Faculty Bibliography

OBJECTIVES/OBJECTIVE:To explore: (A) the underlying motivators and barriers to smoking cessation among young Arabic speaking smokers and (B) to examine the suitability and preferences for tobacco cessation interventions (specifically text messages) and study the possibility of enrollment methods for a randomised controlled study using text messages as an intervention for tobacco cessation. DESIGN/METHODS:Qualitative research using focus group discussions and content analysis. SETTINGS/METHODS:Two universities, one of them is the first and foremost comprehensive national university in the United Arab Emirates (UAE). The third setting is the largest hospital in the UAE and the flagship institution for the public health system in the emirate of Abu Dhabi. PARTICIPANTS/METHODS:Six focus group discussions with a total of 57 participants. Forty-seven men and 10 women. Fifty-three of them were current smokers. RESULTS:The analysis of six focus groups was carried out. Main themes arose from the data included: preferences for tobacco cessation interventions and acceptability and feasibility of text messaging as tobacco cessation intervention. Different motives and barriers for quitting smoking including shisha and dokha were explored. CONCLUSION/CONCLUSIONS:Interventions using text messaging for smoking cessation have not been used in the Middle East and they could potentially be effective; however, tailoring and closely examining the content and acceptability of text messages to be used is important before the conduction of trials involving their use. Social media is perceived to be more effective and influential, with a higher level of penetration into communities of young smokers.

Objective: Epidemiologic studies have found that a greater degree of comorbidity is associated with worse fertility potential. However, these findings are largely based on retrospective studies of men interacting with the health care system. Our objective was to evaluate the association of fertility and health status in men in the United States using a nationally representative survey.
Design(s): We compared the demographics, healthcare utilization, and overall health status of fertile and infertile men in the National Survey for Family Growth (NSFG).
Material(s) and Method(s): We performed an analysis of the male 2011-2017 cycles of the NSFG, a nationally representative survey of family planning. Infertile men were defined as men who had ever used infertility services or men who self-reported as non-surgically sterile. Men who reported completed pregnancies were considered fertile.
Result(s): Of the 13,861 men surveyed, 1,071 men were infertile, and 5,661 men were known to be fertile. Projecting to the national population, this translates to 5,205,771 infertile men and a 26,577,702 fertile men. Of the total population of sexually active men aged 15-49, roughly 8.5% (95%CI: 7.8-9.3) of men were infertile. Compared to known fertile men, infertile men had significant demographic and healthcare utilization differences (Table). Infertile men were wealthier, better educated, more likely to be white, more likely to be married, and more likely to have private insurance. Importantly, infertile men and fertile men had similar overall health status. On multivariate analysis, differences in income, marital status, and usual healthcare place remained significant.
Conclusion(s): While infertile men do have significant demographic and healthcare utilization differences compared to fertile men, the overall health status of both infertile and fertile men appear similar. [Figure presented]
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Objective: Posthumous assisted reproduction (PAR) raises complicated ethical and legal issues. ASRM recommends that assisted reproductive technology (ART) and fertility preservation (FP) programs develop written policies regarding cases of PAR, though little is known about adoption of such policies and how they have been implemented. Our objective was to assess the presence and content of policies toward PAR using oocytes and embryos amongSociety for Assisted Reproductive Technology (SART) member clinics in the U.S.
Design(s): Cross-sectional questionnaire-based study.
Material(s) and Method(s): Our study consists of three phases of communication: email-, postal mail-, and phone-based survey. We report on the first phase of anonymous email survey responses. Surveys were emailed to ASRM-member medical directors of all SART member clinics (n=332) during March and April 2019 using a modified Dillman Method; contact information was acquired from SART and ASRM membership data. The survey included 23 multiple-choice and 3 opened-ended questions assessing practice characteristics (practice type, location, IVF cycle volume), presence of a clinic policy towards PAR, and the content of such policy. Descriptive data are presented as %, with Fisher's exact test used where appropriate, and thematic content analysis was applied to open-ended responses.
Result(s): The first phase of the study received 39 clinic responses (12% response rate). Respondents were distributed across the U.S.; average volume of IVF cycles per year ranged from < 250 to > 1500. More than one-third (35.9%, n=14) of clinics reported participating in any cases of PAR over the past five years, and 5.1% (n=2) reported participation in more than five cases. Participation in cases of PAR was not significantly associated with practice type or IVF cycle volume (p>0.05). 57.9% (n=22) had written policies towards PAR using oocytes or embryos, while 36.8% (n=14) reported they did not have a policy. Practice type, IVF cycle volume, FP volume, and prior participation in cases of PAR were not significantly associated with the presence of a policy (p>0.05). Of those with a policy, 52.4% (n=11) reported they had used that policy, 66.7% (n=10) without a policy reported they had considered adopting one, and 60.0% (n=9) reported they had received a request for PAR services. Only 44% (n=15) of clinics specified that patients not expected to survive to use oocytes due to terminal illness were eligible for oocyte cryopreservation, while 50.0% (n=17) did not specify. Open-ended comments suggested need for case-by-case appraisal and firm consent polices regarding gamete disposition.
Conclusion(s): Our preliminary results suggest that SART programs are receiving an increasing number of requests for PAR services, but many SART programs lack PAR policies, and those with policies do not always follow ASRM recommendations. As PAR cases become more common, clinics should be equipped to manage the complexities of PAR. More data are needed as this study continues, and future research is needed to understand barriers to the creation and implementation of these increasingly needed policies.
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Introduction: Increasing evidence suggests that disparities in outcomes exist among patients with traumatic brain injury (TBI), but much less is known about such disparities in the elderly. The objective of this study was to determine if race and insurance status are associated with mortality among elderly patients with isolated moderate and severe TBI.
Method(s): A 4-year retrospective analysis of the Trauma Quality Improvement Program database (2013-2016) was performed to identify patients aged 60 and older with isolated moderate or severe TBI. Patients were stratified by race and insurance status comparing demographic characteristics and outcomes. A logistic regression analysis was performed to determine the relationship between race, insurance status, and mortality among elderly patients with isolated moderate and severe TBI.
Result(s): A total of 27,951 patients with isolated TBI were identified. Of those, 7.8% were black with 50.2% having insurance and 79.5% were white with 45.3% having insurance. The overall mortality rate was 9.22% with no significant differences in Head AIS. Black patients with insurance were significantly older (73 vs 63, p<0.001) and had more comorbidities (1 [0,2] vs 0 [0,1], p=0.002) when compared with black patients without insurance. With the exception of age, no significant differences were found among white patients. After adjusting for confounding variables, black race was independently associated with decreased mortality (AOR 0.69, 95% CI 0.5-0.96, p= 0.016).
Conclusion(s): Black race, independent of insurance, is associated with decreased mortality among older adults with isolated moderate and severe TBI. The role of race in affecting mortality following TBI warrants further investigation.
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Introduction: Venous thromboembolism (VTE) represents a significant source of morbidity after traumatic brain injury (TBI). The safety and timing of VTE chemoprophylaxis after TBI remain a concern, given the risk of intracranial hemorrhage progression. We evaluated the safety of anti-factor Xa assay-guided dosing for chemoprophylaxis in adult TBI patients. We hypothesized that Xa assay-guided chemoprophylaxis would be safe compared with fixed-dosing.
Method(s): An observational analysis of adult TBI patients was performed at a Level I trauma center from August 2016 to September 2017. Patients in the assay-guided group received an initial enoxaparin dose of 0.5 mg/kg, with peak anti-factor Xa activity measured 4 hours after the third dose. Prophylactic range was defined as 0.2 to 0.5 IU/mL with dose adjustment of +/-10 mg based on the assay result. The assay-guided group compared with historical fixed-dose controls, and a TBI cohort from the most recent Trauma Quality Improvement Program data set.
Result(s): Of the 179 patients included in the study, 85 patients were in the assay-guided group and 94 were in the fixed-dose group. Relative to the fixed-dose group, the assay-guided group had a lower Glasgow Coma Scale score and higher Injury Severity Score (Table). The proportion of severe (Abbreviated Injury Scale head >=4) TBI, intracranial hemorrhage progression, and VTE rates were similar between groups. However, the assay-guided group had chemoprophylaxis initiated earlier and had a higher percentage of low molecular weight heparin use relative to the Trauma Quality Improvement Program sample.
Conclusion(s): Early initiation of low molecular weight heparin anti-factor Xa assay-guided VTE prophylaxis is safe in TBI patients. These findings should be validated prospectively in a multicenter study. [Figure presented]
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Introduction: The decision of admitting a stable patient to the ICU after major operation currently relies on clinical judgment and local hospital policies. We programmed an artificial intelligence (AI) to determine the appropriate level of care after major operation and compared its performance with clinician's judgement.
Method(s): ICU admission was deemed "appropriate" when at least 1 of 15 criteria (eg re-intubation, prolonged hypotension, new-onset arrhythmia) was observed. Using Institutional data (512 patients, 87 clinical variables), we programmed an AI to predict when ICU admission would have been appropriate. We prospectively evaluated whether surgeon, anesthesiologist, intensivist, or AI was the most accurate predictor in determining appropriateness of ICU admissions across 50 patients undergoing major surgery (general, vascular, urological). Accuracy of predictions was compared using receiver operating characteristic curve analysis.
Result(s): ICU care was appropriate (at least 1 of 15 objective criteria met) in 9 of 50 patients. Artificial intelligence correctly triaged to the appropriate level of care 82% of patients (surgeon 70%, anesthesiologist 58%, intensivist 64%). Receiver operating characteristic curve analysis revealed that AI's triage was the most accurate (area under the curve [AUC] 0.82), followed by anesthesiologist's (AUC 0.70), intensivist's (AUC 0.69), and surgeon's (AUC 0.60). Overall, clinicians leaned toward over-triaging patients to the ICU (Table).
Conclusion(s): Our study provides the first evidence that AI can have a role in supporting clinical decisions on postoperative triage. In the future, more sophisticated platforms can become integrated in daily clinical practice. [Figure presented]
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OBJECTIVE:The current Phase 2b study aimed to evaluate the efficacy of mindfulness-based cognitive therapy for migraine (MBCT-M) to reduce migraine-related disability in people with migraine. BACKGROUND:Mindfulness-based interventions represent a promising avenue to investigate effects in people with migraine. MBCT teaches mindfulness meditation and cognitive-behavioral skills and directly applies these skills to address disease-related cognitions. METHODS:Participants with migraine (6-30 headache days/month) were recruited from neurology office referrals and local and online advertisements in the broader New York City area. During the 30-day baseline period, all participants completed a daily headache diary. Participants who met inclusion and exclusion criteria were randomized in a parallel design, stratified by chronic migraine status, to receive either 8 weekly individual MBCT-M sessions or 8 weeks of waitlist/treatment as usual (WL/TAU). All participants completed surveys including primary outcome evaluations at Months 0, 1, 2, and 4. All participants completed a headache diary during the 30-day posttreatment evaluation period. Primary outcomes were the change from Month 0 to Month 4 in the headache disability inventory (HDI) and the Migraine Disability Assessment (MIDAS) (total score ≥ 21 indicating severe disability); secondary outcomes (headache days/30 days, average headache attack pain intensity, and attack-level migraine-related disability [Migraine Disability Index (MIDI)]) were derived from the daily headache diary. RESULTS:Sixty participants were randomized to receive MBCT-M (n = 31) or WL/TAU (n = 29). Participants (M age = 40.1, SD = 11.7) were predominantly White (n = 49/60; 81.7%) and Non-Hispanic (N = 50/60; 83.3%) women (n = 55/60; 91.7%) with a graduate degree (n = 35/60; 55.0%) who were working full-time (n = 38/60; 63.3%). At baseline, the average HDI score (51.4, SD = 19.0) indicated a moderate level of disability and the majority of participants (50/60, 83.3%) fell in the "Severe Disability" range in the MIDAS. Participants recorded an average of 16.0 (SD = 5.9) headache days/30 days, with an average headache attack pain intensity of 1.7 on a 4-point scale (SD = 0.3), indicating moderate intensity. Average levels of daily disability reported on the MIDI were 3.1/10 (SD = 1.8). For the HDI, mean scores decreased more from Month 0 to Month 4 in the MBCT-M group (-14.3) than the waitlist/treatment as an usual group (-0.2; P < .001). For the MIDAS, the group*month interaction was not significant when accounting for the divided alpha, P = .027; across all participants in both groups, the estimated proportion of participants falling in the "Severe Disability" category fell significantly from 88.3% at Month 0 to 66.7% at Month 4, P < .001. For diary-reported headache days/30 days an average headache attack pain intensity, neither the group*month interaction (Ps = .773 and .888, respectively) nor the time effect (Ps = .059 and .428, respectively) was significant. Mean MIDI scores decreased in the MBCT-M group (-0.6/10), whereas they increased in the waitlist/treatment as an usual group (+0.3/10), P = .007. CONCLUSIONS:MBCT-M demonstrated efficacy to reduce headache-related disability and attack-level migraine-related disability. MBCT-M is a promising emerging treatment for addressing migraine-related disability.