Faculty Bibliography

BACKGROUND: Cesarean scar pregnancy is a serious complication of pregnancy, which consists of implantation of the gestational sac in the hysterotomy scar. This condition is increasing in frequency and often poses a diagnostic challenge. Its diagnosis is dependent on visual assessment of the uterus on the longitudinal sagittal ultrasound plane. Misdiagnosing a low intrauterine chorionic sac as a cesarean scar pregnancy, or a true scar pregnancy as an intrauterine pregnancy may lead to adverse outcomes including hysterectomy. OBJECTIVE: The objective of the study is to describe a sonographic method for the differential diagnosis of cesarean scar pregnancy versus intrauterine pregnancy in early gestation. The current study addressed to test the hypothesis that on a first-trimester ultrasound performed between 5 and 10 weeks of gestation, the relative location of the center of gestational sac to the midpoint of the uterus along a longitudinal line between the external cervical os and the fundus, can be used for early detection of cesarean scar pregnancies. STUDY DESIGN: This is a retrospective review of electronically archived ultrasound images of intrauterine and cesarean scar pregnancies between 5 and 10 weeks of gestation. A total of 242 ultrasound images were analyzed: 185 cases of normal intrauterine pregnancies (including 128 in anteverted uteri, 31 in retroverted uteri and 26 intrauterine pregnancies with history of previous cesarean delivery) and 57 cases of cesarean scar pregnancies diagnosed throughout 2004-2015 in a single institution. The following measurements were made for each case: distance from the external cervical os to the uterine fundus, the midpoint axis of the uterus, the distance from the external cervical os to the center of gestational sacs and the distance from the external cervical os to the most distant edge of the gestational sacs from the cervix. RESULTS: The location of the center of the gestational sac relative to the midpoint axis of the uterus between 5 and 10 weeks of gestation differentiated between intrauterine and cesarean scar pregnancies (mean, 17.8 vs -10.6 mm, respectively, p = 0.0001), indicating that most of the cesarean scar pregnancies are located proximally to the midpoint axis of the uterus whereas most of the normal intrauterine pregnancies are located distally from the midpoint of the uterus. Using location of the center of the gestational sac as a marker of cesarean scar pregnancies between 5 and 10 weeks of gestation yielded the following characteristics of diagnostic accuracy: sensitivity 93.0% and specificity 98.9%. The likelihood ratio of the positive test was 84.5. The likelihood ratio of the negative test was 0.07. CONCLUSIONS: The location of the center of the gestational sac relative to the midpoint axis of the uterus can be used as an easy, method for sonographic differentiation of intrauterine and cesarean scar pregnancies between 5 and 10 weeks of gestation.

OBJECTIVE: Diffusion tensor imaging (DTI) can identify structural connectivity alterations in attention-deficit/hyperactivity disorder (ADHD). Most ADHD DTI studies have concentrated on regional differences in fractional anisotropy (FA) despite its limited sensitivity to complex white matter architecture and increasing evidence of global brain differences in ADHD. Here, we examine multiple DTI metrics in separate samples of children and adults with and without ADHD with a principal focus on global between-group differences. METHOD: Two samples: adults with ADHD (n = 42) and without (n = 65) and children with ADHD (n = 82) and without (n = 80) were separately group matched for age, sex, and head motion. Five DTI metrics (FA, axial diffusivity, radial diffusivity, mean diffusivity, and mode of anisotropy) were analyzed via tract-based spatial statistics. Group analyses tested for diagnostic differences at the global (averaged across the entire white matter skeleton) and regional level for each metric. RESULTS: Robust global group differences in diffusion indices were found in adults, with the largest effect size for mode of anisotropy (MA; Cohen's d = 1.45). Global MA also differed significantly between groups in the pediatric sample (d = 0.68). In both samples, global MA increased classification accuracy compared to the model with clinical Conners' ADHD ratings alone. Regional diagnostic differences did not survive familywise correction for multiple comparisons. CONCLUSION: Global DTI metrics, particularly the mode of anisotropy, which is sensitive to crossing fibers, capture connectivity abnormalities in ADHD across both pediatric and adult samples. These findings highlight potential diffuse white matter microarchitecture differences in ADHD.

BACKGROUND: Ecstasy (MDMA) in the US is commonly adulterated with other drugs, but research has not focused on purity of ecstasy since the phenomenon of "Molly" (ecstasy marketed as pure MDMA) arose in the US. METHODS: We piloted a rapid electronic survey in 2015 to assess use of novel psychoactive substances (NPS) and other drugs among 679 nightclub/festival-attending young adults (age 18-25) in New York City. A quarter (26.1%) of the sample provided a hair sample to be analyzed for the presence of select synthetic cathinones ("bath salts") and some other NPS. Samples were analyzed using fully validated UHPLC-MS/MS methods. To examine consistency of self-report, analyses focused on the 48 participants with an analyzable hair sample who reported lifetime ecstasy/MDMA/Molly use. RESULTS: Half (50.0%) of the hair samples contained MDMA, 47.9% contained butylone, and 10.4% contained methylone. Of those who reported no lifetime use of "bath salts", stimulant NPS, or unknown pills or powders, about four out of ten (41.2%) tested positive for butylone, methylone, alpha-PVP, 5/6-APB, or 4-FA. Racial minorities were more likely to test positive for butylone or test positive for NPS after reporting no lifetime use. Frequent nightclub/festival attendance was the strongest predictor of testing positive for MDMA, butylone, or methylone. DISCUSSION: Results suggest that many ecstasy-using nightclub/festival attendees may be unintentionally using "bath salts" or other NPS. Prevention and harm reduction education is needed for this population and "drug checking" (e.g., pill testing) may be beneficial for those rejecting abstinence.

CONTEXT: Measuring What Matters identified quality indicators to examine the percentage of patients with documentation of a surrogate decision maker and preferences for life-sustaining treatments. OBJECTIVES: To determine the rate of advance care planning in older adults presenting to the Emergency Department (ED) and translation into medical directives in the electronic medical record (EMR). METHODS: A convenience sample of adults 65 years old or older were recruited from a large, urban ED beginning in January 2012. We administered a baseline interview and survey in English or Spanish, including questions about whether patients had a documented health care proxy or living will. For patients admitted to the hospital who had a health care proxy or living will, chart abstraction was performed to determine whether their advance care preferences were documented in the EMR. RESULTS: From February 2012 to May 2013, 53.8% (367/682) of older adults who completed the survey in the ED reported having a health care proxy and 40.2% (274/682) had a living will. Of those admitted to the hospital, only 4% (4/94) of patients that said they had a living will had medical directives documented in the EMR. Similarly, only 4% (5/115) of patients who had a health care proxy had the person's name or contact information documented in their medical record. CONCLUSION: About half of patients 65 years of age or older arriving in the ED have done significant advance care planning, but the majority of plans are not recorded in the EMR.

Objective: To evaluate structural volumetric changes in basal gangliathalamocortical (BGTC) regions related to cognitive function in Parkinson's disease (PD) patients with and without cognitive impairment. Methods: In a cohort of 35 PD patients (24 males, 11 females) and 31 controls (11males, 20 females), we evaluated the volumes of the following BGTC structures: lateral and medial orbitofrontal cortex, anterior cingulate cortex, and caudate nuclei based on automated segmentation of T1- weighted 3T brain MRI images with FreeSurfer 5.3. All images were manually inspected for accuracy of segmentation. SPM12 was used to generate intracranial volumes (ICV) for normalization of all measured structures. All subjects underwent clinical and neuropsychological assessments to determine cognitive status. Results: Based on a battery of neuropsychological tests and a clinicians' multidisciplinary consensus conference, we classified 15 PD subjects as cognitively impaired (PD-impaired; 11 males, 4 females; MOCA 22.9 +/- 3.63) and 20 as cognitively normal (PD-NC; 13 males, 7 females; MOCA 27 +/- 1.86). PD-impaired had smaller left caudate (0.22 +/- 0.02 vs. 0.25 +/- 0.03, p<0.05) and smaller right lateral orbitofrontal cortex than controls (0.45 +/- 0.04 vs. 0.50 +/- 0.05, p<0.05). PD-NC showed a trend towards smaller left caudate as compared to controls (0.23 +/- 0.02 vs. 0.25 +/- 0.03, p=0.05). Compared to PD-NC, PD-impaired had smaller right lateral orbitofrontal volumes (0.45 +/- 0.04 vs. 0.50 +/- 0.06, p<0.05). Conclusion: PD patients with cognitive impairment have more widespread structural changes in basal ganglia-thalamocortical circuits than PD without cognitive impairment. Automated volumetric measures of such cortical volumes may serve as a potential biomarker of cognitive status of PD patients

BACKGROUND: Children referred to child welfare (CW) due to suspected maltreatment are vulnerable and need many services, particularly minority children. OBJECTIVE: To assess whether service use has improved over the past decade and whether racial-ethnic disparities in service use have decreased. METHODS: We used two national data sets (the National Survey of Child and Adolescent Well-Being I and II) collected a decade apart to assess changes over time in health, education, mental health (MH), dental services and overall service use. RESULTS: In NSCAW II, more children were young, had lower child behavior checklist (CBCL) scores, and were Hispanic. We found significant increases in dental services, a decrease in special education services and a decrease in MH services on the bivariate level (all p<.01). A large proportion of the change in MH services occurred in school settings, but the pattern continued when examining only those services delivered outside of school. The greatest decrease occurred for children with CBCL scores <64. However, in multivariate analyses, older children, white non-Hispanic children and children placed out of the home were significantly more likely to receive MH services. Rates of MH services controlling for CBCL scores showed no improvement over the decade, nor was there a decrease in racial and ethnic disparities CONCLUSION: These data show no change in MH services over time for children referred for CW evaluation, but improvement in dental services. Racial and ethnic disparities persist. MH services decrease occurred predominantly among children whose MH symptoms are below the clinical range.

PURPOSE: The purpose of the study was to assess nursing students' knowledge, beliefs, behaviors, and social norms regarding use of alternative tobacco products (ATPs). DESIGN AND METHODS: This anonymous online survey was conducted with all students enrolled in a college of nursing. The survey utilized measures from several national tobacco studies to assess knowledge and beliefs about ATPs (hookahs, cigars or cigarillos, bidis, kreteks, smokeless tobacco, electronic cigarettes) compared to cigarettes, health effects of ATPs, personal use of ATPs, and social norms. Data were analyzed in SPSS 22.0 (SPSS Inc., Chicago, IL, USA). Descriptive statistics and frequencies were performed for basic sociodemographic data. Paired samples t tests were performed to determine differences for scaled measures. FINDINGS: Nursing students demonstrated very low levels of knowledge about ATPs and their health consequences, despite high rates of ATP personal use. About 76% of participants reported use of one or more ATPs once or more in their lifetimes. A greater proportion of students had used hookahs or waterpipes (39.6%) compared to cigarettes (32.7%). CONCLUSIONS: Nurses' lack of knowledge about the emerging use and health threats associated with ATPs may undermine their ability to provide appropriate tobacco cessation counseling. Research is needed to identify gaps in nurses' education regarding tobacco cessation counseling and to develop new counseling approaches specific to use of ATPs. CLINICAL RELEVANCE: Nurses play critical roles in counseling their patients for tobacco cessation. Further research and education about the risks presented by ATPs are critical to reducing excess tobacco-related mortality.

In clinical trials with survival endpoint, it is common to observe an overlap between two Kaplan-Meier curves of treatment and control groups during the early stage of the trials, indicating a potential delayed treatment effect. Formulas have been derived for the asymptotic power of the log-rank test in the presence of delayed treatment effect and its accompanying sample size calculation. In this paper, we first reformulate the alternative hypothesis with the delayed treatment effect in a rescaled time domain, which can yield a simplified sample size formula for the log-rank test in this context. We further propose an intersection-union test to examine the efficacy of treatment with delayed effect and show it to be more powerful than the log-rank test. Simulation studies are conducted to demonstrate the proposed methods