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JAMA Surgery Dec 2023Up to 40% of women experience dissatisfaction after breast reconstruction due to unexpected outcomes that are poorly aligned with personal preferences. Identifying what...
IMPORTANCE
Up to 40% of women experience dissatisfaction after breast reconstruction due to unexpected outcomes that are poorly aligned with personal preferences. Identifying what attributes patients value when considering surgery could improve shared decision-making. Adaptive choice-based conjoint (ACBC) analysis can elicit individual-level treatment preferences.
OBJECTIVES
To identify which attributes of breast reconstruction are most important to women considering surgery and to describe how these attributes differ by those who prefer flap vs implant reconstruction.
DESIGN, SETTING, AND PARTICIPANTS
This web-based, cross-sectional study was conducted from March 1, 2022, to January 31, 2023, at Duke University and between June 1 and December 31, 2022, through the Love Research Army with ACBC analysis. Participants were 105 women at Duke University with a new diagnosis of or genetic predisposition to breast cancer who were considering mastectomy with reconstruction and 301 women with a history of breast cancer or a genetic predisposition as identified through the Love Research Army registry.
MAIN OUTCOMES AND MEASURES
Relative importance scores, part-worth utility values, and maximum acceptable risks were estimated.
RESULTS
Overall, 406 women (105 from Duke University [mean (SD) age, 46.3 (10.5) years] and 301 from the Love Research Army registry [mean (SD) age, 59.2 (11.9) years]) participated. The attribute considered most important was the risk of abdominal morbidity (mean [SD] relative importance [RI], 28% [11%]), followed by chance of major complications (RI, 25% [10%]), number of additional operations (RI, 23% [12%]), appearance of the breasts (RI, 13% [12%]), and recovery time (RI, 11% [7%]). Most participants (344 [85%]) preferred implant-based reconstruction; these participants cared most about abdominal morbidity (mean [SD] RI, 30% [11%]), followed by the risk of complications (mean [SD], RI, 26% [11%]) and additional operations (mean [SD] RI, 21% [12%]). In contrast, participants who preferred flap reconstruction cared most about additional operations (mean [SD] RI, 31% [15%]), appearance of the breasts (mean [SD] RI, 27% [16%]), and risk of complications (mean [SD] RI, 18% [6%]). Factors independently associated with choosing flap reconstruction included being married (odds ratio [OR], 2.30 [95% CI, 1.04-5.08]; P = .04) and higher educational level (college education; OR, 2.43 [95% CI, 1.01-5.86]; P = .048), while having an income level of greater than $75 000 was associated with a decreased likelihood of choosing the flap profile (OR, 0.45 [95% CI, 0.21-0.97]; P = .01). Respondents who preferred flap appearance were willing to accept a mean (SD) increase of 14.9% (2.2%) chance of abdominal morbidity (n = 113) or 6.4% (4.8%) chance of complications (n = 115).
CONCLUSIONS AND RELEVANCE
This study provides information on how women value different aspects of their care when making decisions for breast reconstruction. Future studies should assess how decision aids that elicit individual-level preferences can help tailor patient-physician discussions to focus preoperative counseling on factors that matter most to each patient and ultimately improve patient-centered care.
Topics: Female; Humans; Middle Aged; Mastectomy; Breast Neoplasms; Patient Preference; Cross-Sectional Studies; Mammaplasty; Genetic Predisposition to Disease
PubMed: 37755818
DOI: 10.1001/jamasurg.2023.4432 -
Diabetes Technology & Therapeutics Oct 2023Studies have reported significantly higher hemoglobin A1c (A1C) in African American patients than in White patients with the same mean glucose, but less is known about...
Studies have reported significantly higher hemoglobin A1c (A1C) in African American patients than in White patients with the same mean glucose, but less is known about other racial/ethnic groups. We evaluated racial/ethnic differences in the association between mean glucose, based on continuous glucose monitor (CGM) data, and A1C. Retrospective study among 1788 patients with diabetes from Kaiser Permanente Northern California (KPNC) who used CGM devices during 2016 to 2021. In this study population, there were 5264 A1C results; mean glucose was calculated from 124,388,901 CGM readings captured during the 90 days before each A1C result. Hierarchical mixed models were specified to estimate racial/ethnic differences in the association between mean glucose and A1C. Mean A1C was 0.33 (95% confidence interval: 0.23-0.44; < 0.0001) percentage points higher among African American patients relative to White patients for a given mean glucose. A1C results for Asians, Latinos, and multiethnic patients were not significantly different from those of White patients. The slope of the association between mean glucose and A1C did not differ significantly across racial/ethnic groups. Variance for the association between mean glucose and A1C was substantially greater within groups than between racial/ethnic groups (65% vs. 9%, respectively). For African American patients, A1C results may overestimate glycemia and could lead to premature diabetes diagnoses, overtreatment, or invalid assessments of health disparities. However, most of the variability in the mean glucose-A1C association was within racial/ethnic groups. Treatment decisions driven by guideline-based A1C targets should be individualized and supported by direct measurement of glycemia.
Topics: Humans; Glycated Hemoglobin; Glucose; Diabetes Mellitus, Type 2; Retrospective Studies; Blood Glucose; White
PubMed: 37535058
DOI: 10.1089/dia.2023.0153 -
Shoulder & Elbow Oct 2023We performed a retrospective review of patients undergoing surgery for elbow spasticity. We present our findings and expected outcomes according to degree of elbow fixed...
BACKGROUND
We performed a retrospective review of patients undergoing surgery for elbow spasticity. We present our findings and expected outcomes according to degree of elbow fixed flexion contracture.
METHODS
Data collected included age, Modified Ashworth Score, pre and post-operative range of motion, indications for surgery and the Goal Attainment Score. Contracture severity was classified into five groups based on goniometric measurements. Surgical procedures were categorised into three groups.
RESULTS
A total of 114 elbows underwent surgical release. The mean age at surgery was 18.5 years and the mean follow-up was 20 months. Preoperatively, the median Modified Ashworth Score was 2 and the mean contracture was 68° (35° fixed and 33° dynamic). The median number of structures released was 3 (range: 1-6). Surgical procedures were classified as biceps sparing (27%), biceps lengthening (53%) and extended releases (18%). Mean improvement in extension was 59°, and the mean improvement in Goal Attainment Score was 36 (mean attainment score 62). The mean residual contracture was 9°. Patient satisfaction was high with over 90% of surgical indications met.
DISCUSSION
Contracture severity of the spastic elbow can be categorised by degree of fixed flexion deformity and therefore treatment can be allocated accordingly.
PubMed: 37811394
DOI: 10.1177/17585732221102399 -
JAMA Cardiology Sep 2023Cardiac magnetic resonance (CMR) imaging-derived extracellular volume (ECV) mapping, generated from precontrast and postcontrast T1, accurately determines treatment...
IMPORTANCE
Cardiac magnetic resonance (CMR) imaging-derived extracellular volume (ECV) mapping, generated from precontrast and postcontrast T1, accurately determines treatment response in cardiac light-chain amyloidosis. Native T1 mapping, which can be derived without the need for contrast, has demonstrated accuracy in diagnosis and prognostication, but it is unclear whether serial native T1 measurements could also track the cardiac treatment response.
OBJECTIVE
To assess whether native T1 mapping can measure the cardiac treatment response and the association between changes in native T1 and prognosis.
DESIGN, SETTING, AND PARTICIPANTS
This single-center cohort study evaluated patients diagnosed with cardiac light-chain amyloidosis (January 2016 to December 2020) who underwent CMR scans at diagnosis and a repeat scan following chemotherapy. Analysis took place between January 2016 and October 2022.
MAIN OUTCOMES AND MEASURES
Comparison of biomarkers and cardiac imaging parameters between patients with a reduced, stable, or increased native T1 and association between changes in native T1 and mortality.
RESULTS
The study comprised 221 patients (mean [SD] age, 64.7 [10.6] years; 130 male [59%]). At 6 months, 183 patients (mean [SD] age, 64.8 [10.5] years; 110 male [60%]) underwent repeat CMR imaging. Reduced native T1 of 50 milliseconds or more occurred in 8 patients (4%), all of whom had a good hematological response; by contrast, an increased native T1 of 50 milliseconds or more occurred in 42 patients (23%), most of whom had a poor hematological response (27 [68%]). At 12 months, 160 patients (mean [SD] age, 63.8 [11.1] years; 94 male [59%]) had a repeat CMR scan. A reduced native T1 occurred in 24 patients (15%), all of whom had a good hematological response, and was associated with a reduction in N-terminal pro-brain natriuretic peptide (median [IQR], 2638 [913-5767] vs 423 [128-1777] ng/L; P < .001), maximal wall thickness (mean [SD], 14.8 [3.6] vs 13.6 [3.9] mm; P = .009), and E/e' (mean [SD], 14.9 [6.8] vs 12.0 [4.0]; P = .007), improved longitudinal strain (mean [SD], -14.8% [4.0%] vs -16.7% [4.0%]; P = .004), and reduction in both myocardial T2 (mean [SD], 52.3 [2.9] vs 49.4 [2.0] milliseconds; P < .001) and ECV (mean [SD], 0.47 [0.07] vs 0.42 [0.08]; P < .001). At 12 months, an increased native T1 occurred in 24 patients (15%), most of whom had a poor hematological response (17 [71%]), and was associated with an increased N-terminal pro-brain natriuretic peptide (median [IQR], 1622 [554-5487] vs 3150 [1161-8745] ng/L; P = .007), reduced left ventricular ejection fraction (mean [SD], 65.8% [11.4%] vs 61.5% [12.4%]; P = .009), and an increase in both myocardial T2 (mean [SD], 52.5 [2.7] vs 55.3 [4.2] milliseconds; P < .001) and ECV (mean [SD], 0.48 [0.09] vs 0.56 [0.09]; P < .001). Change in myocardial native T1 at 6 months was independently associated with mortality (hazard ratio, 2.41 [95% CI, 1.36-4.27]; P = .003).
CONCLUSIONS AND RELEVANCE
Changes in native T1 in response to treatment, reflecting a composite of changes in T2 and ECV, are associated with in changes in traditional markers of cardiac response and associated with mortality. However, as a single-center study, these results require external validation in a larger cohort.
Topics: Humans; Male; Middle Aged; Cardiomyopathies; Stroke Volume; Cohort Studies; Ventricular Function, Left; Amyloidosis; Biomarkers
PubMed: 37466990
DOI: 10.1001/jamacardio.2023.2010 -
Statistics in Medicine Jan 2024Accurate assessment of the mean-variance relation can benefit subsequent analysis in biomedical research. However, in most biomedical data, both the true mean and the...
Accurate assessment of the mean-variance relation can benefit subsequent analysis in biomedical research. However, in most biomedical data, both the true mean and the true variance are unavailable. Instead, raw data are typically used to allow forming sample mean and sample variance in practice. In addition, different experimental conditions sometimes cause a slightly different mean-variance relation from the majority of the data in the same data set. To address these issues, we propose a semiparametric estimator, where we treat the uncertainty in the sample mean as a measurement error problem, the uncertainty in the sample variance as model error, and use a mixture model to account for different mean-variance relations. Asymptotic normality of the proposed method is established and its finite sample properties are demonstrated by simulation studies. The data application shows that the proposed method produces sensible results compared with methods either ignoring the uncertainty in the sample means or ignoring the potential different mean-variance relations.
Topics: Humans; Models, Statistical; Computer Simulation; Uncertainty
PubMed: 37994214
DOI: 10.1002/sim.9970 -
Journal of the American Society of... Dec 2023The role of echocardiography in deriving transvalvular mean gradients from transaortic velocities in aortic stenosis (AS) and in structural valve degeneration (SVD) is...
BACKGROUND
The role of echocardiography in deriving transvalvular mean gradients from transaortic velocities in aortic stenosis (AS) and in structural valve degeneration (SVD) is well established. However, reports following surgical aortic valve replacement, post-transcatheter aortic valve replacement (TAVR), and valve-in-valve-TAVR (ViV-TAVR) have cautioned against the use of echocardiography-derived mean gradients to assess normal functioning bioprosthesis due to discrepancy compared with invasive measures in a phenomenon called discordance.
METHODS
In a multicenter study, intraprocedural echocardiographic and invasive mean gradients in AS, SVD, post-native TAVR, and post-ViV-TAVR were compared, when obtained concomitantly, and discharge echocardiographic gradients were recorded. Absolute discordance (intraprocedural echocardiographic - invasive mean gradient) and percent discordance (intraprocedural echocardiographic - invasive mean gradient/echocardiographic mean gradient) were calculated. Multivariable regression analysis was performed to determine variables independently associated with elevated postprocedure invasive gradients ≥20 mm Hg, absolute discordance >10 mm Hg, and discharge echocardiographic mean gradient ≥20 mm Hg.
RESULTS
A total of 5,027 patients were included in the registry: 4,725 native TAVR and 302 ViV-TAVR. Intraprocedural concomitant echocardiographic and invasive mean gradients were obtained pre-TAVR in AS (n = 2,418), pre-ViV-TAVR in SVD (n = 101), in post-ViV-TAVR (n = 77), and in post-TAVR (n = 823). Echocardiographic and invasive mean gradients demonstrated strong correlation (r = 0.69) and agreement (bias, 0.11; 95% CI, -0.4-0.62) in AS, moderate correlation (r = 0.56) and agreement (bias, 1.08; 95% CI, -2.53 to 4.59) in SVD, moderate correlation (r = 0.61) and weak agreement (bias, 6.47; 95% CI, 5.08-7.85) post-ViV-TAVR, and weak correlation (r = 0.18) and agreement (bias, 3.41; 95% CI, 3.16-3.65) post-TAVR. Absolute discordance occurs primarily in ViV-TVR and is not explained by sinotubular junction size and increases with increasing echocardiographic mean gradient. Percent discordance in AS and SVD (1.3% and 4%, respectively) was lower compared with post-TAVR/ViV-TAVR (66.7% and 100%, respectively). Compared with self-expanding valves, balloon expanding valves were independently associated with elevated discharge echocardiographic but lower invasive mean gradient (odds ratio = 3.411, 95% CI, 1.482-7.852, P = .004; vs odds ratio = 0.308, 95% CI, 0.130-0.731, P = .008, respectively).
CONCLUSIONS
Post-TAVR/ViV-TAVR, echocardiography is discordant from invasive mean gradients, and absolute discordance increases with increasing echocardiographic mean gradient and is not explained by sinotubular junction size. Percent discordance is significantly higher post-TAVR/ViV-TAVR than in AS and SVD. Post-TAVR/ViV-TAVR, poor correlation and wide limits of agreement suggest echocardiographic and invasive mean gradients may not be used interchangeably and a high residual echocardiographic mean gradient should be confirmed invasively before considering any additional procedure to "correct" the gradient. Transcatheter aortic valve replacement valve types have variable impact on echocardiographic and invasive mean gradients.
Topics: Humans; Aortic Valve; Prosthesis Design; Prosthesis Failure; Treatment Outcome; Transcatheter Aortic Valve Replacement; Aortic Valve Stenosis; Heart Valve Prosthesis Implantation; Heart Valve Prosthesis; Bioprosthesis; Echocardiography
PubMed: 37507058
DOI: 10.1016/j.echo.2023.06.016 -
Psychoneuroendocrinology Aug 2024Positive and negative affect have been shown to have implications for hormones like cortisol but how moment to moment changes in affect (i.e., affect variability)...
Positive and negative affect have been shown to have implications for hormones like cortisol but how moment to moment changes in affect (i.e., affect variability) influence cortisol secretion is less well understood. Additionally, context characteristics such as mean affect and stress may influence the association between affect variability and cortisol output. In the current study, we examined affect, stress, and cortisol data from 113 participants (age range = 25-63, M = 35.63, SD = 11.34; 29% male; 42% White/Caucasian, 37% Asian or Pacific Islander, 13% Hispanic/Latino, 4% Black/African American, 1% Native American, Eskimo, or Aleut, 4% selected "other" for their race/ethnicity). Participants completed ecological momentary assessments assessing positive and negative affect and stress four times per day for five days and provided saliva samples at each time point. Saliva was assayed for cortisol, and area under the curve with respect to ground was computed. In a three-way interaction, both positive affect mean level and stress moderated the association between positive affect variability and cortisol (b = -1.55, t(100) = -3.29, SE = 0.47, p <.01, β = -4.05). When breaking down this three-way interaction, in the context of low stress and high mean positive affect, variability was positively related to total cortisol output. In contrast, in the context of high stress and high mean positive affect, variability was negatively related to total cortisol output. While greater positive affect variability is generally worse for health-relevant outcomes (as prior research has shown and as we show here at low levels of stress), at high levels of stress, fluctuation in affect may be adaptive. For someone experiencing a high stress week, having fluctuations in positive affect may mean that they are adaptively changing to meet their environmental needs especially when they typically report high mean positive affect levels. There were no associations between negative affect variability and cortisol secretion nor did mean negative affect or stress play a moderating role for negative affect variability. This study provides evidence that positive affect variability's association with cortisol secretion throughout the day may vary based on stress and mean positive affect levels.
Topics: Humans; Hydrocortisone; Male; Saliva; Female; Stress, Psychological; Adult; Affect; Middle Aged; Ecological Momentary Assessment
PubMed: 38713929
DOI: 10.1016/j.psyneuen.2024.107064 -
Physical Review. E Oct 2023The notion of mean temperature is crucial for a number of fields, including climate science, fluid dynamics, and biophysics. However, so far its correct thermodynamic...
The notion of mean temperature is crucial for a number of fields, including climate science, fluid dynamics, and biophysics. However, so far its correct thermodynamic foundation is lacking or even believed to be impossible. A physically correct definition should not be based on mathematical notions of the means (e.g., the mean geometric or mean arithmetic), because they are not unique, and they ignore the fact that temperature is an ordinal level variable. We offer a thermodynamic definition of the mean temperature that is based upon the following two assumptions. First, the correct definition should necessarily involve equilibration processes in the initially nonequilibrium system. Among such processes, reversible equilibration and fully irreversible equilibration are the two extreme cases. Second, within the thermodynamic approach we assume that the mean temperature is determined mostly by energy and entropy. Together with the dimensional analysis, the two assumptions lead to a definition of the mean temperature that is determined up to a weight factor that can be fixed to 1/2 due to the maximum ignorance principle. The mean temperature for ideal and (van der Waals) nonideal gases with temperature-independent heat capacity is given by a general and compact formula that (besides the initial temperatures) only depends on the heat capacities and concentration of gases. Our method works for any nonequilibrium initial state, not only two-temperature states.
PubMed: 37978650
DOI: 10.1103/PhysRevE.108.044112 -
Journal of General Internal Medicine May 2024Novel statistical methods have emerged in recent medical literature, which clinicians must understand to properly appraise and integrate evidence into their practice.... (Review)
Review
Novel statistical methods have emerged in recent medical literature, which clinicians must understand to properly appraise and integrate evidence into their practice. Some of these key concepts include win ratios, restricted mean survival time, responder analyses, and standardized mean difference. This article offers guidance to busy clinicians on the comprehension and practical applicability of the results to patients. Win ratios provide an alternative method to analyze composite outcomes by prioritizing individual components of the composite; prioritization of the outcomes should be evidence-based, pre-specified, and patient-centered. Restricted mean survival time presents a method to analyze Kaplan-Meier curves when assumptions required for Cox proportional hazards analysis are not met. As it only considers outcomes that occur within a specific timeframe, the duration of follow-up must be appropriately defined and based on prior epidemiologic and mechanistic evidence. Researchers can analyze continuous outcomes with responder analyses, in which participants are dichotomized into "responders" or "non-responders." While clinicians and patients may more easily grasp outcomes analyzed in this way, they should be aware of the loss of information and resulting imprecision, as well as potential to manipulate data presentation. When meta-analyzing continuous outcomes, point estimates can be converted to standardized mean differences to facilitate the combination of data utilizing various outcome measures. However, clinicians may find it challenging to grasp the clinical meaningfulness of a standardized mean difference, and may benefit from converting it to well-known outcomes. By providing the background knowledge of these statistical methods, along with practical applicability, benefits, and inevitable limitations, this article aims to provide clinicians with an approach to appraise the literature and apply the results in clinical practice.
Topics: Humans; Data Interpretation, Statistical; Outcome Assessment, Health Care
PubMed: 38172409
DOI: 10.1007/s11606-023-08582-w