A select issue in the postpartum period: contraception

One half of pregnancies in the United States are unintended and associated with adverse pregnancy outcomes. The postpartum period is an important, yet underutilized, time to initiate contraception. The U.S. Medical Eligibility Criteria for Contraceptive Use, 2010 provides evidence-based guidelines for choosing a contraceptive method and an update in 2011 specifically addresses contraceptive method use in the puerperium. The variety of contraceptive methods include hormonal contraception, lactational amenorrhea, barrier contraception, natural family planning, and sterilization. Ideally, counseling about contraceptive choice should begin early in pregnancy care and continue postpartum; it should also include a variety of teaching modalities. Specifically we recommend LARC options such as intrauterine devices and etonorgestrel implants, postpartum tubal sterilization, and progestin-only pills for those desiring an oral method

Compulsive Hoarding In Children: Six Case Studies

Semi-structured interviews were conducted with the parents of six children who showed signs of compulsive hoarding. The cases revealed a wide variety of hoarding behaviors. Hoarding manifested in difficulties in discarding and maintaining control over possessions. Few cases had problems with clutter or excessive acquisition. In three cases hoarding was episodic and stress-related. Most of the cases showed overlapping ADHD symptoms and a majority demonstrated problems with perfectionism. Only two had clear obsessive-compulsive disorder, although concerns about others touching or moving possessions, which was present in all of the cases, may represent a form of ordering and arranging compulsions. None of the cases demonstrated clear insight, and several showed abnormal personification of inanimate objects and exaggerated “essentialism.

A select issue in the postpartum period: contraception

One half of pregnancies in the United States are unintended and associated with adverse pregnancy outcomes. The postpartum period is an important, yet underutilized, time to initiate contraception. The U.S. Medical Eligibility Criteria for Contraceptive Use, 2010 provides evidence-based guidelines for choosing a contraceptive method and an update in 2011 specifically addresses contraceptive method use in the puerperium. The variety of contraceptive methods include hormonal contraception, lactational amenorrhea, barrier contraception, natural family planning, and sterilization. Ideally, counseling about contraceptive choice should begin early in pregnancy care and continue postpartum; it should also include a variety of teaching modalities. Specifically we recommend LARC options such as intrauterine devices and etonorgestrel implants, postpartum tubal sterilization, and progestin-only pills for those desiring an oral method

Concordance of Cross-Sectional Imaging and Adrenal Venous Sampling Results for Patients with Surgically Treated Primary Hyperaldosteronism​

Background Adrenal venous sampling (AVS) is used to distinguish unilateral from bilateral aldosterone hypersecretion as a cause of primary hyperaldosteronism (PHA). This distinction is critical because unilateral disease is treated, and often cured, by adrenalectomy, whereas bilateral hypersecretion should be managed medically. Methods We performed a retrospective cohort review of adult patients undergoing index adrenalectomy for PHA at the University of Nebraska Medical Center from July of 2013 to June of 2022. Clinical and pathologic variables were assessed including patient age at surgery, sex, race or ethnicity, body mass index, systolic and diastolic blood pressure, number and type of antihypertensive medications pre- and post-operatively, potassium level and supplementation, PAC, PRA, ARR, imaging findings, adrenal venous sampling results and concordance of imaging findings with AVS and surgical outcomes. Statistical analysis was performed with Mann Whitney U and chi-squared Fisher’s exact using STATA version 17. Results In our cohort, 21 patients were identified who underwent adrenalectomy for primary hyperaldosteronism. Of these, 2 patients did not have any imaging findings and 19 were image localized. For patients with image localization AVS was concordant in 9, discordant in 4, and nondiagnostic in 6. For both patients without image localization the AVS was lateralizing. The overall discordance between imaging results and AVS was 40%. The only significant difference between patients with concordant and discordant results was the aldosterone level with concordant patients having a mean of 58ng/dL compared with discordant patients 23ng/dL (p = 0.0022). There was a significant reduction in antihypertensive medications in the entire cohort from a mean of 3.2 medications to 1.2 medications (p \u3c 0.001). Conclusions and Future Directions In this cohort, 40% of patients with selective AVS had discordant imaging and AVS results. Preoperative plasma aldosterone concentration was positively associated with concordance, with higher PAC more likely to have imaging and AVS concordance. Overall, hypertension was significantly improved following adrenalectomy for PHA with a median decrease of 2 antihypertensives. Our results support the recommendation to perform AVS on all candidates for adrenalectomy for PHA. Further study is warranted to identify factors associated with discordance.https://digitalcommons.unmc.edu/surp2022/1008/thumbnail.jp

Quality of Life among Cancer Survivors: Comparison of Multiple Cancers Using iCaRe2

Background: The number of cancer survivors continues to increase due to dramatic improvements in cancer treatment, accounting for approximately 5% of the entire population. As cancer survivors continue to live longer, it is important to understand their quality of life (QoL) in order to maximize supportive care efforts. Objectives: In this study, the quality of life (QoL) among patients with different types of cancer was examined. The objectives were to: 1) compare patient-reported outcome measures of QoL using the Short-Form (SF-36) Health Survey scores among patients of different cancer types and 2) identify demographic, oncologic, and clinical factors that are associated with SF-36 QOL scores. Methods: We performed a retrospective review of prospectively collected data from a multi-center cancer registry data collected between January 2007 and February 2020. Multiple linear regression analysis was conducted to identify demographic and clinical factors that are associated with SF-36 Physical Component Score (PCS) and Mental Component Score (MCS). Findings: Both mental and physical aspects of QoL were affected in all cancer patients, regardless of the type, prognosis, and time since diagnosis and treatment. Individual, socioeconomic, disease, and treatment-related variables were associated with QoL among different cancer populations and should be addressed as part of shared treatment decision-making

Relaxin and the Immune Landscape of Benign and Malignant Thyroid Disease

Thyroid cancer is the most common endocrine cancer, and its incidence has significantly increased over the last 40 years. Recent studies have suggested relaxin—a peptide hormone secreted by the ovaries during pregnancy with anti-fibrotic actions in chronic inflammation—as a potential marker of thyroid cancer occurrence and progression. However, it is unknown how relaxin behaves in benign versus malignant thyroid tissue. We hypothesized that relaxin levels would be decreased in benign and normal cancer-adjacent thyroid tissue relative to malignant tissue and increased in patients with lymphocytic thyroiditis, an autoimmune disorder involving chronic inflammation of the thyroid. Using the Integrated Cancer Repository for Cancer Research, benign, malignant, and normal cancer-adjacent thyroid tissue and accompanying clinical information were obtained. Tissue microarrays of each group were created, and immunofluorescence was performed to evaluate levels of relaxin. Our results indicated that relaxin is increased in malignant tissue relative to both normal cancer-adjacent and benign thyroid tissue, but there is no significant difference between benign and normal cancer-adjacent thyroid tissue. There is also an association between increased relaxin levels and lymphocytic thyroiditis. However, there is no association between significant differences in relaxin and other clinical factors like hypothyroidism and hyperthyroidism.https://digitalcommons.unmc.edu/surp2022/1016/thumbnail.jp

Should BRAFV600E be Incorporated into Treatment Recommendations for Thyroid Cancer?

Around 90% of all well-differentiated thyroid cancers are papillary thyroid carcinomas (PTC). PTCs have a recurrence rate of around 20% and a low mortality rate of around 5%. Within PTCs, around 60% of them have the BRAFV600E mutation. Currently, there is a debate on whether BRAFV600E is an independent predictor of tumor aggressiveness and recurrence. This study looks at whether BRAFV600E is an independent predictor of recurrence and outcomes in PTC. Tissue microarrays (TMA) were made from well-differentiated thyroid tumors and stained for the BRAFV600E mutation. BRAFV600E expression was calculated using an H-score: the staining intensity (0-3) multiplied by the amount of tumor that stained positive. A univariate analysis showed that BRAFV600E was significantly associated with age (p=0.0259), gender (p=0.019), extrathyroidal extension (p=0.049), positive margins (p=0.033), lymph node ratio (p=0.0106), N stage (p=0.015), AJCC 8 stage (p=0.0042), ATA risk category (p=0.018), and time to recurrence (p=0.0487). A multivariable analysis found that only extrathyroidal extension was an independent predictor of recurrence. Overall, BRAFV600E was not an independent predictor of recurrence in this cohort. Current treatment plans based on risk of recurrence appear to be appropriate, and it is not recommended that BRAFV600E be included as an independent variable.https://digitalcommons.unmc.edu/surp2021/1058/thumbnail.jp

Blinding and Sham Control Methods in Trials of Physical, Psychological, and Self-Management Interventions for Pain (Article I): a Systematic Review and Description of Methods

Blinding is challenging in randomised controlled trials (RCTs) of physical, psychological, and self-management therapies (PPS) for pain, mainly due to their complex and participatory nature. To develop standards for the design, implementation, and reporting of control interventions in efficacy and mechanistic trials, a systematic overview of currently employed sham interventions and other blinding methods was required. Twelve databases were searched for placebo or sham controlled RCTs of PPS treatments in a clinical pain population. Screening and data extraction were performed in duplicate, and trial features, description of control methods and their similarity to the active intervention under investigation were extracted (protocol registration ID: CRD42020206590). The review included 198 unique control interventions, published between 2008 and December 2021. Most trials studied people with chronic pain, and more than half were manual therapy trials. The described control interventions ranged from clearly modelled based on the active treatment, to largely dissimilar control interventions. Similarity between control and active interventions was more frequent for certain aspects (e.g., duration and frequency of treatments) than others (e.g., physical treatment procedures and patient sensory experiences). We also provide an overview of additional, potentially useful methods to enhance blinding, as well as the reporting of processes involved in developing control interventions. A comprehensive picture of prevalent blinding methods is provided, including a detailed assessment of the resemblance between active and control interventions. These findings can inform future developments of control interventions in efficacy and mechanistic trials and best-practice recommendations