Zhang, Nan

AbstractBackgroundThe pleiotropic effects of statin therapy on inflammation and coagulation may reduce the risk of venous thromboembolism. This study evaluated whether statin therapy is associated with decreased venous thromboembolic (VTE) events following kidney transplantation.MethodsWe performed a retrospective analysis of all primary kidney transplants performed between January 2014 and December 2019 at Mayo Clinic Arizona. Patients were divided into two groups depending on sustained statin therapy during the first year following transplantation. Recipient and donor clinical and demographic data were collected. The primary outcome was admission for symptomatic VTE events (deep vein thrombosis [DVT] or pulmonary embolism [PE]).ResultsSustained statin therapy in the first year following transplant was observed in 16.1% (n = 223) of 1384 kidney transplants. The overall incidence of VTE events in the year following kidney transplant was 3.8%. VTE occurred in 4.1% of recipients treated with statins and 3.8% of the controls – (hazard ratio [HR] .92, 95% confidence interval [95% CI] .39, 2.21, p = .86). However, there were significant differences between the groups in terms of age, sex, race/ethnicity, body mass index, indication for transplant, diagnosis of diabetes and discharge antiplatelet or anticoagulant therapy. Following sensitivity analysis in which cohort matching was performed to account for these differences, there was no difference in VTE event‐free survival (HR .89, 95% CI .41, 1.96, p = .78) or overall survival (HR .54, 95% CI .15, 1.94, p = .35) between patients treated with statins compared to controls.ConclusionStatin therapy in the year following successful kidney transplant was not associated with a reduction in risk of VTE.

ImportanceThere was a shift in patient volume from in-person to video telemedicine visits during the COVID-19 pandemic.ObjectiveTo determine the concordance of provisional diagnoses established at a video telemedicine visit with diagnoses established at an in-person visit for patients presenting with a new clinical problem.Design, Setting, and ParticipantsThis is a diagnostic study of patients who underwent a video telemedicine consultation followed by an in-person outpatient visit for the same clinical problem in the same specialty within a 90-day window. The provisional diagnosis made during the video telemedicine visit was compared with the reference standard diagnosis by 2 blinded, independent medical reviewers. A multivariate logistic regression model was used to determine factors significantly related to diagnostic concordance. The study was conducted at a large academic integrated multispecialty health care institution (Mayo Clinic locations in Rochester, Minnesota; Scottsdale and Phoenix, Arizona; and Jacksonville, Florida; and Mayo Clinic Health System locations in Iowa, Wisconsin, and Minnesota) between March 24 and June 24, 2020. Participants included Mayo Clinic patients residing in the US without age restriction. Data analysis was performed from December 2020 to June 2021.ExposuresNew clinical problem assessed via video telemedicine visit to home using Zoom Care Anyplace integrated into Epic.Main Outcomes and MeasuresConcordance of provisional diagnoses established over video telemedicine visits compared against a reference standard diagnosis.ResultsThere were 2393 participants in the analysis. The median (IQR) age of patients was 53 (37-64) years; 1381 (57.7%) identified as female, and 1012 (42.3%) identified as male. Overall, the provisional diagnosis established over video telemedicine visit was concordant with the in-person reference standard diagnosis in 2080 of 2393 cases (86.9%; 95% CI, 85.6%-88.3%). Diagnostic concordance by International Statistical Classification of Diseases and Related Health Problems, Tenth Revision chapter ranged from 64.7% (95% CI, 42.0%-87.4%) for diseases of the ear and mastoid process to 96.8% (95% CI, 94.7%-98.8%) for neoplasms. Diagnostic concordance by medical specialty ranged from 77.3% (95% CI, 64.9%-89.7%) for otorhinolaryngology to 96.0% (92.1%-99.8%) for psychiatry. Specialty care was found to be significantly more likely than primary care to result in video telemedicine diagnoses concordant with a subsequent in-person visit (odds ratio, 1.69; 95% CI, 1.24-2.30; P < .001).Conclusions and RelevanceThis diagnostic study of video telemedicine visits yielded a high degree of diagnostic concordance compared with in-person visits for most new clinical concerns. Some specific clinical circumstances over video telemedicine were associated with a lower diagnostic concordance, and these patients may benefit from timely in-person follow-up.

Abstract Objective To compare the artificial intelligence‐enabled electrocardiogram (AI‐ECG) atrial fibrillation (AF) prediction model output in patients with migraine with aura (MwA) and migraine without aura (MwoA). Background MwA is associated with an approximately twofold risk of ischemic stroke. Longitudinal cohort studies showed that patients with MwA have a higher incidence of developing AF compared to those with MwoA. The Mayo Clinic Cardiology team developed an AI‐ECG algorithm that calculates the probability of concurrent paroxysmal or impending AF in ECGs with normal sinus rhythm (NSR). Methods Adult patients with an MwA or MwoA diagnosis and at least one NSR ECG within the past 20 years at Mayo Clinic were identified. Patients with an ECG‐confirmed diagnosis of AF were excluded. For each patient, the ECG with the highest AF prediction model output was used as the index ECG. Comparisons between MwA and MwoA were conducted in the overall group (including men and women of all ages), women only, and men only in each age range (18 to <35, 35 to <55, 55 to <75, ≥75 years), and adjusted for age, sex, and six common vascular comorbidities that increase risk for AF. Results The final analysis of our cross‐sectional study included 40,002 patients (17,840 with MwA, 22,162 with MwoA). The mean (SD) age at the index ECG was 48.2 (16.0) years for MwA and 45.9 (15.0) years for MwoA ( p < 0.001). The AF prediction model output was significantly higher in the MwA group compared to MwoA (mean [SD] 7.3% [15.0%] vs. 5.6% [12.4%], mean difference [95% CI] 1.7% [1.5%, 2.0%], p < 0.001). After adjusting for vascular comorbidities, the difference between MwA and MwoA remained significant in the overall group (least square means of difference [95% CI] 0.7% [0.4%, 0.9%], p < 0.001), 18 to <35 (0.4% [0.1%, 0.7%], p = 0.022), and 35 to <55 (0.5% [0.2%, 0.8%], p < 0.001), women of all ages (0.6% [0.3%, 0.8%], p < 0.001), men of all ages (1.0% [0.4%, 1.6%], p = 0.002), women 35 to <55 (0.6% [0.3%, 0.9%], p < 0.001), and men 18 to <35 (1.2% [0.3%, 2.1%], p = 0.008). Conclusions Utilizing a novel AI‐ECG algorithm on a large group of patients, we demonstrated that patients with MwA have a significantly higher AF prediction model output, implying a higher probability of concurrent paroxysmal or impending AF, compared to MwoA in both women and men. Our results suggest that MwA is an independent risk factor for AF, especially in patients <55 years old, and that AF‐mediated cardioembolism may play a role in the migraine–stroke association for some patients.

Abstract Objective The purpose of this study was to characterize cutaneous heat and light‐induced pain thresholds in people with post‐traumatic headache (PTH) compared with healthy controls (HCs). Background Photophobia and allodynia are common in PTH, and there is emerging evidence to support multimodal sensory dysfunction. Methods In this age‐ and sex‐matched cohort study, individuals with PTH ( n = 20) and HCs ( n = 20), aged 18–65 years, were recruited from an institutional database of research volunteers, from the concussion clinic, and via the use of approved flyers posted on the Mayo Clinic Campus in Scottsdale, Arizona. Participants were assessed using the Allodynia Symptom Checklist (ASC‐12), Photosensitivity Assessment Questionnaire (PAQ), State Trait Anxiety Inventory (STAI), and Beck Depression Inventory (BDI). Quantitative sensory testing quantified heat pain thresholds. A light stimulation device quantified light‐induced pain thresholds. Subsequently, heat pain thresholds were obtained immediately, 10, and 40 min after a bright light stressor. Results The mean photophobia symptom severity score, based on the PAQ, was higher in participants with PTH compared with HCs, mean 0.62 (SD = 0.25) versus mean 0.24 (SD = 0.24), p < 0.001. Light‐induced pain thresholds were lower in participants with PTH (median = 90.5 lux and quartiles = 17.8 to 378.5) compared with HCs (median = 863.5 lux and quartiles = 519.9 to 4906.5) and were independent from BDI and STAI ( p < 0.001). Allodynia scores did not differ between participants with PTH and HCs after adjusting for BDI and STAI scores. Baseline forehead heat pain thresholds were not different, participants with PTH mean 41.9°C (SD = 0.89) versus HCs mean 44.3°C (SD = 0.89), p = 0.061; however, forearm heat pain thresholds were lower in participants with PTH compared with HCs, mean 40.8°C (SD = 0.80) versus mean 44.4°C (SD = 0.80), p = 0.002. The forehead heat pain threshold change from baseline post bright light stressor in participants with PTH versus HCs was different immediately (mean −1.2 (SD = 0.53), p = 0.025), 10 min (mean −1.8 (SD = 0.74), p = 0.015), and 40 min (mean −1.8 (SD = 0.88), p = 0.047). The forearm heat pain threshold change immediately post bright light stressor in participants with PTH versus HCs was different, mean −1.9°C (SD = 0.58), p = 0.001, however, not different at 10 and 40 min. Conclusions Photophobia is higher and light‐induced pain thresholds are lower in participants with PTH. Exposure to a light stressor reduced heat pain thresholds in participants with PTH immediately post bright light stressor, but not in HCs. This study provides evidence for multimodal sensory dysfunction in people with PTH.

Studies have shown that prosection and dissection facilitate similar academic outcomes and promote meaningful learning in anatomy laboratory courses. While dissection is the mainstay of many graduate level anatomy curricula, financial and other constraints have increased the use of prosection. This research evaluates student preference for studying different body regions and accomplishing learning outcomes related to content knowledge, teamwork, career preparation, humanistic learning, and wellness. First‐year medical students (n=51) who completed a hybrid prosection and dissection course completed a post‐course survey about their perceptions of the effectiveness of each lab learning modality. Response options included prosection, dissection, no preference (equally effective), and no preference (equally ineffective). A one‐way ANOVA was used to evaluate performance differences on course assessments between students in the hybrid course and students in past years who participated in a dissection based course. The response rate was 51%. Respondents preferred dissection for learning the back (62%), thorax (68%), abdomen (54%), shoulder, axilla, and arm (61.5%), and hip, thigh, and leg (46%). Prosection was favored for the pelvis (perineum 81%, cavity 69%), foot (58%), hand (46%), and head/neck (64%). Students favored dissection for gaining hands‐on skills relevant to surgical practice, appreciating anatomical variation, becoming more comfortable handling the human body, engaging in self‐directed learning, and fostering teamwork. Respondents felt prosection provided more time for independent study and wellness activities. Prosection and dissection were rated equally effective for developing a medical vocabulary, applying anatomical knowledge to clinical conditions, and gaining a 3D appreciation of the body. A hybrid prosection and dissection course was preferred by 73% of respondents, compared to 4% who ranked prosection alone as their preference; no students ranked dissection alone as their first choice. There were no statistically significant differences in academic performance related to teaching methods (F(3,195) = 2.65, p=0.34) between students in the hybrid course and students in previous dissection only courses. Students prefer prosection for learning more spatially complex and intricate regions requiring time‐consuming and skilled dissection. However, learners recognize distinct benefits of dissection for acquiring various technical and non‐technical skills. Hybrid courses should capitalize on the strengths of each method, aligning instructional methods with outcomes and incorporating learner preferences to achieve meaningful, lasting learning.

ObjectivesThis study was designed to evaluate significant differences in treatment and survival outcomes between patients with T1a and T1b glottic cancer.MethodsPatients within the SEER Research Plus, 18 Registries dataset who were diagnosed with Stage I T1a or T1b cancer of the glottis between 2004 and 2015 were included in this study. Data prior to 2004 could not be included, as the SEER database did not distinguish between T1a and T1b glottic cancer until that year.ResultsThe 5‐year disease‐specific survival for T1a patients was significantly better than that of patients diagnosed with T1b glottic cancer. Age and year of diagnosis were also independent factors that impacted mortality. More patients who were diagnosed with T1b glottic cancer underwent external beam radiation than those diagnosed with T1a glottic cancer.ConclusionOur data shows that there are several independent factors effecting mortality including T classification, age at time of diagnosis, and year of diagnosis. T1a glottic cancers also show a significantly better prognosis compared with T1b. T1b glottic cancers are much more likely to be treated with primary radiotherapy compared with surgery.Level of Evidence4 Laryngoscope, 132:2187–2193, 2022

ABSTRACT Background Nephrolithiasis in allograft kidneys is rare, but this diagnosis may lead to allograft complications and patient morbidity. Previous studies that have evaluated nephrolithiasis posttransplant have focused on surgical stone management, with limited data on urine metabolic risk factors and the presence of stones after follow-up. Methods We retrospectively evaluated kidney transplant recipients who were diagnosed with transplant nephrolithiasis between 2009 and 2019. Computed tomography and ultrasound imaging were used to confirm stone presence. Results The incidence of allograft kidney stone formation was 0.86% of 6548 kidney transplant recipients. Of the 56 cases identified, 17 (30%) had a pretransplant history of nephrolithiasis. Only four (7%) patients received a known kidney stone at the time of allograft implantation. Of the 56 cases, 34 had a 24-h supersaturation study. The urine supersaturation study showed 32 patients (94%) had a urine citrate of &lt;450 mg excreted in 24 h (median 124.5 mg/24 h, reference range &gt;500 mg/24 h), along with 22 patients (61%) having a urine oxalate excretion of ≥30 mg in 24 h (median 34.4 mg/24 h, reference range &lt;30 mg/24 h). Calcium oxalate composition was most common (91% with &gt;1 supersaturation for calcium oxalate crystals), with normal median urine calcium levels (median urine calcium 103.5 mg/24 h, reference range &lt;200 mg/24 h). After a 4-year follow-up, 50% (n = 28) required surgical intervention and 43 (77%) patients continued to have evidence of transplant nephrolithiasis on imaging. Conclusions This is the largest study of transplant nephrolithiasis confirming that hypocitraturia and hyperoxaluria were the most significant urine metabolic risk factors associated with allograft nephrolithiasis and that hyperoxaluria was the most prevalent driver for calcium oxalate stone composition. Our study is first to show low stone-free rates at the last follow-up and a significant proportion requiring surgical intervention.

ObjectivesTo determine whether renal transplant diagnoses substantially change when 2 biopsy sites are chosen and whether contrast‐enhanced ultrasound (CEUS) has value for targeting the second site.MethodsWe prospectively enrolled 40 patients undergoing ultrasound‐guided renal transplant biopsy within 2 years of transplant: 20, surveillance; and 20, for cause. A CEUS examination was performed to identify cortical regions with subjectively altered flow. One biopsy was performed at the operator‐preferred (primary) site regardless of CEUS findings. Another biopsy was done at a second location, either targeted to an area in which CEUS perfusion findings differed from the primary site (targeted) or at a random location (secondary) if no other area differed. Specimens were randomly labeled A or B; pathologists were blinded to the CEUS result and biopsy location. Location‐specific CEUS assessments were recorded. Pathologic results were compared, including acute and chronic Banff scores and any new findings from the targeted or secondary biopsy.ResultsForty patients were enrolled between January 2016 and December 2018. No location‐specific pathologic differences correlated with differences in CEUS assessments. The second biopsy provided additional information that changed management in 4 of 40 patients (10.0% [95% confidence interval, 2.8%–23.7%]). Major bleeding complications occurred in 3 of 40 (7.5%) patients.ConclusionsContrast‐enhanced ultrasound targeting was not useful. Major bleeding complications were higher than expected, possibly due to the additional biopsy away from the operator‐preferred location. Obtaining a second renal transplant biopsy from a substantially different area than the initial operator‐preferred location provided additional clinically useful information in 10% of patients.