Atezolizumab plus bevacizumab as a downstaging therapy for liver transplantation in hepatocellular carcinoma with portal vein thrombosis: The first report.

Atezolizumab plus bevacizumab is the preferred first-line treatment regimen for patients with advanced hepatocellular carcinoma. Limited data have shown promising results with the use of immune checkpoint inhibitors like nivolumab to downstage these patients for liver transplantation (LT). Here, we describe the first case of successful downstaging with atezolizumab plus bevacizumab in a patient with multifocal hepatocellular carcinoma and main portal vein tumoral thrombosis, followed by ABO-incompatible live donor LT. This illustrated case highlights that atezolizumab plus bevacizumab therapy may be a potential bridging tool for curative LT.

High prevalence of outpatient falls following elective shoulder arthroplasty.

BACKGROUND: This study characterized the prevalence and risk factors of inpatient and outpatient postoperative falls in patients undergoing elective shoulder arthroplasty. METHODS: A retrospective chart review of 198 patients undergoing anatomic or reverse total shoulder arthroplasty or hemiarthroplasties at one institution between 2015 and 2017 was reviewed to determine the prevalence of inpatient and outpatient falls up to 90 days after discharge. Univariate and multivariate analyses were conducted to assess potential risk factors for postoperative falls including demographics, indication for surgery, surgical procedure, medical history, length of hospital stay, perioperative hemoglobin, need for transfusion, and discharge disposition. RESULTS: There were 23 falls in 22 patients within a 90-day postoperative period. The inpatient fall rate was 1.0% (2 of 198). The outpatient fall rate was 10.6% (21 of 198). Outpatient falls resulted in emergency department evaluation in 23.8% of cases (5 of 21), readmission in 19.0% (4 of 21), injury to an anatomic site other than the shoulder in 19.0% (4 of 21), and injury at the surgical site (eg, periprosthetic humeral fracture) in 4.8% (1 of 21). No significant risk factors were identified for inpatient falls. Independent risk factors for an outpatient fall were female sex (adjusted odds ratio [aOR] = 4.79; 95% confidence interval [CI]: 1.32, 17.4; P = .007), increased length of hospital stay (aOR = 1.23; 95% CI: 1.04, 1.45; P = .02), and history of a movement disorder (aOR = 7.20; 95% CI: 1.22, 42.6; P = .03). CONCLUSION: A high outpatient fall rate of 10.6% within 90 days after discharge raises the concern that falls after shoulder arthroplasty are significantly higher than previously reported.

Understanding the Value of Total Shoulder Arthroplasties at Physician-Owned Hospitals.

BACKGROUND: Owing to concerns regarding higher cost, low quality of care and cherry-picking in physician-owned hospitals (POHs), the Affordable Care Act imposed sanctions that prevented the formation of new POHs. With an increasing utilization of total shoulder arthroplasties (TSAs), there is a need for re-evaluation and assessment of quality and cost of TSAs performed at these POHs. METHODS: The 2011 to 2014 Medicare 100% Standard Analytical Files was used to identify patients undergoing a reverse TSA or anatomic TSA at POHs and non-POHs. Multivariate regression analyses were used to assess differences in 90-day and 1-year outcomes between the two groups. RESULTS: A total of 1,626 (2.2%) patients received a TSA at a POH (N = 50). No notable differences were noted between POH versus non-POHs regarding 90-day surgical site infections (P = 0.645), dislocation (P = 0.068), periprosthetic fractures (P = 0.556), revision arthroplasty (P = 0.114), pulmonary embolism (P = 0.155), deep vein thrombosis (P = 0.208), acute myocardial infarction (P = 0.219), sepsis (P = 0.288), urinary tract infections (P = 0.186), all-cause readmissions (P = 0.427), 1-year dislocations (P = 0.475), 1-year periprosthetic fractures (P = 0.697), and 1-year revision arthroplasties (P = 0.225). TSAs performed at POHs had higher odds of postoperative stiffness at 90-day (odds ratio 1.39; P < 0.001) and 1-year follow-up points (odds ratio 1.51; P < 0.001). TSAs at POHs had markedly lower risk-adjusted 90-day charges (-$8,904) and 90-day costs (-$1,659). CONCLUSION: Apart from slightly higher rates of stiffness and renal complications, patients undergoing TSAs at POHs seem to have similar outcomes as compared to non-POHs, while having lower costs of care. The findings suggest a need for further research, evaluating the value of care at POHs. LEVEL OF EVIDENCE: Level III.

Analysis of stochastic fluctuations in responsiveness is a critical step toward personalized anesthesia.

Traditionally, drug dosing is based on a concentration-response relationship estimated in a population. Yet, in specific individuals, decisions based on the population-level effects frequently result in over or under-dosing. Here, we interrogate the relationship between population-based and individual-based responses to anesthetics in mice and zebrafish. The anesthetic state was assessed by quantifying responses to simple stimuli. Individual responses dynamically fluctuated at a fixed drug concentration. These fluctuations exhibited resistance to state transitions. Drug sensitivity varied dramatically across individuals in both species. The amount of noise driving transitions between states, in contrast, was highly conserved in vertebrates separated by 400 million years of evolution. Individual differences in anesthetic sensitivity and stochastic fluctuations in responsiveness complicate the ability to appropriately dose anesthetics to each individual. Identifying the biological substrate of noise, however, may spur novel therapies, assure consistent drug responses, and encourage the shift from population-based to personalized medicine.