The Physician Fee Schedule Look-up Tool from the Centers for Medicare and Medicaid Services was analyzed for reimbursement rates and relative value units associated with the top 20 most utilized Current Procedural Terminology (CPT) codes in lower extremity imaging from 2005 to 2020. Reimbursement rates were adjusted for inflation and listed in 2020 US dollars using the US Consumer Price Index. To compare year-to-year changes, the percentage change per year and compound annual growth rate were calculated. A 2-tailed t test was used to compare the unadjusted and adjusted percentage change over the 15-year period. Results: After adjusting for inflation, mean reimbursement for all procedures decreased by 32.41% ( P = .013). The mean adjusted percentage change per year was –2.82%, and the mean compound annual growth rate was –1.03%. Compensation for the professional and technical components for all CPT codes decreased by 33.02% and 85.78%, respectively. Mean compensation for the professional component decreased by 36.46% for radiography, 37.02% for CT, and 24.73% for MRI. Mean compensation for the technical component decreased by 7.76% for radiography, 127.66% for CT, and 207.88% for MRI. Mean total relative value units decreased by 38.7%. The commonly billed imaging procedure CPT 73720 (MRI lower extremity, other than joint, with and without contrast) had the greatest adjusted decrease of 69.89%. Conclusion: Medicare reimbursement for the most billed lower extremity imaging studies decreased by 32.41% between 2005 and 2020. The greatest decreases were noted in the technical component. Of the modalities, MRI had the largest decrease, followed by CT and then radiography.

Introduction: The prevalence of nonalcoholic fatty liver disease (NAFLD) in US adults is over 25%, yet the etiology of lifestyle factors in the development of NAFLD remains understudied. We examined the independent and joint associations among aerobic physical activity (PA) intensity (moderate, vigorous) and PA type (aerobic, muscle strengthening), television viewing (TV), and odds of NAFLD. Hypothesis: Higher levels of aerobic and muscle strengthening PA are associated with lower odds of NAFLD, and higher levels of TV are associated with higher odds of NAFLD. Methods: We analyzed data from Year 25 of the CARDIA cohort study. Our exposures (moderate and vigorous aerobic and muscle strengthening PA, TV; hr/wk) were assessed using validated questionnaires. Our outcome (NAFLD) was measured using non-contrast computed tomography. We constructed multivariable logistic regression models to examine the independent and joint associations between PA (moderate or vigorous aerobic and strength), TV, and odds of NAFLD. Covariates were sex, age, race, study center, education, diet, smoking status, alcohol consumption, and waist circumference. Results: 2726 participants (648 with NAFLD) were analyzed (mean (SD) age, 50.1 (3.6) years; 49% Black; 43% male). Fully adjusted odds ratios per IQR-standardized continuous PA and TV were: moderate aerobic PA (IQR = 4.3), 0.93 (95% CI, 0.81-1.07); vigorous aerobic PA (IQR = 1.9), 0.63 (95% CI, 0.55-0.73); muscle strengthening PA (IQR = 3.3), 0.80 (95% CI, 0.07-0.92); and TV (IQR = 14.0), 1.20 (95% CI, 1.10-1.32). Only vigorous aerobic PA remained statistically significant after waist circumference adjustment, 0.83 (95% CI, 0.70-0.98). A PA-TV index model (Figure) indicated the combination of higher vigorous aerobic and muscle strengthening PA and lower TV resulted in an odds ratio of 0.23 (95% CI, 0.15-0.37). Conclusion: Concurrent higher levels of vigorous aerobic PA (≥2 hr/wk), muscle strengthening PA (≥2 hr/wk), and lower levels of TV (<7 hr/wk) were associated with 77% lower odds of NAFLD.

Objective: We aimed to characterize seasonal variation in US population-based blood pressure (BP) control and BP-related metrics and evaluate the association between outdoor temperature and BP control variation. Methods: We queried electronic health records (EHRs) from 26 health systems, representing 21 states, to summarize BP metrics by quarters of 12-month periods from January 2017 to March 2020. Patients with at least one ambulatory visit during the measurement period and a hypertension diagnosis during the first 6 months or prior to the measurement period were included. Changes in BP control, BP improvement, medication intensification, average SBP reduction after medication intensification across quarters and association with outdoor temperature were analyzed using weighted generalized linear models with repeated measures. Results: Among 1 818 041 people with hypertension, the majority were more than 65 years of age (52.2%), female (52.1%), white non-Hispanic (69.8%) and had stage 1/2 hypertension (64.8%). Overall, BP control and process metrics were highest in quarters 2 and 3, and lowest in quarters 1 and 4. Quarter 2 had the highest percentage of improved BP (31.95 ± 0.90%) and average SBP reduction after medication intensification (16 ± 0.23 mmHg). Quarter 3 had the highest percentage of BP controlled (62.25 ± 2.55%) and lowest with medication intensification (9.73 ± 0.60%). Results were largely consistent in adjusted models. Average temperature was associated with BP control metrics in unadjusted models, but associations were attenuated following adjustment. Conclusion: In this large, national, EHR-based study, BP control and BP-related process metrics improved during spring/summer months, but outdoor temperature was not associated with performance following adjustment for potential confounders.

AbstractBackgroundCurrent guidelines recommend immunomodulators, tocilizumab or baricitinib, for the management of severe coronavirus disease‐2019 (COVID‐19) in patients with increasing oxygen requirements. Given their immunosuppressive effects, there is a concern for higher rates of infection among transplant recipients.MethodsA retrospective cohort study of transplant patients with severe COVID‐19 between April 2020 and January 2022 was performed at the Mayo Clinic. The primary outcome was incidence of secondary infections after COVID‐19 diagnosis. Secondary outcomes were 90‐day mortality, ventilatory days, and thromboembolic events.ResultsA total of 191 hospitalized transplant patients were studied, including 77 (40.3%) patients who received an immunomodulator. Overall, 89% were solid organ transplant recipients, with kidney as the most common transplanted organ (50.3%). The majority (89.0%) required oxygen supplementation on admission, and 39.8% of these patients required mechanical ventilation during the hospital course. There was no significant difference in the incidence of secondary infections between those who received or did not receive an immunomodulator (p = .984). Likewise, there was no difference in 90‐day mortality between patients who received or did not receive an immunomodulator (p = .134). However, higher mortality was observed among patients that developed a secondary infection (p < .001).ConclusionThe use of immunomodulators in transplant patients with severe COVID‐19 was not significantly associated with an increased risk of secondary infections. Secondary infections were associated with higher risk of all‐cause mortality. Future studies of larger cohorts are needed to explore the effect of immunomodulators on survival among transplant patients with COVID‐19. image

AbstractBackgroundTo determine the impact of personalized risk communication and opioid prescribing on nonprescribed opioid use, we conducted a secondary analysis of randomized controlled trial participants followed prospectively for 90 days after an emergency department (ED) visit for acute back or kidney stone pain.MethodsA total of 1301 individuals were randomized during an encounter at four academic EDs into a probabilistic risk tool (PRT) arm, a narrative‐enhanced PRT arm, or a general risk information arm (control). In this secondary analysis, both risk tool arms were combined and compared with the control arm. We used logistic regressions to determine associations between receiving personalized risk information, receiving an opioid prescription in the ED, and nonprescribed opioid use in general and by race.ResultsComplete follow‐up data were available for 851 participants; 23.3% (n = 198) were prescribed opioids (34.2% of White vs. 11.6% of Black participants, p < 0.001). Fifty‐six (6.6%) participants used nonprescribed opioids. Participants in the personalized risk communication arms had lower nonprescribed opioid use odds (adjusted odds ratio [aOR] 0.58, 95% confidence interval [CI] 0.4–0.83). Black versus White participants had greater nonprescribed opioid use odds (aOR 3.47, 95% CI 2.05–5.87, p < 0.001). Black participants who were prescribed opioids had a lower marginal probability of using nonprescribed opioids versus those who were not (0.06, 95% CI 0.04–0.08, p < 0.001 vs. 0.10, 95% CI 0.08–0.11, p < 0.001). The absolute risk difference in nonprescribed opioid use for Black and White participants, respectively, in the risk communication versus the control arm, was 9.7% and 0.1% (relative risk ratio 0.43 vs. 0.95).ConclusionsAmong Black but not White participants, personalized opioid risk communication and opioid prescribing were associated with lower odds of nonprescribed opioid use. Our findings suggest that racial disparities in opioid prescribing—which have been previously described within the context of this trial—may paradoxically increase nonprescribed opioid use. Personalized risk communication may effectively reduce nonprescribed opioid use, and future research should be designed specifically to explore this possibility in a larger cohort.