Citations

Introduction: Limited research explores dermoscopy use among physician associates (PAs), outside of one prior study examining dermoscopy in PA student education. This study sought to investigate dermoscopy use among practicing PAs and its impact on their overall diagnostic confidence, including in darker skin tones, when differentiating between benign and malignant skin lesions. Methods: An anonymous survey was developed in 2023 with input from experts in dermoscopy and survey creation to assess PA confidence in skin lesion evaluation as well as PA dermoscopy knowledge and use, perceptions, barriers to use, and prior education. The dermoscopy survey was included as an optional module in the 2024 American Academy of Physician Associates (AAPA) Salary Survey. Results: Of 3,174 invited PAs, 995 (31.4%) responded. Most had never used dermoscopy in practice (81%) but knew or recognized the term (71%). A majority (53%) believed PAs should be trained in dermoscopy during PA school, and 26% reported no interest in future dermoscopy use. Dermatology PAs reported more frequent dermoscopy use and generally greater confidence in evaluating skin lesions, both overall and in darker skin tones, than PAs in other specialties. PAs in surgical (OR=0.2, 95% CI 0.1-0.6) and medical (OR=0.3, 95% CI 0.2-0.5) subspecialties were less likely to use dermoscopy at least annually compared with PAs in primary care. PAs in rural areas were more likely to feel confident in differentiating skin lesions than those in urban areas (OR 2.9, 95% CI 1.7-5.0). Conclusion: Dermoscopy use is associated with higher overall skin lesion assessment confidence. Wider adoption, especially outside dermatology, requires training, increased advocacy, and expanded education.

Abstract Background Atypical clinical presentations of Alzheimer's disease (AD) are associated with heterogeneous patterns of cortical tau‐PET uptake. The medial‐temporal (MTL) meta‐ROI is typically used to determine tau‐PET abnormality in AD, but this approach may not detect focal uptake in atypical patients. Our goal was to develop regional tau‐PET cut‐points and determine whether the number of positive regions better captures positive tau‐PET signal in atypical AD. Method 127 amyloid‐positive atypical AD (visual=68, language=39, motor=15, others=5) and 62 amyloid‐negative cognitively unimpaired (CU) individuals were recruited by the Neurodegenerative Research Group, Mayo Clinic, and underwent, amyloid‐PET and 18 F‐AV‐1451(tau)‐PET. Images were parcellated using the modified Harvard‐Oxford atlas and we focused on 67 AD‐specific regions. Rather than using the average SUVR across voxels within a region to quantify uptake, we used the 95 th percentile of SUVR values across voxels within a region to capture focal cases. We then used receiver operating characteristic (ROC) methods and a Youden threshold to define regional abnormality. The number of abnormal regions was calculated for each participant and used to discriminate between CU and atypical AD at the individual level. Result Across 64 regions, our approach showed excellent (AUROC>0.90) differentiation between atypical AD and CU. The temporal‐fusiform, parahippocampal gyrus and inferior temporal gyrus showed the best differentiation (Figure 1). All 67 regions showed excellent specificity (>85%), with 63 regions showing excellent sensitivity (≥80%). The lateral occipital cortex, temporal‐fusiform and parahippocampal gyrus showed the best specificity and sensitivity (Figure 2). The distribution of the number of tau‐elevated regions is shown in Figure 3. 74% of CU had no positive regions, while 43% of the atypical AD patients had all 67 regions affected. An optimal threshold of 7 tau‐elevated regions classified all CU below, and 123 (97%) atypical AD above threshold. Using a standard approach based on the average SUVR in the MTL meta‐ROI, only 116 (91%) atypical AD patients were tau‐PET positive. Conclusion Tau uptake in temporal regions showed the greatest group‐level differentiation. However, examining regional tau‐positivity may offer better sensitivity in atypical AD patients compared to the temporal meta‐ROI, likely due to the presence of focal non‐temporal patterns of uptake.

Immune checkpoint inhibitors (ICIs) have improved cancer prognosis significantly, but their use has been avoided in liver transplant recipients (LTr) due to poorly characterized rejection risk. Data surrounding rejection risk are extremely suboptimal, with highly variable immunosuppression approaches and follow-up, and do not account for the learning curve in managing immunosuppression in the setting of ICI. A standardized institutional clinical practice protocol was developed in 2021 for immunosuppression management to facilitate ICI therapy with prospective close follow-up for immunosuppression levels and allograft function. Of 20 LTr, 12 (60%) were male, 18 (90%) were Caucasian, with a mean age of 54.0 (SD 11.2) years. However, 13/20 had 2 or more failed cancer therapies before ICI. Hepatocellular carcinoma ​(HCC) (N=7), lung (N=3), and melanoma (N=3) were the most frequent. Time from first ICI treatment to death was <30 days (N=5), 30–59 days (N=4), 60–89 days (N=1), and >90 days (N=6). Most deaths were cancer-related, reflecting the late stage of disease. ICI toxicity occurred in 3 LTr; pneumonitis (N=1, 5%), myocarditis (N=1, 5%), and acute cellular rejection (N=1, 5%). Four patients remain alive 178–341 days with stable allograft function and slow reduction in immunosuppression. Three out of 4 patients have a partial cancer response, and 1 with slowed progression of disease. ICI treatment in the immunosuppressed LTr is feasible with careful immunosuppression management and follow-up. Demonstrating a low rejection risk should allow for earlier utilization of these agents to improve cancer prognosis. Optimizing rejection risk with cancer response requires ongoing study.

Abstract Introduction Comparing sleep and rest-activity rhythms (RARs) across the spectrum of cognitive aging can reveal novel risk factors and potential mechanisms underlying dementia disorders. However, our current understanding is restricted by differences in sleep measurement, limited longitudinal data, and heterogeneous cognitive aging processes. We aimed to determine (1) which sleep/RAR features exhibit meaningful changes within three distinct cognitive pathways; and (2) which sleep/RAR features differ between cognitive aging pathways prior to and after the onset of mild cognitive impairment (MCI) and/or dementia. Methods Longitudinal self-reported sleep and actigraphy data were obtained from 1,449 participants in the Rush Memory and Aging Project (mean age= 81.2±7.1 years, 75.2% female, 5.2% Black, 94.8% White). We applied flexible cubic spline models to quantify differences in the levels and trajectories of sleep amount (self-reported duration; actigraphy rest interval length and alpha), regularity (actigraphy interdaily stability, intradaily variability, and midpoint standard deviation), and timing (self-reported midpoint; actigraphy midpoint and acrophase) within and between three cognitive aging pathways over 12 years: Normal Cognitive Aging (‘Normal’), Progression to MCI (‘Stable MCI’), and Progression to Dementia (‘Dementia’). Models were adjusted for key sociodemographic and health variables. Results Sleep amount was lowest in the Dementia pathway prior to MCI or dementia, but increased with age, most rapidly following dementia. The greatest effect was observed in self-reported duration (standardized mean change, d[95%CI]=0.912 [0.47, 1.36]. Regularity declined across all pathways, most rapidly after cognitive diagnoses, with the largest increases in intradaily variability occurring among the Stable MCI (d=0.97 [0.70, 1.23]) and Dementia paths (d=1.11 [0.84, 1.38). Shifts toward earlier sleep timing were observed in actigraphy measures across all three pathways (-0.54≤d≤-0.31). Conclusion Shorter sleep amount in cognitively healthy older adults may be a risk factor or prodromal indicator of dementia, while longer sleep amounts and decreasing regularity following dementia may reflect neurodegeneration. Advances in sleep timing may be less useful as a clinical indicator of future cognitive impairment or decline. Differences between self-reported and actigraphy-measured sleep/RAR outcomes may reflect distinct underlying mechanisms, warranting further research. Support (if any) NIH: T32HL082610, RF1AG056331, R01AG052488, R01AG071638, RF1AG070436, R01AG17917

AbstractINTRODUCTIONComparing sleep and rest–activity rhythms across different cognitive aging pathways can identify novel risk factors and potential mechanisms. However, our current understanding is restricted by differences in sleep measurement, limited longitudinal data, and heterogeneous cognitive aging processes.METHODSWe applied cubic splines to longitudinal self‐reported sleep and actigraphy data from 1449 participants in the Rush Memory and Aging Project and quantified differences in the levels and trajectories of sleep amount, regularity, and timing within and between three cognitive aging pathways: normal, stable mild cognitive impairment, dementia.RESULTSSleep amount was lowest in the dementia pathway prior to cognitive impairment but increased with age, most rapidly after dementia. Regularity declined across all pathways, most rapidly after cognitive diagnoses. Timing advanced across all pathways.DISCUSSIONShorter sleep amount in cognitively healthy older adults may be a risk factor or prodromal indicator of dementia, while longer sleep amounts and decreasing regularity may reflect neurodegeneration.Highlights We quantified longitudinal changes in sleep across three cognitive‐aging pathways. We incorporated both subjective and objective measures of sleep health. Self‐report duration increased noticeably from before to after cognitive diagnosis. Sleep irregularity increased most prominently after cognitive diagnosis. Advances in sleep timing occurred in both normal and pathological aging.

Abstract Context Pituitary adenomas and cysts are rare in pediatric patients and improved understanding can guide management recommendations. Objective To report incidence, presentation, management, and outcomes in a pediatric population-based cohort with pituitary adenomas and cysts, and to explore the relationship between these lesions and brain magnetic resonance imaging (MRI) rates, as well as lesion size and headaches with disease progression. Methods In this retrospective cohort study of pediatric patients (≤18 years) with incident pituitary adenomas and cysts in Olmsted County, MN, from 1976 to 2021, 234 unique patients were identified using diagnostic codes through the Rochester Epidemiology Project, with 37 confirmed cases of pituitary adenoma or cyst included. Incidence rates were calculated using census data. Descriptive statistics were used for extracted clinical data. Results Incidence of pediatric adenomas and cysts was 2.29 cases per 100 000 person-years. Of the 37 cases, 68% were nonfunctioning adenomas or cysts, 27% were prolactinomas, and there was 1 each of growth hormone (GH)– and thyrotropin (TSH)-secreting adenomas. Median lesion diameter was 5.5 mm (IQR, 4.0-8.0). Median follow-up was 7.4 years (IQR, 4.5-15.4). Four patients had disease progression which stabilized with second-line therapy. Brain MRI rates did not correlate with lesion incidence. No clinically meaningful relationship was found between lesion size or headache and disease progression. Conclusion Pituitary adenomas and cysts are rare in pediatric patients. Most are small, nonfunctioning, and stable on long-term follow-up. Larger studies on small nonfunctioning pituitary lesions are needed to enhance understanding of their natural history and develop long-term management recommendations.

Abstract Racial inequities in postpartum weight have been documented with limited studies on the influences of racism and other forms of discrimination. In a prospective longitudinal study applying ecological momentary assessment (EMA) and ambulatory assessment of weight, we measured the association between discrimination, stress, and postpartum weight change. The Postpartum Mothers Mobile Study is a cohort of 313 pregnant and birthing individuals who were followed during their second and third trimesters through 1 year postpartum. They were recruited in clinical settings between 2017 and 2020 in a major city center in Pennsylvania. Measures of racism and gender-based discrimination were collected via random EMA surveys throughout pregnancy and postpartum, and weight was collected via Bluetooth-enabled scales at least weekly. Among Black participants, a 10% increase in the number of days a participant experienced racial discrimination in the past month was associated with retaining 0.3 more pounds, a 10% increase in EMA gender discrimination was associated with retaining 0.4 more pounds, and EMA stress reported in the past month was associated with decreased weight retention. Chronic experiences of racial and gender discrimination may contribute to weight retention immediately after pregnancy and beyond.