Hepatocellular carcinoma (HCC) versus non-HCC: accuracy and reliability of Liver Imaging Reporting and Data System v2018

Abdominal Radiology - The Liver Imaging Reporting and Data System (LI-RADS) was created to standardize the diagnostic criteria for hepatocellular carcinoma (HCC) and has undergone multiple...     

Prevalence,Trends, and Outcomes of Higher-Risk Percutaneous Coronary Interventions Among Patients Without Acute Coronary Syndromes

Background/purpose

Patients and lesions at a higher procedural risk for percutaneous coronary intervention (PCI) are an understudied population. We examined the frequency, clinical characteristics, and outcomes of higher risk and non-higher risk PCIs at a large tertiary center.

A New Standard for Advance Care Planning (ACP) Conversations in the Hospital: Results from a Delphi Panel

BackgroundFewer than half of the US population has an advance healthcare directive. Hospitalizations offer a key opportunity for clinicians to engage patients in advance care planning (ACP) conversations. Guidelines suggest screening for the presence of “serious illness” but do not further specify how to prioritize the 12.4 million patients hospitalized each year.ObjectiveTo establish a normative standard for prioritizing hospitalized patients for ACP conversations.Design and SettingA modified Delphi study, with three iterative rounds of online surveys.ParticipantsMulti-disciplinary group of US-based clinicians with research and practical expertise in ACP.Main MeasuresIndirect and direct elicitation of short-term and 1-year risk of mortality that prompt experts to prioritize ACP conversations for hospitalized adults.Main resultsFifty-seven of 108 (52%) candidate panelists completed round 1, and 47 completed rounds 2 and 3. Panelists were primarily physicians (84%), with significant experience (mean years 23 [SD 9.8]), who either taught (55%) and/or performed research about ACP (55%). In round 1, > 70% of panelists agreed that all hospitalized adults ≥ 65 years should have an ACP conversation before discharge, but disagreed about the timing and content of the conversation. By round 3, > 70% of participants agreed that patients with either high (> 10%) short-term or high (≥ 34%) 1-year risk of mortality should have a goals of care conversation (i.e., focused on preferences for near-term treatment), while patients with low (≤ 10%) short-term and low (< 19%) 1-year risk of mortality warranted an ACP conversation (i.e., focused on preferences for future care) before discharge.LimitationsUse of case vignettes to elicit clinician judgment; response rate.ConclusionsPanelists agreed that clinicians should have an ACP conversation with all hospitalized adults over 65 years in an ACP conversation, adjusting the content and timing of the conversation conditional on the patient’s risk of short-term and 1-year mortality.Electronic supplementary materialThe online version of this article (10.1007/s11606-020-06150-0) contains supplementary material, which is available to authorized users.KEY WORDS: advance care planning, Delphi survey, physician performance

Numerous stakeholders recommend advance care planning (ACP) to improve the quality of care that patients receive as they approach the end-of-life.^1–3 Hospitalizations offer one opportunity for clinicians to initiate ACP conversations with patients.⁴ However, high-quality conversations, which allow patients to reveal (or potentially construct) their preferences, require clinicians to have the communication skills, the willingness to engage in emotionally complex interactions, and the time necessary to facilitate this process.^5–8 Guidelines suggest screening patients to prioritize those with near-term mortality or morbidity risk based on the presence of “serious illness,” defined as the presence of a condition that carries a high risk of mortality or impacts quality of life.⁴ In the absence of a quantifiable definition of this term, the surprise question (which requires the treating clinician to consider whether or not he/she would be surprised if the patient died in the next year) has been widely promoted.^{9, 10} Pooled results of two different meta-analyses, however, suggest poor to modest accuracy of the surprise question for predicting death at 12 months.^{10, 11} Efforts to improve the quality of care for patients at the end-of-life therefore require better strategies to screen and prioritize patients for ACP conversations.The objective of this study was to establish a consensus-based normative standard for risk of mortality that should prompt hospitalists to have an ACP conversation with their patients. Recognizing that people, even experts, struggle with probability-based judgments, we embedded a behavioral experiment within a Delphi process, sequentially presenting experts with cases selected from across the distribution of mortality risk and observing their judgments as the sampling frame changed. We hypothesized that experts would be more likely to recommend an immediate ACP conversation as the risk of mortality increased.     

Critical role for estrogen receptor alpha in negative feedback regulation of gonadotropin-releasing hormone mRNA expression in the female mouse

Estrogen exerts an important regulatory influence upon the functioning of the gonadotropin-releasing hormone (GnRH) neurons. Whether this is mediated by estrogen receptor alpha (ERalpha) or ERbeta or both ERs is presently unclear. Using female mice with targeted disruptions of ERalpha and ERbeta (alphaERKO and betaERKO, respectively) we have investigated the in vivo role of the two ERs in the negative feedback influence of estrogen upon GnRH mRNA expression. Compared with intact wild-type mice, plasma luteinizing hormone (LH) levels were substantially (p < 0.01) higher in intact alphaERKO females and increased modestly (p < 0.05) in intact betaERKO mice. Three weeks after ovariectomy, LH concentrations were elevated significantly in wild-type (p < 0.01) and betaERKO (p < 0.05) mice but not changed in alphaERKO females. Quantitative analysis of GnRH mRNA expression using in situ hybridization revealed that cellular GnRH mRNA content was greater (p < 0.05) in intact alphaERKO mice compared with intact wild-type and betaERKO mice. Following ovariectomy, GnRH mRNA expression was elevated in wild-type (p = 0.06) and betaERKO (p < 0.05) females but not alphaERKO mice. These data demonstrate that both ERalpha and ERbeta are involved in inhibiting LH levels at times of estrogen-negative feedback in vivo. However, only ERalpha appears to be critical for the estrogen-negative feedback suppression of GnRH mRNA expression in the female mouse.     

Developing Empirically Based, Culturally Grounded Drug Prevention Interventions for Indigenous Youth Populations

This article describes the relevance of a culturally grounded approach toward drug prevention development for indigenous youth populations. This approach builds drug prevention from the “ground up” (i.e., from the values, beliefs, and worldviews of the youth that are the intended consumers of the program) and is contrasted with efforts that focus on adapting existing drug prevention interventions to fit the norms of different youth ethnocultural groups. The development of an empirically based drug prevention program focused on rural Native Hawaiian youth is described as a case example of culturally grounded drug prevention development for indigenous youth; the impact of this effort on the validity of the intervention and on community engagement and investment in the development of the program are discussed. Finally, implications of this approach for behavioral health services and the development of an indigenous prevention science are discussed.     

Acute Onset of Intracerebral Hemorrhage due to Autonomic Dysreflexia

Autonomic dysreflexia is a clinical emergency syndrome of uncontrolled sympathetic output that can occur in patients who have a history of spinal cord injury. Despite its frequency in spinal cord injury patients, central nervous system complications are very rare. We report a man with traumatic high level incomplete spinal cord injury who suffered hypertensive right thalamic hemorrhage secondary to an episode of autonomic dysreflexia. Prompt recognition and removal of the triggering factor, the suprapubic catheter obstruction which led to hypertensive attack, the patient had a favorable functional outcome after the resorption of the hematoma and effective rehabilitation programme.     

Public Health Perspectives on Hearing Loss and Aging Outcomes: Preventive Care Utilization among Adults with Hearing Loss in the United States

Hearing loss (HL) can negatively impact patient–provider communication and limit access to health promotion information, which may lead to decreased preventive care utilization. Using data from the 2015 and 2018 National Health Interview Survey, we examined the association between perceived HL with and without hearing aid use with self-reported age-appropriate uptake of breast and colon cancer screening, and influenza and pneumococcal vaccination. In models adjusted for sociodemographic characteristics, access to care, and health status, people with HL had lower odds of receiving breast cancer screening (odds ratio [OR] = 0.83, 95% confidence interval [CI] = 0.72–0.96) and higher odds of receiving pneumococcal vaccination (OR = 1.11, 95% CI = 1.00–1.24) relative to those without HL. There were no differences in their colon cancer or influenza vaccination uptake. Compared with those without HL, people with HL who used hearing aids had increased odds of colon cancer screening and influenza and pneumococcal vaccination, while people with HL who did not use hearing aids were less likely to report cancer screening. Overall, Americans with untreated HL were less likely to report completing cancer screening. Hearing aid use may modify the association between HL and preventive care uptake. Screening for HL in primary care settings and communication trainings for providers may help reduce cancer screening disparities.