Progress in the seasonal variations of blood lipids: a mini-review.

The seasonal variations of blood lipids have recently gained increasing interest in this field of lipid metabolism. Elucidating the seasonal patterns of blood lipids is particularly helpful for the prevention and treatment of cardiovascular and cerebrovascular diseases. However, the previous results remain controversial and the underlying mechanisms are still unclear. This mini-review is focused on summarizing the literature relevant to the seasonal variability of blood lipid parameters, as well as on discussing its significance in clinical diagnoses and management decisions

Abstract 13987: Underutilization of Oral Anticoagulant Therapy in At-Risk Patients With Atrial Fibrillation—Insights From a Multistate Healthcare System

Introduction: Oral anticoagulant (OAC) therapy significantly reduces the risk of thromboembolism among at-risk patients with atrial fibrillation (AF). Current guidelines provide strong support for an OAC in men and women with AF and CHA2DS2-VASc scores of \u3e2 and \u3e3, respectively. In spite of this, previous data has suggested that up to 40% of these patients are not treated in accordance with guideline recommendations. Hypothesis: We hypothesized that OAC therapy continues to remain significantly underutilized among at-risk patients with AF in real-world settings. Methods: We sought to evaluate the prevalence of OAC underuse and contributing factors in an ambulatory population of at-risk AF patients within a large multistate healthcare system. EHR and coding (ICD-10) data were used to identify patients with AF, calculate their CHA2DS2-VASc score, and define their current antithrombotic regimen. Demographics were assessed to allow for comparison between those receiving an OAC from those who were not. Chi square or Fisher exact tests were used to examine differences between groups. Results: Data was pulled from our EHR on 8/1/18, identifying 147,455 unique patients with AF, of which 102,728 (76.3%) had a CHA2DS2-VASc score \u3e2 (excluding female gender) (Table). Compared to those on an OAC, patients on antiplatelet therapy were more likely to have coronary artery disease, peripheral vascular disease, and prior MI (p Conclusions: In a contemporary, non-registry setting, OAC underuse remains substantial among at-risk patients with AF. Further investigation into tools that facilitate implementation of guideline-directed medical therapy is needed to limit preventable thromboembolic events in this population

Abstract 14012: Opportunities to Improve the Efficacy and Safety of Oral Anticoagulant Therapy in Atrial Fibrillation—Insights From a Multistate Healthcare System

Introduction: Vitamin K antagonists (VKAs) effectively reduce thromboembolic risk in atrial fibrillation (AF), but are limited by a narrow therapeutic window. Patients with reduced time in the therapeutic range (TTR) also face an increased risk of bleeding and ischemic events. Based in part on this, current guidelines give preference to direct-acting oral anticoagulants (DOACs) over VKAs in AF. Hypothesis: We hypothesized that DOACs are underutilized among those on oral anticoagulant therapy and that TTR remains suboptimal for large numbers of individuals on VKAs in real-world settings. Methods: We sought to evaluate a) the breakdown of OAC type and b) TTR for those on VKAs in an ambulatory population of at-risk AF patients within a large multistate healthcare system. EHR and coding (ICD-10) data were used to identify patients with AF, calculate their CHA2DS2-VASc score, and define their current antithrombotic regimen. For those on a VKA, TTR was assessed with the Rosendaal method and reported as mean values. Demographics were assessed to allow for comparison between those receiving a DOAC and a VKA, as well as, those with high (\u3e70%) vs. low ( Results: Data was pulled from our EHR on 8/1/18, identifying 147,455 unique patients with AF, of which 102,728 (76.3%) had a CHA2DS2-VASc score \u3e2 (excluding female gender). Among these at-risk patients, 61,698 (60.1%) were receiving an OAC, of which 47.8% were on a VKA and 52.2% were on a DOAC. The mean TTR was 56.3%, with 37.1%, 49.9% and 60.8% with TTRs \u3e70%, \u3e60%, and \u3e50%, respectively. Patients on a DOAC were more likely to be female and less likely to have heart failure, coronary artery disease, peripheral vascular disease, diabetes and renal disease (p70% were more likely to be male and less likely to have heart failure, diabetes, and renal disease (p Conclusions: In a contemporary, non-registry setting, VKAs continue to be used in nearly half of at-risk patients on an OAC for AF, with a suboptimal TTR in nearly two thirds. Further investigation is needed into tools that facilitate interchange from a VKA to a DOAC, particularly among those with a suboptimal TTR

Results of Lung Cancer Screening in the Community.

PURPOSE: To address doubts regarding National Lung Screening Trial (NLST) generalizability, we analyzed over 6,000 lung cancer screenings (LCSs) within a community health system. METHODS: Our LCS program included 10 sites, 7 hospitals (2 non-university tertiary care, 5 community) and 3 free-standing imaging centers. Primary care clinicians referred patients. Standard criteria determined eligibility. Dedicated radiologists interpreted all LCSs, assigning Lung Imaging Reporting and Data System (Lung-RADS) categories. All category 4 Lung-RADS scans underwent multidisciplinary review and management recommendations. Data was prospectively collected from November 2013 through December 2018 and retrospectively analyzed. RESULTS: Of 4,666 referrals, 1,264 individuals were excluded or declined, and 3,402 individuals underwent initial LCS. Second through eighth LCSs were performed on 2,758 patients, for a total of 6,161 LCSs. Intervention rate after LCS was 14.6% (500 individuals) and was most often additional imaging. Invasive interventions (n = 226) were performed, including 141 diagnostic procedures and 85 surgeries in 176 individuals (procedure rate 6.6%). Ninety-five lung cancers were diagnosed: 84 non-small cell (stage 1: 60; stage 2: 7; stage 3: 9; stage 4: 8), and 11 small cell lung cancers. The procedural adverse event rate was 23/226 (10.1%) in 21 patients (0.6% of all screened individuals). Pneumothorax (n = 10) was the most frequent, 6 requiring pleural drainage. There were 2 deaths among 85 surgeries or 2.3% surgical mortality. CONCLUSIONS: Our LCS experience in a community setting demonstrated lung cancer diagnosis, stage shift, intervention frequency, and adverse event rate similar to the NLST. This study confirms that LCS can be performed successfully, safely, and with equivalence to the NLST in a community health care setting

Trends in Diagnosis Related Groups for inpatient admissions and associated changes in payment from 2012 to 2016

Importance: Hospitals are reimbursed based on Diagnosis Related Groups (DRGs), which are defined, in part, by patients having 1 or more complications or comorbidities within a given DRG family. Hospitals have made substantial investment in efforts to document these complications and comorbidities. Objective: To examine temporal trends in DRGs with a major complication or comorbidity, compare these findings with 2 alternative measures of disease severity, and estimate associated changes in payment. Design, Setting, and Participants: This retrospective cohort study used data from the all-payer National Inpatient Sample for admissions assigned to 1 of the top 20 reimbursed DRG families at US acute care hospitals from January 1, 2012, to December 31, 2016. Data were analyzed from July 10, 2018, to May 29, 2019. Exposures: Quarter year of hospitalization. Main Outcomes and Measures: The primary outcome was the proportion of DRGs with a major complication or comorbidity. Secondary outcomes were comorbidity scores, risk-adjusted mortality rates, and estimated payment. Changes in assigned DRGs, comorbidity scores, and risk-adjusted mortality rates were analyzed by linear regression. Payment changes were estimated for each DRG by calculating the Centers for Medicare & Medicaid Services weighted payment using 2012 and 2016 case mix and hospitalization counts. Results: Between 2012 and 2016, there were 62 167 976 hospitalizations for the 20 highest-reimbursed DRG families; the sample was 32.9% male and 66.8% White, with a median age of 57 years (interquartile range, 31-73 years). Within 15 of these DRG families (75%), the proportion of DRGs with a major complication or comorbidity increased significantly over time. Over the same period, comorbidity scores were largely stable, with a decrease in 6 DRG families (30%), no change in 10 (50%), and an increase in 4 (20%). Among 19 DRG families with a calculable mortality rate, the risk-adjusted mortality rate significantly decreased in 8 (42%), did not change in 9 (47%), and increased in 2 (11%). The observed DRG shifts were associated with at least $1.2 billion in increased payment. Conclusions and Relevance: In this cohort study, between 2012 and 2016, the proportion of admissions assigned to a DRG with major complication or comorbidity increased for 15 of the top 20 reimbursed DRG families. This change was not accompanied by commensurate increases in disease severity but was associated with increased payment

Tooth micro-hardness changes after applying bioactive glass-containing, anti-microbial sealants

The AAPD recommends placement of dental pit and fissure sealants on surfaces that are high risk or that already exhibit incipient carious lesions. Protection provided by sealants may be enhanced by the addition of ion-releasing, anti-microbial filler particles of bioactive glass. Objective: We prepared novel dental pit and fissure sealant materials containing bioactive glass (BAG) fillers and tested their ability to prevent tooth demineralization in a bacterial broth. Methods: Two types of BAG were synthesized in our lab: BAG1 (61 wt% silica - 31 wt% calcia - 4 wt% phosphate - 4 wt% flouride); and BAG2 (81 wt% silica - 11 wt% calcia - 4 wt% phosphate - 4 wt% flouride). Ultraseal XT (USXT) resin without filler was supplied by the manufacturer (Ultradent Products, Inc. South Jordan, UT). BAGs were individually incorporated into the resin (25 wt%) and provided handling properties similar to USXT. Caries-free teeth (n=5 each) were randomly assigned to three groups (BAG1-sealant, BAG2-sealant,or USXT) and sealants were placed by the same practitioner. Acid-resistant nail polish was used to cover half of the tooth surface. Teeth were immersed in a bacterial culture system of sucrose-rich brain-heart infusion (BHI) media containing Streptococcus mutans strain #25175, an acid-producing microbe and incubated at 37˚C, 5%CO2; media was changed every other day. Bacterial growth was confirmed throughout the test period. At two weeks, teeth were sectioned sagitally and microhardness testing compared changes in hardness as a function of location on the tooth. Results : Overall, the BAG2-sealant samples were significantly harder than the BAG1-sealant or USXT samples. Areas adjacent to the BAG2-sealant were harder than the original tooth surface. (ANOVA/Tukey’s; α=0.05). Conclusion: The inclusion of anti-bacterial, ion-releasing BAG as a filler component results in a harder tooth that may be better able to resist demineralization.This presentation was presented at the American Association for the Advancement of Science (AAAS) Pacific Division 93rd Annual Meeting in Boise, Idaho. It was also presented at the American Association for Dental Research Annual Conference in 2012 (AADR)

Duodenal GI stromal tumors: Is radical resection necessary?

BACKGROUND AND OBJECTIVES: Duodenal gastrointestinal stromal tumors (GISTs) are rare tumors that pose a surgical challenge, and long-term outcomes after resection have not been detailed outside of small case series. This study uses the National Cancer Database (NCDB) to examine the determinants of radical resection for duodenal GISTs as well as the impact of local vs radical resection on overall survival (OS). METHODS: The NCDB was queried for nonmetastatic duodenal GISTs from 2004 to 2014. Predictors of radical resection were determined using multivariate logistic regression stratified by extent of tumor involvement. Factors associated with OS were identified with Cox proportional regression analysis. RESULTS: Treatment at an academic center, size \u3e5 cm, and extra-duodenal extension were associated with radical resection. On multivariate analysis, radical resection was associated with decreased OS (HR, 1.93; P \u3c .03). Systemic therapy, extra-duodenal extension, grade, stage, mitoses, and receipt of systemic therapy did not impact OS. CONCLUSION: Local resection of duodenal GISTs is associated with improved OS compared to radical resection after controlling for tumor factors and systemic treatment. Traditional indicators of tumor aggressiveness were associated with radical resection, but not OS. When feasible, local resection should be considered for resection of duodenal GISTs

A multi-institutional approach for decreasing narcotic prescriptions after laparoscopic appendectomy.

BACKGROUND: Appendicitis is a common indication for surgical hospital admission. Uncomplicated appendicitis is typically treated with surgical intervention, most commonly a laparoscopic appendectomy. As with many procedures, narcotic utilization is highly varied among surgeons for postoperative pain control. With the opioid epidemic and a demonstrated link between excessive narcotic prescriptions paving the way to dependence and addiction, it is more important than ever to decrease the circulation of these medications. We hypothesized that a perioperative, multimodal analgesia strategy coupled with monthly feedback reports comparing hospitals narcotic prescribing habits would decrease, and in some cases eliminate, the use of outpatient narcotics in adults after laparoscopic appendectomy. METHODS: A quality improvement project was initiated to provide monthly feedback to surgeons on narcotic prescribing habits after adult laparoscopic appendectomies. A multi-hospital database was created to include adult patients that were diagnosed with acute appendicitis, treated with laparoscopic appendectomy, and discharged within 48 h of surgery. The database provided information regarding the number of narcotic doses prescribed on discharge. Participating hospitals selected a site champion who distributed monthly prescribing reports. A protocol was created and distributed to participating sites that provided a guideline for preoperative and postoperative pain medication management. The intervention period was 10/1/2019-3/31/2020. We utilized the preceding year\u27s data (October 1, 2018-September 30, 2019) as the pre-intervention control group. We also compared results between local and distant sites to see if personal connection to surgeons influenced the results. RESULTS: A total of 1785 appendectomies were performed during the study period at participating hospitals. The average number of prescribed narcotics decreased from 23.6 doses during the control period to 14.2 during the intervention (p \u3c 0.001). There was no change in the number of total narcotic prescriptions (8.9 vs 7.9%, p = 0.52). Overall, the average number of narcotics prescribed decreased by 40% with similar decrease in average prescribed narcotics for local and distant hospitals, respectively (47.7% vs 42.1%). Average narcotic dose during the first 2 months of intervention at the local hospitals was 9.7 and 11.1 for the last 2 months of intervention (p = 0.69). Average narcotic dose during the first 2 months of intervention at the distant hospitals was 19.5 and 13.4 for the last 2 months of intervention (p = 0.005). CONCLUSION: A multimodal pain regimen combined with a monthly narcotic prescription report provided to prescribers decreases the average number of narcotic prescriptions after laparoscopic appendectomy. Local sites demonstrated immediate decrease in narcotic utilization compared to distant sites whose change occurred more gradually