Follicular GH and IGF1 Levels Are Associated With Oocyte Cohort Quality: A Pilot Study

IntroductionOocyte quality contributes to the development of an optimal embryo and thus a successful pregnancy. The objective of this study was to analyse the association between oocyte cohort quality and the follicular levels of growth hormone (GH), insulin-like growth factor 1 (IGF1), 25-hydroxy vitamin D (25OHD), thyroid-stimulating hormone (TSH), free triiodothyronine (fT3), free thyroxine (fT4) and antithyroid antibodies, as a function of intracytoplasmic sperm injection (ICSI) outcomes.Material and methodsWe conducted a prospective comparative pilot study from January 2013 to December 2017. 59 ICSI cycles constituted an abnormal oocyte cohort (n=34 cycles, in which more than 50% of oocytes presented at least one morphological abnormality) and a normal oocyte cohort (n=25 cycles, in which 50% or less of the oocytes presented at least one morphological abnormality). GH, IGF1, 25OHD, TSH, fT3, fT4 and antithyroid antibodies were measured in follicular fluid.ResultsThe fertilisation rate was lower in the abnormal oocyte cohort (65.5% vs. 80%, respectively, p=0.012). Oocytes’ proportion with at least one abnormality was 79.4% in the abnormal oocyte cohort and 29.0% in the normal oocyte cohort. The mean number of morphological abnormalities per oocyte was significantly higher in the abnormal oocyte cohort. The follicular levels of GH (4.98 vs. 2.75 mIU/L, respectively; p <0.01) and IGF1 (72.1 vs. 54.2 ng/mL, respectively; p=0.05) were higher in the normal oocyte cohort. There was no association with follicular levels of TSH, fT3, fT4, antithyroid antibodies, or 25OHD.ConclusionOocyte cohort quality appears to be associated with follicular levels of GH and IGF1.

Efficacy of a Viokace Pancreatic Enzyme Protocol for Clearing Occluded Enteral Feeding Tubes: A Quality Assurance Evaluation

Background: A previous retrospective study documented restored patency to 48.2% of occluded enteral feeding tubes using alkalinized Creon pancreatic enzyme capsules. In light of the low efficacy rate, the institutional enteral feeding tube clearance protocol was subsequently revised to incorporate a newly marketed non–enteric-coated Viokace pancreatic enzyme tablet, despite the lack of published data for this indication. Objective: This study aims to evaluate the effectiveness of a Viokace-based alkalinized pancreatic enzyme protocol to clear occluded enteral feeding tubes in a university health system. Methods: This retrospective, cohort quality assurance study included adult and pediatric patients receiving a Viokace-based pancreatic enzyme protocol for enteral feeding tube occlusions in a university health system during a 12-month period. The primary outcome was effectiveness in enteral tube clearance as documented in the electronic medical record. Efficacy of the new protocol was also compared with a Creon-based alkalinized solution using historical data. Results: The Viokace protocol successfully cleared 176 of the 277 (63.5%) occluded enteral feeding tubes occurring in 205 patients included in the analysis. The revised protocol was significantly more effective at clearing occluded enteral feeding tubes ( P = 0.0056) than a protocol using Creon pancreatic enzyme capsules. Conclusion: According to this retrospective evaluation, an alkalinized Viokace pancreatic enzyme protocol was effective in clearing 63.5% of occluded enteral feeding tubes. This significantly higher success rate than previously documented with a Creon-based protocol supports the change in pancreatic enzyme formulations in the institutional protocol.

Essays in policy evaluation and labor economics

This dissertation contains three chapters. The first chapter evaluates the effect of a gun control act in California. State legislators in the U.S. are striving to curb gun violence. A common approach is to extend the existing firearms ban list. This paper examines the effect of legislation restricting sales of selected firearms in California using the synthetic control method. This case study method forms a synthetic unit using a linear combination of other states in the U.S. as the control group. The results show substantial increases in firearm sales in California from the point of passage until the law becomes effective. After the surge ends when the law becomes effective, the sale of firearms is only moderately affected thereafter. This paper also creates robustness checks to confirm that the synthetic control method is working properly with low firearm density in California, which calls into question some of the assumptions underlying the synthetic control method. The Difference-in-Difference regression reaches the same conclusion. The second chapter focuses on immigrant assimilation in the U.S. Assimilation is the process in which immigrants improve earnings as they become more adapted to the host country society. Cross-sectional studies show that immigrants have lower earnings upon arrival and faster earnings growth compared to natives. Longitudinal studies conclude that estimates based on cross-sectional data are positively biased due to decreasing cohort quality and negatively selected outmigration. I reproduce such estimates with recent U.S. data. The estimates would appear to show "bias," as inclusion of cohort fixed effects alter estimates. However, in contrast to expectations based on the current literature, decreasing cohort quality and outmigration do not explain the difference. Next, I apply a non-parametric method to make the wage distributions visually comparable across cohorts and time. I find that the linear specification of assimilation is misleading. Finally, I revisit the classic model with a quadratic assimilation term and expand it to explore the assimilation process's heterogeneity. I find that the "bias" disappears with a quadratic assimilation effect. The assimilation effect is sensitive to age at arrival and country of origin. The third chapter considers an unexplained puzzle in one of the most widely used public datasets in the U.S. The American Community Survey (ACS) replaced the Decennial Census as the primary data source for identifying immigrants' socioeconomic characteristics. This paper focuses on cohort analysis, in which a cohort combines immigrants arriving in a given year from surveys in multiple years. Tracking the sizes of cohorts from 2006 to 2019 using the ACS, we observe an abnormal increase in cohort size in the 10th and 20th years since arrival. Two hypotheses are tested, population estimate structural break and the renewal of green card. Neither appears to explain the puzzle.

Preventing excess narcotic prescriptions in MIS urologic oncology discharges (PENN): A prospective cohort quality improvement initiative.

6502 Background: In the setting of the national opioid crisis, there is increasing interest in non-narcotic pain strategies, particularly for oncology patients. Robotic urologic surgeries for cancer have been shown to result in less pain than open approaches. We hypothesized that the majority of these patients could be safely discharged with adequate analgesia without opioids. Methods: This prospective cohort study aimed to reduce narcotics prescribed at discharge after robotic radical prostatectomy (RARP), robotic radical nephrectomy (RARN) and robotic partial nephrectomy (RAPN). Prior to 9/2018, 100% of patients were discharged on varying amounts of oxycodone (range: 75-337.5 oral morphine milligram equivalents [MME]). We implemented a standard non-opioid analgesia pathway with escalation options across the continuum of care. Patients received gabapentin 300 mg and acetaminophen 975 mg once PO pre-operatively, as well as gabapentin 300 mg every 8 hours, acetaminophen 975 mg every 8 hours PO, and ketorolac 15 mg every 6 hours IV post-operatively. If complaining of persistent pain despite the standing regimen, patients were given 50 mg or 100 mg of tramadol every 6 hours as needed for pain level 5-7 or 8-10 on the visual analog scale, respectively. If requiring further escalation, patients were given 5 or 10 mg of oxycodone every 6 hours as needed on the aforementioned scale. Regardless of escalation status, all patients were discharged on the standing non-narcotic protocol. If escalated, ten pills of tramadol 50 mg or oxycodone 5 mg were prescribed accordingly. Results: Our cohort (n = 170) consisted of patients undergoing RARP (n = 87), RARN (n = 25), RAPN (n = 58) between 9/1/2018-1/9/2019. Overall, 67.7% were discharged without opioids, 24.4% with ten pills of tramadol 50 mg (50 MME) and 8.2% with ten pills of oxycodone 5 mg (75 MME). On multivariate analysis, older age (OR: 0.961, 95% CI: 0.923-0.995, p = 0.026) was associated with lower odds of needing opioids at discharge. There was no difference in postoperative telephone encounters between those discharged with or without opioids. Conclusions: The majority of robotic surgery patients do not require opioids upon discharge. An escalation protocol allows for a patient centered approach to reduce narcotic prescribing while still addressing cancer and surgical pain.

Altering standard admission order sets to promote clinical laboratory stewardship: a cohort quality improvement study

BackgroundCareful design of preprinted order sets is needed to prevent medical overuse. Recent work suggests that removing a single checkbox from an order set changes physicians’ clinical decision-making.Local problemDuring a 2-month period, our coronary care unit (CCU) ordered almost eight times as many serum thyroid-stimulating hormone (TSH) tests as our neighbouring intensive care unit, many without a reasonable clinical basis. We postulated that we could reduce inappropriate testing and improve clinical laboratory stewardship by removing the TSH checkbox from the CCU admission order set.MethodsAfter we retrospectively evaluated CCU TSH ordering before intervention, the checkbox was removed from the CCU admission order set. Twelve weeks later, we commenced a prospective 2-month assessment of TSH testing and clinical sequelae of thyroid disease among all CCU admissions. If clinical indications were absent or testing had occurred within 6 weeks, TSH requests were labelled as ‘inappropriate’.ResultsPhysician ordering and, specifically, inappropriate ordering decreased substantially after the intervention. In 2016 among physician-ordered TSH tests, 60.6% (66/109) were inappropriate; in 2017 this decreased to 20% (2/10, p=0.01). Overall, the net effect of checkbox removal saw the decrease in TSH testing without clinical indication outweigh an increase in missed testing where indications appear to exist.ConclusionsProvision of an optional checkbox for a laboratory test in an admission order set can promote overuse of laboratory resources. Simple removal of a checkbox may dramatically change test ordering patterns and promote clinical laboratory stewardship. Given our reliance on order sets, particularly by trainees, changes to order sets must be cautious to assure guideline-directed care is maintained.

Therapeutic hypothermia during neonatal transport at Regional Perinatal Centers: active vs. passive cooling

Background Earlier initiation of therapeutic hypothermia in term infants with hypoxic-ischemic encephalopathy has been shown to improve neurological outcomes. The objective of the study was to compare safety and effectiveness of servo-controlled active vs. passive cooling used during neonatal transport in achieving target core temperature. Methods We undertook a prospective cohort quality improvement study with historic controls of therapeutic hypothermia during transport. Primary outcome measures were analyzed: time to cool after initiation of transport, time to achieve target temperature from birth and temperature on arrival to cooling centers. Safety was assessed by group comparison of vital signs, diagnosis of persistent pulmonary hypertension (PPHN) and coagulation profiles on arrival. Results A total of 65 infants were included in the study. Time to cool after initiation of transport and time to achieve target temperature from birth were statistically significantly shorter in the actively cooled group with time reduction of 24% with P<0.01 and 15.6% with P<0.01, respectively. On arrival to our cooling center, we noted a significance difference in the mean core temperature (active 33.8°C vs. passive 35.4°C, P<0.01). Seven percent (2/30) of infants in the passively cooled group were overcooled (temperature <33°C). Patients in the actively cooled group had significantly lower mean heart rate compared to the passively cooled group. There was no statistically significant difference in diagnosis of PPHN or coagulation profiles on admission. Conclusion Our study indicates that active cooling with a servo-controlled device on neonatal transport is safe and more effective in achieving target temperature compared to passive cooling.

The “Negative” Assimilation of Immigrants: A Special Case

This chapter studies whether “negative” assimilation among immigrants living in the United States occurs if skills are highly transferable internationally. It outlines the conditions for negative assimilation in the context of the traditional immigration assimilation model, in which negative assimilation arises not from a deterioration of skills but from a decline in the wages afforded by skills coincident with the duration of residence. The authors use U.S. Census data from 1980, 1990, and 2000 to test the hypothesis on immigrants to the United States from English-speaking developed countries. They present comparisons with native-born workers to determine whether the findings are sensitive to immigrant cohort quality effects and find that even after controlling for these effects, negative assimilation still occurs for immigrants in the sample. They also find that negative assimilation occurs for immigrants from English-speaking developed countries living in Australia and for immigrants from Nordic countries living in Sweden.