Dimitre G. Stefanov

Abridged Mindfulness Intervention to Support Wellness in First-Year Medical Students

Background: Medical students experience a high burden of stress and suffer elevated rates of depression, burnout, and suicide compared to the general population, yet there is no consensus on how to address student wellness. Purposes: The purpose of this study was to determine whether an abridged mindfulness based stress reduction (MBSR) intervention can improve measures of wellness in a randomized sample of 1st-year medical students. Methods: Fifty-eight participants were randomized to control or 8-week MBSR intervention and then invited to participate in the study. All participants were assessed using the Perceived Stress Scale (PSS), the Resilience Scale (RS), and Self-Compassion Scale (SCS) at 3 separate time points: baseline, at the conclusion of the study intervention (8 weeks), and at 6 months after the conclusion of the intervention. The intervention consisted of 75 minutes of weekly class time, suggested meditation at home, and a half-day retreat in the last week. Results: The intervention group achieved significant increase on SCS scores both at the conclusion of the study (0.58, p =.002), 95% confidence interval (CI) [0.23, 0.92], and at 6 months (0.56, p =.001), 95% CI [0.25, 0.87]. PSS scores achieved significant reduction at the conclusion of the study (3.63, p =.03), 95% CI [0.37, 6.89], but not at 6 months poststudy (2.91, p =.08), 95% CI [–0.37, 6.19]. The study did not demonstrate a difference in RS after the intervention, though RS was significantly correlated with both SCS and PSS. Conclusions: An abridged MBSR intervention improves perceived stress and self-compassion in 1st-year medical students and may be a valuable curricular tool to enhance wellness and professional development.

Validation of a clinical assessment score for pediatric sleep-disordered breathing.

To validate a clinical assessment score for pediatric sleep‐disordered breathing.

Inverse Correlation Between Helicobacter pylori Colonization and Obesity in a Cohort of Inner City Children

Recently, publications in adults and children have documented a potential role of Helicobacter pylori (H. pylori) in decreasing the likelihood of obesity. The present study compares the prevalence of H. pylori colonization between obese (body mass index [BMI] ≥ 95th percentile) and healthy weight (BMI ≥ 5th to <85th percentiles) children seen at an inner city medical center in the United States.

Eating Behavior, Low-Frequency Functional Mutations in the Melanocortin-4 Receptor (MC4R) Gene, and Outcomes of Bariatric Operations: A 6-Year Prospective Study.

OBJECTIVE Data on the effects of eating behavior and genetics on outcomes of gastrointestinal surgery for diabesity have been sparse, often flawed, and controversial. We aimed to assess long-term outcomes of bariatric operations in patients characterized for eating behavior and rare mutations in the melanocortin-4 receptor (MC4R) gene, which is strongly implicated in energy balance. RESEARCH DESIGN AND METHODS Between 1996 and 2005, 1,264 severely obese Swiss patients underwent current laparoscopic adjustable gastric banding, gastroduodenal bypass, or a hybrid operation. Of these, 872 patients were followed for a minimum of 6 years and were screened for MC4R mutations. Using regression models, we studied relationships between eating behavior and MC4R mutations and postoperative weight loss, complications, and reoperations after 6 years. RESULTS At baseline, rare functional MC4R mutation carriers exhibited a significantly higher prevalence of binge eating disorder (BED) or loss-of-control eating independent of age, sex, and BMI. Six years after bariatric surgery, the mutation carriers had more major complications than wild-type subjects independent of age, baseline BMI, sex, operation type, and weight loss. Furthermore, high baseline BMI, male sex, BED, and functional MC4R mutations were independent predictors of higher reoperation rates. CONCLUSIONS Sequencing of MC4R and eating typology, combined with stratification for sex and baseline BMI, might significantly improve patient allocation to banding or bypass operations for diabesity as well as reduce both complication and reoperation rates.

Mortality after Renal Allograft Failure and Return to Dialysis

Introduction: The outcomes of patients who fail their kidney transplant and return to dialysis (RTD) has not been investigated in a nationally representative sample. We hypothesized that variations in management of transplant chronic kidney disease stage 5 leading to kidney allograft failure (KAF) and RTD, such as access, nutrition, timing of dialysis, and anemia management predict long-term survival. Methods: We used an incident cohort of patients from the United States Renal Data System who initiated hemodialysis between January 1, 2003 and December 31, 2008, after KAF. We used Cox regression analysis for statistical associations, with mortality as the primary outcome. Results: We identified 5,077 RTD patients and followed them for a mean of 30.9 ± 22.6 months. Adjusting for all possible confounders at the time of RTD, the adjusted hazards ratio (AHR) for death was increased with lack of arteriovenous fistula at initiation of dialysis (AHR 1.22, 95% CI 1.02-1.46, p = 0.03), albumin <3.5 g/dL (AHR 1.33, 95% CI 1.18-1.49, p = 0.0001), and being underweight (AHR 1.30, 95% CI 1.07-1.58, p = 0.006). Hemoglobin <10 g/dL (AHR 0.96, 95% CI 0.86-1.06, p = 0.46), type of insurance, and zip code-based median household income were not associated with higher mortality. Glomerular filtration rate <10 mL/min/1.73 m2 at time of dialysis initiation (AHR 0.83, 95% CI 0.75-0.93, p = 0.001) was associated with reduction in mortality. Conclusions: Excess mortality risk observed in patients starting dialysis after KAF is multifactorial, including nutritional issues and vascular access. Adequate preparation of patients with failing kidney transplants prior to resuming dialysis may improve outcomes.

Mortality on the Kidney Waiting List and After Transplantation in Patients With Peripheral Arterial Disease: An Analysis of the United States Renal Data System

BACKGROUND Reports from the United States Renal Data System (USRDS) indicated that kidney transplantation, whether from a living donor (LD) or deceased donor (DD), offers survival advantage over being on the waiting list. Whether this is true for patients with peripheral arterial disease (PAD) is unknown given that patients with PAD have significant comorbidities. METHODS We used a cohort of USRDS incident dialysis patients from 2001 to 2007, with follow-up through 2008. Patients with PAD younger than the age of 70 were included and divided into 3 groups; PAD waitlisted, PAD patients who received a first transplant from a DD, or PAD patients who received a first transplant from a LD. Time-dependent Cox regression models were used to compare differences in mortality. RESULTS In this study, 23,699 incident dialysis patients met inclusion criteria; only 16.7% (n = 3964) were waitlisted, of which 8.9 % (n = 2121) underwent transplantation. Patient survival in the LD group at any time point was significantly better than being on the waiting list (P < .001). For DD, mortality was higher in the first year compared with waitlisted patients (P < .001), however, after 1 year survival did not differ as compared with remaining on the waiting list. After adjusting for confounders, the relative risk (RR) of dying was significantly higher for patients with history of severe vascular disease requiring amputation (RR, 1.45; 95% confidence interval [CI], 1.15-1.84) in the DD group. CONCLUSIONS Kidney transplantation from a DD did not offer survival advantage over being on the waiting list, in part due to a higher rate of severe vascular disease. Careful patient selection may improve outcomes in the DD group.

Clinical utility of corpus callosum measurements in head sonograms of preterm infants: a cohort study

Objective To assess the clinical usefulness of measurement of corpus callosum (CC) size in head ultrasound (HUS) to predict short-term neurodevelopmental (ND) outcomes in preterm infants. We hypothesised that including CC measurements in routine HUS will be an additional tool for early identification of infants at risk of adverse short-term ND outcome, over and above the predictive power of perinatal morbidities. Design Retrospective cohort study. Setting Level III neonatal intensive care unit (NICU) and outpatient NICU follow-up clinic of an academic medical centre in New York City. Participants 929 HUS of 502 infants with gestational age of 23–36 weeks in African-American infants were initially studied. Exclusion criteria included those who died, had gross abnormalities in HUS, infants with race other than African-American, infants with suboptimal quality of HUS, late preterm infants and infants who did not participate in ND follow-up. A total of 173 infants completed the study. Interventions CC size (length and thickness) was measured in a subset of 87 infants who had routine HUS between 23 and 29 weeks (0–6 postnatal weeks). Relevant clinical variables were collected from chart reviews. ND assessments were completed in outpatient follow-up clinics. A statistical model was developed to assess the clinical utility and possible predictive value of CC measurements for adverse short-term ND outcome, while adjusting for perinatal morbidities. Primary and secondary outcome measures CC size and ND status. Results Measurements of CC size did not add substantial predictive power to predict short-term ND outcome beyond the information provided by the presence of morbidities related to prematurity. Conclusions No association was found between morbidities related to prematurity and short-term ND outcome and CC size in preterm infants. CC measurements in HUS early in life did not have an additional value in predicting short-term ND outcome, therefore did not seem to provide further clinical utility.

The Influence of Dosage and Timing of Caffeine Administration on Neurodevelopmental Outcome of Very Preterm Infants

Objective: To analyze starting time (early versus late) and duration of caffeine treatment and its possible influence on neurodevelopmental (ND) outcome in very preterm infants. Hypothesis: Early initiation of caffeine treatment with longer duration of treatment may significantly improve ND outcome in very preterm infants. Design: Retrospective cohort study. Setting: Level III Neonatal Intensive care Unit (NICU) and out-patient NICU follow-up clinic of an academic medical center in New York City. Participants: A total of 146 inborn infants with gestational ages (GA) of 23-32 weeks who received caffeine treatment were included in this study with the following exclusion criteria: incomplete clinical data, insufficient ND follow-up and transfer of infants to other facilities. Interventions: Information on the administration of Caffeine Citrate injection USP and Caffeine Citrate oral solution (20 mg/ml equivalent to 10 mg caffeine base) including duration of treatment were obtained from individual chart reviews. Primary outcome measure: Normal and adverse (mild/moderate, severe) ND outcome. Results: Duration and starting point (early versus late) of caffeine treatment were not associated with ND outcome; adjusted for GA, head ultrasound (HUS) results and gender. The only significant predictor of ND outcome was GA. Conclusion: Gestational age (GA) seems to have more of an influence on ND outcome than caffeine citrate treatment regardless of duration (i.e., dose) and onset (early versus late) of such treatment.

Regulatory BC1 RNA in cognitive control

Dendritic regulatory BC1 RNA is a non-protein-coding (npc) RNA that operates in the translational control of gene expression. The absence of BC1 RNA in BC1 knockout (KO) animals causes translational dysregulation that entails neuronal phenotypic alterations including prolonged epileptiform discharges, audiogenic seizure activity in vivo, and excessive cortical oscillations in the γ frequency band. Here we asked whether BC1 RNA control is also required for higher brain functions such as learning, memory, or cognition. To address this question, we used odor/object attentional set shifting tasks in which prefrontal cortical performance was assessed in a series of discrimination and conflict learning sessions. Results obtained in these behavioral trials indicate that BC1 KO animals were significantly impaired in their cognitive flexibility. When faced with conflicting information sources, BC1 KO animals committed regressive errors as they were compromised in their ability to disengage from recently acquired memories even though recall of such memories was in conflict with new situational context. The observed cognitive deficits are reminiscent of those previously described in subtypes of human autism spectrum disorders.

Impact of music in reducing patient anxiety during pediatric ultrasound

The use of noninvasive ultrasound examinations can potentially result in significant anxiety in the pediatric population. The purpose of this study was to assess the influence of music during pediatric ultrasound examinations to reduce anxiety measured by heart rate. A total of 44 patients were recruited; 21 controls and 23 experimental. Each participant was randomized to either music or no music (control) after parental consent was obtained. Pulse oximeters were used to monitor heart rate at 15 second intervals for a total of 1 minute, with mean values calculated prior to entering the procedure room, during the middle of the procedure, and after the procedure was completed. The total scan time was determined from the initial image acquisition until the last image recorded by the ultrasound technologist. At the completion of each procedure, the ultrasound technologist scored the ease of performance for the scan on a subjective scale of 1-10 based on prior experience. When utilizing music during pediatric ultrasounds examinations, our study demonstrated significantly decreased heart rate variability from pre-procedural to post-procedural periods. There was no statistical significant difference in total scan time or ultrasound technologist scoring between the two groups. This study demonstrates that music is an inexpensive and effective means of reducing anxiety during pediatric ultrasound as indicated by heart rate.