The Association of Body Mass Index with Postoperative Outcomes After Elective Paraesophageal Hernia Repair

Purpose

To evaluate the association between body mass index (BMI) and postoperative outcomes in elective paraesophageal hernia (PEH) repairs.

Methods

A retrospective review of patients who underwent elective PEH repair in the ACS NSQIP database (2005–2015) was performed. Patients were stratified into BMI groups (<?18.5, 18.5–24.9, 25.0–29.9, 30.0–34.9, 35–39.9, and ≥?40.0 kg/m²) according to the World Health Organization classification criteria. A multivariable logistic regression model was developed to characterize the association between BMI class and outcomes, including readmission, reoperation, postoperative complications, and mortality.

Results

The median (IQR) age of the 9641 patients who met inclusion criteria was 64 (55–72) and 72.7% were women. Across each BMI class, age, race, gender, type of procedure, frailty index, smoking, and ASA class varied (p?<?0.05). Underweight patients (BMI <?18.5 kg/m²) had an increased risk of mortality (OR?=?6.35, p?<?0.05). Patients with a BMI 35–39.9 kg/m² (OR?=?0.65, p?<?0.05) and ≥?40 kg/m² (OR?=?0.36, p?<?0.001) were associated with a decreased risk for readmissions.

Conclusion

Underweight patients have an increased risk for postoperative mortality after elective PEH repair. Higher BMI was associated with a diminished risk for readmission, but not for mortality, reoperations, or overall complications.

     

Disruption of antigen-induced inflammatory responses in CD40 ligand knockout mice.

The objective of this study was to investigate the contribution of the interaction between CD40 and its ligand (CD40L) to antigen-induced airways inflammatory responses. To this end, we used a model involving ovalbumin (OVA) sensitization followed by OVA aerosol challenge in CD40L knockout (KO) mice. OVA-specific IgE and IgG1 were detected in the serum of the sensitized control, but not in CD40L-KO mice. After antigen challenge, sensitized control mice developed airway inflammation that was primarily eosinophilic. This inflammatory response was dramatically reduced in CD40L-KO mice. In contrast, similar numbers of eosinophils were observed in both the bone marrow and the peripheral blood in the sensitized controls and mutant strains after antigen challenge. To investigate the mechanisms underlying these findings, we examined levels of the cytokines IL-5, IL-4, and TNFalpha in both bronchoalveolar lavage (BAL) and serum. Similar levels of IL-5 were detected in BAL and serum of control and CD40L-KO mice; however, negligible levels of IL-4 in BAL and serum and of TNFalpha in BAL were detected in CD40L-KO mice when compared with control mice. Furthermore, we demonstrated that endothelial cell expression of vascular cell adhesion molecule 1 in OVA-sensitized and -challenged CD40L-KO mice was, as detected by immunohistochemistry, markedly decreased compared with that observed in similarly treated control mice. In addition, we locally overexpressed IL-4 and TNFalpha by using an adenoviral (Ad)-mediated gene transfer approach. Intranasal administration of either Ad/TNFalpha or Ad/IL-4 into OVA-sensitized and -challenged CD40L-KO mice did not reconstitute airway eosinophilia. However, concurrent administration of Ad/TNFalpha and Ad/IL-4 upregulated endothelial expression of vascular cell adhesion molecule 1, and resulted in full reconstitution of the inflammatory response in the airways. Together, these findings demonstrate the importance of the CD40-CD40L costimulatory pathway in the full expression of the inflammatory response in the airways.     

Recruiting primary care physicians to qualitative research: Experiences and recommendations from a childhood cancer survivorship study

1 Background

Primary care physicians (PCPs) are essential for healthcare delivery but can be difficult to recruit to health research. Low response rates may impact the quality and value of data collected. This paper outlines participant and study design factors associated with increased response rates among PCPs invited to participate in a qualitative study at Sydney Children's Hospital, Australia.

2 Procedure

We invited 160 PCPs by post, who were nominated by their childhood cancer patients in a survey study. We followed‐up by telephone, email, or fax 2 weeks later.

3 Results

Without any follow‐up, 32 PCPs opted in to the study. With follow‐up, a further 42 PCPs opted in, with email appearing to be the most effective method, yielding a total of 74 PCPs opting in (46.3%). We reached data saturation after 51 interviews. On average, it took 34.6 days from mail‐out to interview completion. Nonrespondents were more likely to be male (P = 0.013). No survivor‐related factors significantly influenced PCPs’ likelihood of participating. Almost double the number of interviews were successfully completed if scheduled via email versus phone. Those requiring no follow‐up did not differ significantly to late respondents in demographic/survivor‐related characteristics.

4 Conclusion

PCP factors associated with higher opt in rates, and early responses, may be of interest to others considering engaging PCPs and/or their patients in cancer‐related research, particularly qualitative or mixed‐methods studies. Study resources may be best allocated to email follow‐up, incentives, and personalization of study documents linking PCPs to patients. These efforts may improve PCP participation and the representativeness of study findings.     

Learning outcomes in primary school children with emotional problems: a prospective cohort study

Background

Academic difficulties are common in adolescents with mental health problems. Although earlier childhood emotional problems, characterised by heightened anxiety and depressive symptoms are common forerunners to adolescent mental health problems, the degree to which mental health problems in childhood may contribute independently to academic difficulties has been little explored.

Methods

Data were drawn from a prospective cohort study of students in Melbourne, Australia (N = 1239). Data were linked with a standardised national assessment of academic performance at baseline (9 years) and wave three (11 years). Depressive and anxiety symptoms were assessed at baseline and wave two (10 years). Regression analyses estimated the association between emotional problems (9 and/or 10 years) and academic performance at 11 years, adjusting for baseline academic performance, sex, age and socioeconomic status, and hyperactivity/inattention symptoms.

Results

Students with depressive symptoms at 9 years of age had lost nearly 4 months of numeracy learning two years later after controlling for baseline academic performance and confounders. Results were similar for anxiety symptoms. Regardless of when depressive symptoms occurred there were consistent associations with poorer numeracy performance at 11 years. The association of depressive symptoms with reading performance was weaker than for numeracy if they were present at wave two. Persistent anxiety symptoms across two waves led to nearly a 4 month loss of numeracy learning at 11 years, but the difference was not meaningful for reading. Findings were similar when including hyperactivity/inattention symptoms.

Conclusions

Childhood anxiety and depression are not only forerunners of later mental health problems but predict academic achievement. Partnerships between education and health systems have the potential to not only improve childhood emotional problems but also improve learning.     

Clinical utility of exome sequencing in a pediatric epilepsy cohort

Objective

Exome sequencing (ES) has played an important role in the identification of causative variants for individuals with epilepsy and has proven to be a valuable diagnostic tool. Less is known about its clinical utility once a diagnosis is received. This study systematically reviewed the impact of ES results on clinical decision-making and patient care in a pediatric epilepsy cohort at a tertiary care medical center.

Methods

Pediatric patients with unexplained epilepsy were referred by their neurologist, and informed consent was obtained through an institutional review board–approved research ES protocol. For patients who received a genetic diagnosis, a retrospective chart review was completed of the probands and their relatives' medical records prior to and after genetic diagnosis. The following outcomes were explored: provider management recommendations, changes in care actually implemented, and anticipatory guidance provided regarding the proband's condition.

Results

Fifty-three probands met the inclusion criteria. Genetic diagnosis led to at least one provider recommendation in 41.5% families (22/53). Recommendations were observed in the following categories: medication, screening for non-neurological comorbidities/referrals to specialists, referrals to clinical research/trials, and cascade testing. Anticipatory guidance including information about molecular diagnosis, prognosis, and relevant foundations/advocacy groups was also observed.

Significance

Results demonstrate the clinical utility of ES for individuals with epilepsy across multiple aspects of patient care, including anti-seizure medication (ASM) selection; screening for non-neurological comorbidities and referrals to appropriate medical specialists; referral to reproductive genetic counseling; and access to research, information, and support resources. To our knowledge, this is the first study to evaluate the clinical utility of ES for a pediatric epilepsy cohort with broad epilepsy phenotypes. This work supports the implementation of ES as part of clinical care in this population.