Neera Agrwal

Adverse Effects of Testosterone Therapy in Adult Men: A Systematic Review and Meta-Analysis

CONTEXT The risks of testosterone therapy in men remain poorly understood. OBJECTIVE The aim of this study was to conduct a systematic review and meta-analyses of testosterone trials to evaluate the adverse effects of testosterone treatment in men. DATA SOURCES We searched MEDLINE, EMBASE, and Cochrane CENTRAL from 2003 through August 2008. Review of reference lists and contact with experts further identified candidate studies. STUDY SELECTION Eligible studies were comparative, randomized, and nonrandomized and reported the effects of testosterone on outcomes of interest (death, cardiovascular events and risk factors, prostate outcomes, and erythrocytosis). Reviewers, working independently and in duplicate, determined study eligibility. DATA EXTRACTION Reviewers working independently and in duplicate determined the methodological quality of studies and collected descriptive, quality, and outcome data. DATA SYNTHESIS The methodological quality of the 51 included studies varied from low to medium, and follow-up duration ranged from 3 months to 3 yr. Testosterone treatment was associated with a significant increase in hemoglobin [weighted mean difference (WMD), 0.80 g/dl; 95% confidence interval (CI), 0.45 to 1.14] and hematocrit (WMD, 3.18%; 95% CI, 1.35 to 5.01), and a decrease in high-density lipoprotein cholesterol (WMD, -0.49 mg/dl; 95% CI, -0.85 to -0.13). There was no significant effect on mortality, prostate, or cardiovascular outcomes. CONCLUSIONS The adverse effects of testosterone therapy include an increase in hemoglobin and hematocrit and a small decrease in high-density lipoprotein cholesterol. These findings are of unknown clinical significance. Current evidence about the safety of testosterone treatment in men in terms of patient-important outcomes is of low quality and is hampered by the brief study follow-up.

Adult Height in Patients with Congenital Adrenal Hyperplasia: A Systematic Review and Metaanalysis

CONTEXT Treatment for patients with congenital adrenal hyperplasia (CAH) may affect the final height of these patients. OBJECTIVE Our objective was to determine the distribution of achieved height in patients with classic CAH diagnosed at infancy or early childhood and treated with glucocorticoids. DATA SOURCES We searched MEDLINE, EMBASE, Cochrane Library, ISI Web of Science, and Scopus through September 2008; the reference sections of included studies; and expert files. STUDY SELECTION Eligible studies included patients diagnosed with CAH before age 5 and followed to final height. DATA EXTRACTION Reviewers working in duplicate independently extracted data on study characteristics and outcomes and determined each studys risk of bias. DATA SYNTHESIS The sd score (SDS) for final height and corrected height (defined as final height SDS - midparental height SDS) were estimated from each study and pooled using random-effects metaanalysis. The I(2) statistic was used to assess inconsistency in results across studies. RESULTS We found 35 eligible studies, most of which were retrospective single-cohort studies. The final height SDS achieved by CAH patients was -1.38 (-1.56 to -1.20; I(2) = 90.2%), and the corrected height SDS was -1.03 (-1.20 to -0.86; I(2) = 63.1%). This was not significantly associated with age at diagnosis, gender, type and dose of steroid, and age of onset of puberty. Mineralocorticoid users had a better height outcome in comparison with the nonusers (P = 0.02). CONCLUSION Evidence derived from observational studies suggests that the final height of CAH patients treated with glucocorticoids is lower than the population norm and is lower than expected given parental height.

Prenatal dexamethasone use for the prevention of virilization in pregnancies at risk for classical congenital adrenal hyperplasia because of 21‐hydroxylase (CYP21A2) deficiency: a systematic review and meta‐analyses

Context  Prenatal treatment with dexamethasone to prevent virilization in pregnancies at risk for classical congenital adrenal hyperplasia (CAH) remains controversial.

Derivation and Multicenter Validation of the Drug Resistance in Pneumonia Clinical Prediction Score.

ABSTRACT The health care-associated pneumonia (HCAP) criteria have a limited ability to predict pneumonia caused by drug-resistant bacteria and favor the overutilization of broad-spectrum antibiotics. We aimed to derive and validate a clinical prediction score with an improved ability to predict the risk of pneumonia due to drug-resistant pathogens compared to that of HCAP criteria. A derivation cohort of 200 microbiologically confirmed pneumonia cases in 2011 and 2012 was identified retrospectively. Risk factors for pneumonia due to drug-resistant pathogens were evaluated by logistic regression, and a novel prediction score (the drug resistance in pneumonia [DRIP] score) was derived. The score was then validated in a prospective, observational cohort of 200 microbiologically confirmed cases of pneumonia at four U.S. centers in 2013 and 2014. The DRIP score (area under the receiver operator curve [AUROC], 0.88 [95% confidence interval {CI}, 0.82 to 0.93]) performed significantly better (P = 0.02) than the HCAP criteria (AUROC, 0.72 [95% CI, 0.64 to 0.79]). At a threshold of ≥4 points, the DRIP score demonstrated a sensitivity of 0.82 (95% CI, 0.67 to 0.88), a specificity of 0.81 (95% CI, 0.73 to 0.87), a positive predictive value (PPV) of 0.68 (95% CI, 0.56 to 0.78), and a negative predictive value (NPV) of 0.90 (95% CI, 0.81 to 0.93). By comparison, the performance of HCAP criteria was less favorable: sensitivity was 0.79 (95% CI, 0.67 to 0.88), specificity was 0.65 (95% CI, 0.56 to 0.73), PPV was 0.53 (95% CI, 0.42 to 0.63), and NPV was 0.86 (95% CI, 0.77 to 0.92). The overall accuracy of the HCAP criteria was 69.5% (95% CI, 62.5 to 75.7%), whereas that of the DRIP score was 81.5% (95% CI, 74.2 to 85.6%) (P = 0.005). Unnecessary extended-spectrum antibiotics were recommended 46% less frequently by applying the DRIP score (25/200, 12.5%) than by use of HCAP criteria (47/200, 23.5%) (P = 0.004), without increasing the rate at which inadequate treatment recommendations were made. The DRIP score was more predictive of the risk of pneumonia due to drug-resistant pathogens than HCAP criteria and may have the potential to decrease antibiotic overutilization in patients with pneumonia. Validation in larger cohorts of patients with pneumonia due to all causes is necessary.

The Effects of Deliberate Practice and Feedback to Teach Standardized Handoff Communication on the Knowledge, Attitudes, and Practices of First-Year Residents

Background: Residents’ shift length reduction and communication errors in transitions of care necessitate educating residents on handoff communication. Purpose: We examined the change in knowledge, attitudes, and practices of 1st-year residents after implementing a curriculum using deliberate practice to teach handoff communication. Methods: First-year residents completed a needs assessment survey and a video assessment of handoff practices. They participated in a brief curriculum using lecture and deliberate practice with feedback to teach a standardized approach to handoff communication. Change in knowledge, attitudes, and practices were measured with survey and video assessments. Results: Eleven 1st-year residents completed the course and final assessments. Residents’ comfort with performing handoffs and their perceived efficiency indicated improvement. Practices improved, with increased inclusion of important features of handoffs (6.31 to 7.64, p < .001). Conclusions: A brief curriculum utilizing deliberate practice is an effective way to improve handoff practices of 1st-year residents.

Pulmonary Epithelioid Hemangioendothelioma Diagnosed With Endobronchial Biopsies: A Case Report and Literature Review.

Pulmonary epithelioid hemangioendothelioma (PEHE) is a rare vascular tumor of endothelial origin first described in 1975 as intravascular bronchioloalveolar tumor. Since then, >100 cases have been reported, and most cases require surgical lung biopsy for diagnosis. We report the case of a 46-year-old man with a diagnosis of PEHE from endobronchial biopsies of an intraluminal nodule, a rare presentation of this disease. We summarize a review of the literature and the bronchoscopic findings of PEHE.

Aortic tumor or mobile thrombus

Isolated large mobile mass in the thoracic aorta can be due to thrombus or, rarely, aortic tumor. We report the case of a 61‐year‐old man with no history of medical problems presenting with neurologic deficits and in whom a large mobile echogenic mass in the distal aortic arch was found with transesophageal echocardiography. Given his few cardiovascular risk factors and absence of other systemic symptoms, he received anticoagulant therapy. Subsequent resolution of the aortic mass suggested a diagnosis of thrombus. This case illustrates an unusual manifestation of aortic arch atherosclerosis and underscores the utility of transesophogeal echocardiography for patients with ischemic stroke. (Echocardiography 2010;27:E21‐E22)

Science of Health Care Delivery: An Innovation in Undergraduate Medical Education to Meet Society's Needs

The purpose of this special article is to describe a new, 4-year Science of Health Care Delivery curriculum at Mayo Clinic School of Medicine, including curricular content and structure, methods for instruction, partnership with Arizona State University, and implementation challenges. This curriculum is intended to ensure that graduating medical students enter residency prepared to train and eventually practice within person-centered, community- and population-oriented, science-driven, collaborative care teams delivering high-value care. A Science of Health Care Delivery curriculum in undergraduate medical education is necessary to successfully prepare physicians so as to ensure the best clinical outcomes and patient experience of care, at the lowest cost.

Relation of Telemetry Use and Mortality Risk, Hospital Length of Stay, and Readmission Rates in Patients With Respiratory Illness

The 2004 American Heart Association expert opinion-based guidelines restrict telemetry use primarily to patients with current or high-risk cardiac conditions. Respiratory infections have emerged as a common source of hospitalization, and telemetry is frequently applied without indication in efforts to monitor patient decompensation. In this retrospective study, we aimed to determine whether telemetry impacts mortality risk, length of stay (LOS), or readmission rates in hospitalized patients with acute respiratory infection not meeting American Heart Association criteria. A total of 765 respiratory infection patient encounters with Diagnosis-Related Groups 193, 194, 195, 177, 178 and 179 admitted in 2013 to 2015 to 2 tertiary community-based medical centers (Mayo Clinic, Arizona, and Mayo Clinic, Florida) were evaluated, and outcomes between patients who underwent or did not undergo telemetry were compared. Overall, the median LOS was longer in patients who underwent telemetry (3.0 days vs 2.0 days, p <0.0001). No differences between cohorts were noted in 30-day readmission rates (0.6% vs 1.3%, p = 0.32), patient mortality while hospitalized (0.6% vs 1.3%, p = 0.44), mortality at 30 days (7.9% vs 7.7%, p = 0.94), or mortality at 90 days (13.5% vs 13.5%, p = 0.99). Telemetry predicted LOS for both univariate (estimate 1.18, 95% confidence interval 1.06 to 1.32, p = 0.003) and multivariate (estimate 1.17, 95% confidence interval 1.06 to 1.30, p = 0.003) analyses after controlling for severity of illness but did not predict patient mortality. In conclusion, this study identified that patients with respiratory infection who underwent telemetry without clear indications may face increased LOS without reducing their readmission risk or improving the overall mortality.

Gastric lap-band infection due to Mycobacterium abscessus presenting as new-onset ascites in a cirrhotic patient

Abstract Nontuberculous mycobacteria are ubiquitous environmental organisms that are infrequently implicated as pathogens. Peritoneal infection with nontuberculous mycobacteria is rare and published reports are most commonly associated with peritoneal dialysis. This study describes a case of a 41-year-old woman with cirrhosis who had Mycobacterium abscessus peritonitis and an abdominal abscess resulting from infection of a remotely placed gastric band (Lap-Band; Apollo Endosurgery, Inc).