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Study Design:Retrospective cohort study.Objective:To determine if local administration of liposomal bupivacaine (LB) reduces postoperative pain scores and narcotic use in spinal deformity patients.Methods:Adult patients undergoing elective spinal fusion (7 or more levels) for scoliosis or kyphosis were selected for inclusion. Patients received either periincisional injections of combined liposomal and standard bupivacaine (n = 90, group L) or standard bupivacaine only (n = 69, group C). Perioperative pain scores (VAS [visual analogue scale]), opioid use, length of stay, functional outcome (ODI [Oswestry Disability Index]), and perioperative complications were recorded. No external funding was received for this study.Results:A total of 159 patients met inclusion criteria (mean age was 54.2 years of age). No significant baseline demographic differences were noted between the 2 groups. Group L experienced slight improvements in pain control on postoperative day (POD) 1 ( P = .02). No difference in pain scores were otherwise noted. Group L transitioned off of intravenous (IV) narcotics faster with 52.6% less IV use by POD3 ( P = .03). No differences in total narcotic consumption, perioperative complications, lengths of stay, and functional outcome scores were otherwise noted between the 2 cohorts.Conclusions:The use of LB in adult spinal deformity surgery does not appear to provide clinically important improvements in postoperative pain at the manufacturer’s recommended dosage. Furthermore, while patients receiving LB may transition more quickly off of IV narcotics, this does not appear to translate into an overall decrease in narcotic consumption, hasten return of bowel function, or decrease hospital lengths of stay. Future prospective randomized control trials are warranted. The use of varying dosages of LB may also help further clarify the true efficacy of LB in the setting of spinal deformity surgery.

The role of fatty acid ethyl esters (FAEEs) during human alcoholic pancreatitis is unknown. We compared FAEEs levels with their nonesterified fatty acids (NEFAs) precursors during alcohol intoxication and clinical alcoholic pancreatitis. The pathophysiology underlying FAEEs increase and their role as diagnostic biomarkers for alcoholic pancreatitis was investigated.A prospective blinded study compared FAEEs, NEFAs, and ethanol blood levels on hospitalization for alcoholic pancreatitis (n = 31), alcohol intoxication (n = 25), and in normal controls (n = 43). Serum FAEEs were measured at admission for nonalcoholic pancreatitis (n = 75). Mechanistic cell and animal studies were done.Median FAEEs were similarly elevated during alcohol intoxication (205 nmol/L; 95% confidence interval [CI], 71.8-515 nmol/L, P.001) and alcoholic pancreatitis (103.1 nmol/L; 95% CI, 53-689 nmol/L, P.001) vs controls (1.7 nmol/L; 95% CI, 0.02-4.3 nmol/L) or nonalcoholic pancreatitis (8 nmol/L; 95% CI, 1.1-11.5 nmol/L). Alcoholic pancreatitis increased serum NEFAs (1024 ± 710 μmol/L vs 307 ± 185 μmol/L in controls, P.05). FAEEs comprised 0.1% to 2% of the parent NEFA concentrations. FAEES correlated strongly with NEFAs independent of ethanol levels in alcoholic pancreatitis but not during alcohol intoxication. On receiver operating characteristic curve analysis for diagnosing alcoholic pancreatitis, the area under the curve for serum FAEEs was 0.87 (95% CI, 0.78-0.95, P.001). In mice and cells, alcohol administration transiently increased all FAEEs. Oleic acid ethyl ester was the only FAEE with a sustained increase up to 24 hours after intraperitoneal oleic acid plus ethanol administration.The sustained, alcohol-independent, large (20- to 50-fold) increase in circulating FAEEs during alcoholic pancreatitis results from their visceral release and mirrors the 2- to 4-fold increase in parent NEFA. The large areas under the curve of FAEEs on receiver operating characteristic curve analysis supports their role as alcoholic pancreatitis biomarkers.

Coronavirus disease 2019 has severely affected public health. Under social distancing and lockdown policies, patients with musculoskeletal pain have fewer opportunities than usual to receive routine medical care for pain management in hospitals. Therefore, we provided some suggestions for such patients to manage musculoskeletal pain and techniques that may be performed at home during this period.

Infection with the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) causes the development of the novel 2019 coronavirus disease (COVID-19) and associated clinical symptoms, which typically presents as an upper respiratory syndrome such as pneumonia. Growing evidence indicates an increased prevalence of neurological involvement (e.g., in the form of stroke) during virus infection. COVID-19 has been suggested to be more than a lung infection because it affects the vasculature of the lungs and other organs and increases the risk of thrombosis. Patients with stroke are vulnerable to secondary events as a result not only of their poor vascular condition but also of their lack of access to rehabilitation resources. Herein, we review current knowledge regarding the pathophysiology of COVID-19, its possible association with neurological involvement, and current drug therapies. Suggestions are also offered regarding the potential for current neurorehabilitation therapies to be taught and practiced at home.

This paper reports on the initial stage of a design-based research program that aims to devise student-facing social learning analytics in a postsecondary setting. In order to foster student discussion in online classes, we devised an analytics toolkit that turns discussion forum data into information for students to reflect upon. The first pilot study conducted in an online course showed both early promises and challenges with this effort. In particular, students reported usefulness of the toolkit for monitoring posting behaviors and setting participation goals. Content analysis of post content linked tool usage with students' increased attempts to solicit peer responses to their posts and increased reflection on individual participation. However, the tool was not found useful or easy to use by some students, and it did not show benefits in other aspects of online discussion, such as crafting stronger argumentation or reflecting on group processes. These findings highlight the need of social learning analytics to strive for tool simplicity, scaffold students' development in data literacy, and bring analytics and pedagogical designs into close coordination.

Background: House Dust Mite (HDM) is associated with hypersensitivity such as asthma. Patients with asthma ben­efit from improved living environment by reducing HDM exposure. In this study, we examined the effects of com­mercialized diatomaceous earth product, Casaggia® used as construction materials, on hypersensitivity in HDM-sensitized mice. Methods: Male mice were sensitized with house dust mite extract for 7d and then housed in diatomaceous earth (DE)-coated cages for 14 days at Animal Center of the Taichung Veterans General Hospital, Taichung, Taiwan in 2014. Levels of cytokine were determined using ELISA. White blood cell counts were recorded over 21d. Histologi­cal anal­ysis was conducted to determine the remodeling of respiratory tract. Results: Exposure to DE resulted in a suppression in elevated eosinophilia induced by HDM in mice. In addition, elevated serum IgE responding to HDM sensitization were restored in the presence of DE. DE ameliorated the in­flammation progression in airway. Conclusion: Environmental exposure to DE is suggested to benefit patients with hypersensitivity through relieving inflammatory symptoms. In a sense of prevention, DE represents a potential material against development of asthma.

Comorbidities affect clinical outcomes and costs in medicine. The hematopoietic cell transplantation (HCT)-specific comorbidity index (HCT-CI) predicts mortality risk after HCT. Its association with resource utilization (RU) is unknown. In this single-center, retrospective study, we examined the association of HCT-CI with RU (readmissions, length of hospital stay (LOS) and days out of hospital alive (DOHA)) in first 100 days (n=328) and 1 year (n=226) in allogeneic HCT patients from January 2010 to June 2014. Age, disease risk, conditioning and use of antithymocyte globulin were significantly different in the four groups with HCT-CI 0 to1 (n=138), 2 (n=56), 3 (n=55) or ⩾4 (n=79). Although the readmissions were higher in the first 100 days for patients with HCT-CI >0-1 (P=0.03), they were not significantly different in patients over 1 year (P=0.13). In the multivariable analysis, patients with HCT-CI score of >0 to 1 had increased LOS and fewer DOHA in both 100 days and 1 year after HCT. In this exploratory analysis, we found that HCT-CI >0 to 1 is associated with increased RU after allogeneic HCT. Recognizing predictors of RU can identify patients at risk of high utilization and help understand what drives health-care costs.

Financial burden after allogeneic hematopoietic cell transplantation: a qualitative analysis from the patient’s perspective

This study explored the effects of student engagement in a knowledge-building (KB) environment on their collaborative learning process and the perceived creative climate of that environment. The participants were 30 college students who undertook a living technology course in which KB were employed. The main data sources include students’ online discourse and a creative climate questionnaire. The findings indicate that the students became progressively more collaborative and productive over time, and they also tended to perceive the climate of the learning environment as highly supportive of knowledge creation. Implications for designing creative learning environments are discussed.

Credit unions were established in Taiwan over 40 years ago, and their members now number more than two hundred thousand. This study cites the Technology Acceptance Model by Davis (1989) in its discussion of the internet purchase intentions of Credit Union members in Taiwan. Structural equation modeling (SEM) is used to provide a descriptive statistical analysis of such demographic variables as trust, the characteristics of innovation, perceived usefulness, perceived ease of use, attitude, and purchase intentions, and the differences between them. According to this analysis, trust and the characteristics of innovation (through perceived usefulness, perceived ease of use, and attitude) influence the purchase intentions of credit union members. The most important variable is attitude. Accordingly, credit unions should improve the functionality of their websites. They could provide, for example, online ordering, information on commodities, a message board connecting buyers and sellers, online credit card payment, and an increased diversity of products. Furthermore, credit unions could use internet and placement marketing. This would increase awareness among members and the general public of the benefits of purchasing using the CU Let platform, and lead to its becoming a more popular choice among consumers.

Residents find it difficult to access medical care. Some seek care within their own program. Our objectives were to (1) determine whether family medicine program directors see their own resident physicians as patients, (2) describe whether they perceive the residency culture as actively encouraging of this practice, and (3) assess perceptions about reasons to encourage or discourage this.We used a paper-based self-administered survey November 2013--January 2014. A stratified random sample of family medicine residencies based on administrative type was used. Participants were directors of sampled programs. The main outcome measure was provision of medical care to resident physicians.A total of 137/250 directors (55%) responded. Thirty (22%) reported seeing residents as patients in their family medicine clinic while 107 did not (78%). Some directors who do see resident patients expressed discomfort in doing so (24%). Participants reported that other faculty physicians were significantly more likely to see residents (56%). Eighty-eight percent (114/129) agreed that "Having a doctor-patient relationship with a resident makes a supervisory relationship more difficult." Significant differences in attitudes were noted between directors who do and do not provide resident medical care. Few directors (10 %) agreed that their residency culture actively encouraged residents to establish doctor-patient relationships with faculty physicians. Only 16 (12%) had created written policies.It is uncommon for directors to see residents as patients, but most who do feel comfortable with it. Other faculty physicians provide care more frequently. Directors acknowledge potential difficulties with this practice, but few have addressed these issues by creating specific policies.

Social annotation has become a popular manner for web users to manage and share their information and interests. While users' interests vary with time, tag correlation also changes from users' perspectives. In this work, we explore four methods for estimating temporal correlation between social tags and detect if a long-term trend emerges from the history of temporal correlation between two tags. Three types of trends are specified: steadily-shifting, stabilizing, and cyclic. To compare the results of the four estimation methods, an indirect evaluation is realized by applying detected trends to tag recommendation.

Purpose The purpose of this study was to compare the impact of uncertainties and interplay on 3-dimensional (3D) and 4D robustly optimized intensity modulated proton therapy (IMPT) plans for lung cancer in an exploratory methodology study. Methods and Materials IMPT plans were created for 11 nonrandomly selected non-small cell lung cancer (NSCLC) cases: 3D robustly optimized plans on average CTs with internal gross tumor volume density overridden to irradiate internal target volume, and 4D robustly optimized plans on 4D computed tomography (CT) to irradiate clinical target volume (CTV). Regular fractionation (66 Gy [relative biological effectiveness; RBE] in 33 fractions) was considered. In 4D optimization, the CTV of individual phases received nonuniform doses to achieve a uniform cumulative dose. The root-mean-square dose-volume histograms (RVH) measured the sensitivity of the dose to uncertainties, and the areas under the RVH curve (AUCs) were used to evaluate plan robustness. Dose evaluation software modeled time-dependent spot delivery to incorporate interplay effect with randomized starting phases of each field per fraction. Dose-volume histogram (DVH) indices comparing CTV coverage, homogeneity, and normal tissue sparing were evaluated using Wilcoxon signed rank test. Results 4D robust optimization plans led to smaller AUC for CTV (14.26 vs 18.61, respectively; P =.001), better CTV coverage (Gy [RBE]) (D 95% CTV: 60.6 vs 55.2, respectively; P =.001), and better CTV homogeneity (D 5% -D 95% CTV: 10.3 vs 17.7, resspectively; P =.002) in the face of uncertainties. With interplay effect considered, 4D robust optimization produced plans with better target coverage (D 95% CTV: 64.5 vs 63.8, respectively; P =.0068), comparable target homogeneity, and comparable normal tissue protection. The benefits from 4D robust optimization were most obvious for the 2 typical stage III lung cancer patients. Conclusions Our exploratory methodology study showed that, compared to 3D robust optimization, 4D robust optimization produced significantly more robust and interplay-effect-resistant plans for targets with comparable dose distributions for normal tissues. A further study with a larger and more realistic patient population is warranted to generalize the conclusions.

Two series of new polyamides containing flexible ether linkages and laterally attached side rods ( 3a-i and 4a-i ) were synthesized from 2 ′ ,5 ′ -bis(4-aminophenoxy)-[1,1 ′ ;4 ′ ,1 ″ ]terphenyl ( 1a ) and 2 ′ ,5 ′ -bis(4-amino-2-trifluoromethylphenoxy)-[1,1 ′ ;4 ′ ,1 ″ ]terphenyl ( 1b ), respectively, with various aromatic dicarboxylic acids by the direct phosphorylation polycondensation. The polymers were produced with high yields and moderate to high inherent viscosities (0.41–0.97 dl/g) that corresponded to weight-average molecular weights (by size exclusion chromatography) of 47,000–65,000. Except for some polyamides that derived from rigid diacids, the obtained polyamides were readily soluble in aprotic polar solvents, such as N -methyl-2-pyrrolidone (NMP) and N , N -dimethylacetamide (DMAc), and could afford flexible and tough films via solvent casting. The polymer films cast from DMAc solutions possessed tensile strengths of 85–106 MPa and initial moduli of 1.82–2.96 GPa. These polyamides showed glass-transition temperatures ( T g ) in the range of 206–263 °C (by DSC) and softening temperatures ( T s ) in the range of 211–253 °C (by TMA). Decomposition temperatures ( T d ) for 10% weight loss all occurred above 400 °C (by TGA) in both nitrogen and air atmospheres. The polyamides 4a-i derived from trifluoromethyl-substituted diamine 1b generally showed a higher solubility, T g and T s but lower thermal stability as compared to the analogous polyamides 3a-i based on diamine 1a .

Introduction Although allogeneic hematopoietic cell transplantation (HCT) is an expensive modality of treatment for hematological disorders, very little is known about the financial burden for the patients themselves. We analyzed factors associated with financial burden and its impact on health behaviors of allogeneic HCT recipients. Patients and Methods A questionnaire was mailed to adult patients who were alive after allogeneic HCT performed between 1/06 to 6/12 at Mayo Clinic to collect information regarding financial concerns, household income, employment status, insurance, out-of-pocket expenses and health and functional status. A multivariable logistic regression analysis was performed to determine socio-demographic and clinical factors associated with financial hardship. Results Of 482 patients, 268 responded (response rate 56%). Respondents were more likely to be older and Non-Hispanic Whites. No significant differences were seen in disease or transplant characteristics between the two groups except that respondents were more likely to have received reduced intensity conditioning. Median follow-up after HCT was 2.3 years (range 0.7-6.7 years). All the patients for whom the insurance information was available (missing n=13) were insured. Median physical and mental component score, as derived from the SF-12, were 36.8 [Interquartile range (IQR) 29.3-49.0] and 53.1 (IQR 42.1-57.1) respectively, where the general population score is 50, and lower scores indicate worse functioning. The proportion of patients that reported being on medical disability increased from 8% prior to HCT to 29% after HCT. 73% of the respondents reported that being sick had hurt them financially. 54% experienced adverse financial consequences such as decrease in household income by >50% due to the HCT, need to sell/mortgage home, withdraw money from retirement accounts or having to pay more for medical care than they could afford. 3% declared bankruptcy. 12% had out-of pocket costs for the past 3 months that were> $5000. Median monthly medication copayments were $100 (range $ 0-3000). 36% patients felt that their insurance coverage was poor which was strongly correlated with adverse financial consequences (p=0.0013). Other risk factors for financial burden were poor physical functioning reflected by the physical component score Conclusions A significant proportion of allogeneic HCT survivors experience adverse financial consequences with a few reporting severe outcomes like bankruptcy, despite having health insurance coverage. Future research should investigate potential interventions such as early financial counseling and connecting with sources of financial support to help at-risk patients and prevent long-term adverse financial outcomes after this life-saving procedure. Disclosures: No relevant conflicts of interest to declare.

Introduction Myelofibrosis (MF), both primary myelofibrosis (PMF) and post essential thrombocytosis/polycythemia vera myelofibrosis (post ET/PV-MF), are chronic myeloproliferative neoplasms that are incurable with standard medical therapy. The only potential curative therapeutic modality remains allogeneic stem cell transplant (ASCT), but the optimum conditioning regimen has yet to be defined and may vary due to pre-ASCT factors such as age, donor source, and comorbidities. In the past, traditional myeloablative (MA) regimens have proven toxic. Reduced intensity conditioning (RIC) regimens have generally become the accepted standard of care for patients with PMF or Post PV/ET MF in need of ASCT, but with the potential for increase in relapse especially for high risk disease. The optimal conditioning regimen has yet to be defined. The regimen of Fludarabine, BCNU, and melphalan (FBM) is considered a reduced toxicity regimen that may afford the benefit of reduction in relapse without increase in toxicity and may “bridge the gap” between MA and RIC especially in older patients. Patients with MF have high inflammatory cytokine levels which may act as mediators of MF symptom burden and may further aggravate mediators of acute GVHD, which is one of the most frequent and severe complications of ASCT. Selection of conditioning regimen and GVHD prophylaxis are keys to MF transplant outcomes. We report here the results of 16 patients who received conditioning with FBM with rATG (FBM-A) with PMF and post PV/ET MF. Methods We conducted a retrospective review of all patients from October 2009 to November 2012 with PMF or post ET/PV-MF who underwent an ASCT with FBM-A. Patient demographic and transplant data were analyzed from a comprehensive database. The use of such data for reporting purpose was approved by the Mayo Clinic Arizona Institutional Review Board. Overall survival was estimated using Kaplan-Meier. Results There were 16 patients analyzed who had PMF or post PV/ET MF or overlap syndromes. The median follow-up of surviving patients is 20.4 months (range 8 months – 46 months). The median age was 60 (range 47-68 yrs) with 56% of patients being ≥ 60yrs. There were 8 males and 8 females. The JAK2 V617F mutation was present in 64% of patients. 86% were high risk according to the DIPSS system with 14% being intermediate-2 risk. None of the patients underwent splenectomy prior to transplant. The median HCT-CI score was 1.5 with 6 (38%) of the patients having an HCT-CMI ≥3. Donors were related in 10 patients (8 matched, 2 mismatched at 1 antigen) and unrelated in 6 (matched, n=3, 1-antigen mismatch, n=3). GVHD prophylaxis consisted of tacrolimus, MMF, and ATG 2.5 – 5.0 mg/kg. The cumulative incidence of acute GVHD grades III-IV was 15.3% at 6 months, and the cumulative incidence of NIH-defined moderate-to-severe chronic GVHD was 25% at 2 years. No patient has relapsed, and no patient has developed graft failure. There have been 4 deaths, 3 from GVHD, and 1 from infection. Among the 3 patients who died from GVHD, all were unrelated donor transplants, and 2 were mismatched unrelated transplants. The 2-year Kaplan-Meier estimate of overall survival (OS) is 72% (95% CI, 45 – 91%). The cumulative incidence of TRM was 12.6% (95% CI 3.9%-34%) at 1 year. Conclusion The reduced-toxicity regimen of FBM-A in PMF, Post ET/PV MF and overlap syndromes appear to provide the benefit of an ablative regimen with the tolerance of a RIC. The 2-year overall survival of 72% in our series is encouraging in an older population of predominantly high-risk patients. Treatment failure was related predominately to GVHD, which continues to be a significant obstacle to better long-term outcomes, especially in unrelated and mismatched patients. Reduced toxicity ASCT conditioning regimens in the setting of MF warrant further investigation. Disclosures: Reeder: Celgene: Research Funding; Novartis: Research Funding; Millenium: Research Funding.

Introduction Allogeneic hematopoietic stem cell transplant (HCT) patients are at risk for having a low Vitamin D (VD) level. VD level has been correlated with cancer incidence, pulmonary disease and infection. VD also has immunomodulatory properties and reports suggest that a low VD level increases the incidence of chronic GVHD and may impact mortality in HCT. HCT morbidity and mortality is attributed to infection, organ system toxicity, GVHD and recurrent disease. Identifying a correctable factor that would reduce the occurrence or severity of these complications would be beneficial. It is possible that VD may have significant effect on outcome after HCT due to its described properties. Normal VD level may infer better outcome for HCT patients by improving response in or preventing infection, protecting organ function, decreasing risk of relapse and/or decrease incidence or severity of GVHD. We hypothesize that there is a relationship between VD level and morbidity and mortality after HCT. We therefore studied VD levels pre- and post-HCT to determine if there was an impact of VD level on these outcomes. Patients and Methods Two hundred and fifty patients underwent myeloblative or non-myeloablative HCT between 3/12/2009 and 10/29/2012 at our institution. Baseline demographic data, disease characteristics, transplant variables and outcomes data were obtained from the transplant database. These data were supplemented by retrospective chart review for VD levels prior to transplant, at day 100 and 1 year post-HCT. Data were collected through day 100 for occurrence of infection and admissions to the ICU. Categories for VD level included normal (≥30 ng/ml) or abnormal ( Results Of the 250 patients undergoing HCT VD level was performed on 180 (72%) patients pre-HCT, 149 (60%) patients at day 100 post-HCT and 81 (32%) patients at 1 year post-HCT. The rate of acute or chronic GVHD was not significantly associated with VD level pre or post-HCT. Overall infection risk was not significant pre or post-HCT but when sorted by type of infection bacterial infection (p=0.01), radiologic evidence of pulmonary nodules/consolidation (p=0.03), and ICU admissions (p=0.0313) within the first 100 days post-transplant were significantly increased in patients who had a low VD level at day 100 post -HCT. Pre-HCT and 1 year post-HCT VD level did not impact mortality or relapse but there was a significant increase in one year mortality (p=0.02, HR = 5.99) and relapse (p = 0.03, HR=9.47) in patients who had a low VD level at day 100 post-HCT. Discussion This study shows that VD may play a significant role in bacterial infection, pulmonary infection, ICU admission, mortality and relapse after HCT. Those patients with a low VD level at day 100 post-HCT had significantly worse outcomes for relapse and mortality. Those patients with a low VD level at day 100 post-HCT had a higher incidence of lung infection, bacterial infection and admission to the ICU. In contrast to previous studies, we found no correlation between VD level and incidence of acute or chronic GVHD. This study is one of the largest reported and the first to our knowledge that reports decreased risk of certain types of infection (bacterial and lung), mortality and relapse in those with an adequate VD level receiving HCT. It is possible that supplementation of VD to keep levels ≥30 would reduce these complications of HCT. Future prospective study of VD is warranted. Finding a low cost and easy to administer therapy (such as VD replacement) that would reduce morbidity, mortality and relapse in the HCT population is needed. Disclosures: Reeder: Celgene: Research Funding; Novartis: Research Funding; Millenium: Research Funding.