Eric W. Schaefer

Postpartum Anxiety and Maternal-Infant Health Outcomes

OBJECTIVE: Postpartum anxiety screening does not typically occur, despite changes in life roles and responsibility after childbirth. We sought to determine the prevalence of postpartum anxiety during the maternity hospitalization and its associations with maternal and child outcomes. We further aimed to compare correlates of anxiety with correlates of depression. METHODS: For a randomized controlled trial of mothers with “well” newborns ≥34 weeks’ gestation comparing 2 post–hospital discharge care models, mothers completed baseline in-person interviews during the postpartum stay and telephone surveys at 2 weeks, 2 months, and 6 months to assess health care use, breastfeeding duration, anxiety, and depression. All participants intended to breastfeed. State anxiety scores ≥40 on the State Trait Anxiety Inventory (STAI) and depression scores ≥12 on the Edinburgh Postnatal Depression Survey (EPDS) were considered positive. RESULTS: A total of 192 (17%) of 1123 participating mothers had a positive baseline STAI; 62 (6%) had a positive EPDS. Primiparity was associated with a positive STAI (20% vs 15%, P = .02), but not a positive EPDS (4% vs 7%, P = .05). Positive STAI scores were associated with cesarean delivery (22% vs 15%, P = .001), reduced duration of breastfeeding (P = .003), and increased maternal, but not infant total unplanned health care utilization within 2 weeks of delivery (P = .001). Positive STAI scores occurred more frequently than positive EPDS scores at each assessment through 6 months postpartum. CONCLUSIONS: Postpartum state anxiety is a common, acute phenomenon during the maternity hospitalization that is associated with increased maternal health care utilization after discharge and reduced breastfeeding duration. State anxiety screening during the postpartum stay could improve these outcomes.

Comparison of standard two-dimensional and three-dimensional corrected glenoid version measurements

HYPOTHESIS There is concern regarding the accuracy of 2-dimensional (2D) computed tomography (CT) for measuring glenoid version. Three-dimensional (3D) CT scan reconstructions can properly orient the glenoid to the plane of the scapula and have been reported to accurately measure glenoid version in cadaver models. We hypothesized that glenoid version measured by correcting 2D CT scans to the plane of the scapula by 3D reconstruction would be significantly different compared with standard 2D CT scan measurement of the glenoid in a clinical patient population. MATERIALS AND METHODS Thirty-four patients underwent dedicated axial 2D CT scan of the shoulder with 3D reconstruction. The 2D glenoid version was measured on unmodified midglenoid axial cuts, and the 3D glenoid version measurement was corrected to be perpendicular to the plane of the scapula and then measured in the axial plane. Three observers repeated each measurement on 2 different days. RESULTS The difference between the overall average 2D and 3D measurements was not statistically significant (P = .45). In individual scapulae, 35% of 2D measurements were 5° to 10° different and 12% were greater than 10° different from their corresponding 3D-corrected CT measurement (P < .001 to P = .045). Reproducibility of both 2D and 3D-corrected measurements was good. DISCUSSION Although 2D and 3D corrected methods showed a high degree of both intraobserver and interobserver reliability in this series, axial 2D images without correction were 5 to 15 degrees different than their 3D-corrected counterparts in 47% of all measurements. Correcting 2D glenoid version by 3D reconstruction to the transverse plane perpendicular to the scapular body allows for an accurate assessment of glenoid version in spite of positioning differences and results in increased accuracy while maintaining high reliability. CONCLUSIONS Owing to the variability in scapular position, the axial 2D CT scan measurement was significantly different from 3D-corrected measurement of glenoid version. Averaging the version measurements across patients did not reflect this finding.

Should Large Cell Neuroendocrine Lung Carcinoma be Classified and Treated as a Small Cell Lung Cancer or with Other Large Cell Carcinomas

Background: To compare the presenting and prognostic characteristics of patients with large cell neuroendocrine lung cancer (LCNELC) with those of patients with small cell lung cancer (SCLC) or other large cell carcinomas (OLCs) and to compare overall survival (OS) and lung cancer-specific survival (LCSS) rates for patients undergoing definitive resection without radiotherapy (S-NoRT). Methods: The Surveillance Epidemiology and End Results Database-17 from 2001 to 2007 was used. Differences between population characteristics were compared using &khgr;2 and Wilcoxon tests. The log-rank test and Cox models were used to compare differences in OS and LCSS. Results: There were 1211 patients with LCNELC (324 in the S-NoRT group), 8295 patients with OLC (1120 S-NoRT), and 35,304 patients with SCLC (355 S-NoRT). The proportion of all large cell carcinomas constituted by LCNELC increased from 8 to 21% during the study period; and the proportion of patients with large cell carcinoma undergoing S-NoRT increased from 16 to 26%. Presenting and histopathologic characteristics and treatment factors of patients undergoing S-NoRT for patients with LCNELC were more similar to those of patients with OLC than to those with SCLC. OS and LCSS rates for patients with LCNELC undergoing resection without radiation were similar to those of patients with OLC and better than those for patients with SCLC, but the differences were not statistically significant on multivariate analysis. Conclusions: The clinical, histopathologic, and biologic features of LCNELC are more similar to OLC than to SCLC. Therefore, LCNELC should continue to be classified and treated as a large cell carcinoma.

Effects of ischemic preconditioning and bevacizumab on apoptosis and vascular permeability following retinal ischemia-reperfusion injury

PURPOSE Using transient ischemia followed by reperfusion (IR) to model ischemic retinal disease, this study compares the effects of ischemic preconditioning (IPC) and therapies targeting vascular endothelial growth factor (VEGF) and tumor necrosis factor (TNF)-α on retinal apoptosis, vascular permeability, and mRNA expression. METHODS Rats were subjected to 30 or 45 minutes of retinal ischemia followed by reperfusion for up to 48 hours. Neurodegeneration was quantified by caspase-3 (DEVDase) activity and by measuring nucleosomal DNA content (cell death ELISA). Vascular leakage was quantified by the Evans Blue dye method. A set of IR-responsive mRNAs was identified by whole-genome microarray and confirmed by RT-PCR analyses. VEGF protein was measured by Western blot analysis. IPC was accomplished with 10 minutes of ischemia 24 hours before IR. VEGF and TNFα signaling was inhibited by intravitreal injection of bevacizumab or etanercept, respectively. RESULTS IR caused significant retinal cell apoptosis and vascular permeability after 4 and 48 hours. Whereas IR decreased VegfA mRNA, VEGF protein was significantly increased. IPC effectively inhibited neurodegeneration, bevacizumab effectively inhibited vascular permeability, and etanercept failed to affect either outcome. IPC significantly altered the IR responses of 15 of 33 IR-responsive mRNAs, whereas bevacizumab had no significant effect on these mRNAs. CONCLUSIONS IR provides an acute model of ischemic retinopathy that includes neurodegeneration and VEGF-dependent vascular permeability and is amenable to rapid drug therapy testing. The distinct effects of IPC and bevacizumab demonstrate that the apoptotic and vascular responses to IR may be separated and that therapeutics targeting each pathologic endpoint may be warranted in treating ischemic retinal diseases.

Positive and Negative Volume-Outcome Relationships in the Geriatric Trauma Population

IMPORTANCE In trauma populations, improvements in outcome are documented in institutions with higher case volumes. However, it is not known whether improved outcomes are attributable to the case volume within specific higher-risk groups, such as the elderly, or to the case volume among all trauma patients treated by an institution. OBJECTIVE To test the hypothesis that outcomes of trauma care for geriatric patients are affected differently by the volume of geriatric cases and nongeriatric cases of an institution. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study using a statewide trauma registry was set in state-designated levels 1 and 2 trauma centers in Pennsylvania. It included 39 431 eligible geriatric trauma patients (aged >65 years) in the Pennsylvania Trauma Outcomes Study. MAIN OUTCOMES AND MEASURES In-hospital mortality, major complications, and mortality after major complications (failure to rescue). RESULTS Between 2001 and 2010, 39 431 geriatric trauma patients and 105 046 nongeriatric patients were captured in a review of outcomes in 20 state-designated levels 1 and 2 trauma centers. Larger volumes of geriatric trauma patients were significantly associated with lower odds of in-hospital mortality, major complications, and failure to rescue. In contrast, larger nongeriatric trauma volumes were significantly associated with higher odds of major complications in geriatric patients. CONCLUSIONS AND RELEVANCE Higher rates of in-hospital mortality, major complications, and failure to rescue were associated with lower volumes of geriatric trauma care and paradoxically with higher volumes of trauma care for younger patients. These findings offer the possibility that outcomes might be improved with differentiated pathways of care for geriatric trauma patients.

Bisphenol A Exposure and the Development of Wheeze and Lung Function in Children Through Age 5 Years

IMPORTANCE Bisphenol A (BPA), a prevalent endocrine-disrupting chemical, has been associated with wheezing in children, but few studies have examined its effect on lung function or wheeze in older children. OBJECTIVES To test whether BPA exposure is associated with lung function, with wheeze, and with pattern of wheeze in children during their first 5 years. DESIGN, SETTING, AND PARTICIPANTS A birth cohort study, enrolled during early pregnancy in the greater Cincinnati, Ohio, area among 398 mother-infant dyads. We collected maternal urine samples during pregnancy (at 16 and 26 weeks) and child urine samples annually to assess gestational and child BPA exposure. MAIN OUTCOMES AND MEASURES We assessed parent-reported wheeze every 6 months for 5 years and measured child forced expiratory volume in the first second of expiration (FEV1) at age 4 and 5 years. We evaluated associations of BPA exposure with respiratory outcomes, including FEV1, child wheeze, and wheeze phenotype. RESULTS Urinary BPA concentrations and FEV1 data were available for 208 children and urinary BPA concentrations and parent-reported wheeze data were available for 360 children. The mean maternal urinary BPA concentration ranged from 0.53 to 293.55 µg/g of creatinine. In multivariable analysis, every 10-fold increase in the mean maternal urinary BPA concentration was associated with a 14.2% (95% CI, -24.5% to -3.9%) decrease in the percentage predicted FEV1 at 4 years, but no association was found at 5 years. In multivariable analysis, every 10-fold increase in the mean maternal urinary BPA concentration was marginally associated with a 54.8% increase in the odds of wheezing (adjusted odds ratio, 1.55; 95% CI, 0.91-2.63). While the mean maternal urinary BPA concentration was not associated with wheeze phenotype, a 10-fold increase in the 16-week maternal urinary BPA concentration was associated with a 4.27-fold increase in the odds of persistent wheeze (adjusted odds ratio, 4.27; 95% CI, 1.37-13.30). Child urinary BPA concentrations were not associated with FEV1 or wheeze. CONCLUSIONS AND RELEVANCE These results provide evidence suggesting that prenatal but not postnatal exposure to BPA is associated with diminished lung function and the development of persistent wheeze in children.

Outcome of induction immunosuppression for liver transplantation comparing anti‐thymocyte globulin, daclizumab, and corticosteroid

In addition to standard corticosteroid induction, anti‐thymocyte globulin (ATG) or daclizumab as induction immunosuppression has been reported for liver transplantation. However, the effects and long‐term outcomes of antibody induction therapy are not well known, especially for hepatitis C (HCV). The United Network for Organ Sharing (UNOS) database was utilized to analyze 16 898 adult primary liver transplant patients who received ATG alone (n = 452), ATG and steroids (ATG + S) (n = 1758), daclizumab alone (n = 683), or steroid alone (n = 14 005), listed as induction immunosuppression. Graft and patient survival, and donor and recipient factors for survival were analyzed for HCV and all liver diseases. For patients with HCV, ATG + S had significantly inferior graft survival compared with daclizumab (P = 0.01) and steroids (P = 0.03). The Cox proportional hazards model also showed that ATG + S was a marginal risk factor for graft failure (P = 0.05). On the other hand, for patients with all the liver diseases, graft and patient survival were not significantly different between induction regimens. ATG induction appeared to be preferentially used in patients with renal dysfunction, with improvement in renal function after liver transplantation. Thus, ATG induction can be used for patients with renal dysfunction in non‐HCV diseases. Daclizumab induction achieved satisfactory short‐term and long‐term outcomes of liver transplantation in all the liver diseases including HCV disease.

Early Weight Loss Nomograms for Exclusively Breastfed Newborns

BACKGROUND: The majority of newborns are exclusively breastfed during the birth hospitalization, and weight loss is nearly universal for these neonates. The amount of weight lost varies substantially among newborns with higher amounts of weight loss increasing risk for morbidity. No hour-by-hour newborn weight loss nomogram exists to assist in early identification of those on a trajectory for adverse outcomes. METHODS: For 161 471 term, singleton neonates born at ≥36 weeks’ gestation at Northern California Kaiser Permanente hospitals in 2009–2013, data were extracted from the birth hospitalization regarding delivery mode, race/ethnicity, feeding type, and weights from electronic records. Quantile regression was used to create nomograms stratified by delivery mode that estimated percentiles of weight loss as a function of time among exclusively breastfed neonates. Weights measured subsequent to any nonbreastmilk feeding were excluded. RESULTS: Among this sample, 108 907 newborns had weights recorded while exclusively breastfeeding with 83 433 delivered vaginally and 25 474 delivered by cesarean. Differential weight loss by delivery mode was evident 6 hours after delivery and persisted over time. Almost 5% of vaginally delivered newborns and >10% of those delivered by cesarean had lost ≥10% of their birth weight 48 hours after delivery. By 72 hours, >25% of newborns delivered by cesarean had lost ≥10% of their birth weight. CONCLUSIONS: These newborn weight loss nomograms demonstrate percentiles for weight loss by delivery mode for those who are exclusively breastfed. The nomograms can be used for early identification of neonates on a trajectory for greater weight loss and related morbidities.

Attributable Inpatient Costs of Recurrent Clostridium difficile Infections

OBJECTIVE To determine the attributable inpatient costs of recurrent Clostridium difficile infections (CDIs). DESIGN Retrospective cohort study. SETTING Academic, urban, tertiary care hospital. PATIENTS A total of 3,958 patients aged 18 years or more who developed an initial CDI episode from 2003 through 2009. METHODS Data were collected electronically from hospital administrative databases and were supplemented with chart review. Patients with an index CDI episode during the study period were followed up for 180 days from the end of their index hospitalization or the end of their index CDI antibiotic treatment (whichever occurred later). Total hospital costs during the outcome period for patients with recurrent versus a single episode of CDI were analyzed using zero-inflated lognormal models. RESULTS There were 421 persons with recurrent CDI (recurrence rate, 10.6%). Recurrent CDI case patients were significantly more likely than persons without recurrence to have any hospital costs during the outcome period (P < .001). The estimated attributable cost of recurrent CDI was

Posttraumatic contrast-induced acute kidney injury: minimal consequences or significant threat?

11,631 (95% confidence interval,