Merkel Cell Polyomavirus Antibody in Tumor and Plasma Specimens in Patients with Merkel Cell Carcinoma.

BACKGROUND: Merkel cell carcinoma (MCC) is associated with Merkel cell polyomavirus (MCPyV) infection. MCPyV antibodies (MCPyV-Ab) in plasma correlate with survival, while MCPyV-Ab within the tumor has never been investigated. This study evaluated plasma MCPyV-Ab and tumor MCPyV-Ab titers to evaluate their role in outcomes and prognostication. METHODS: A single-institution, prospective database was retrospectively reviewed for patients diagnosed with MCC from 2014 to 2021. MCPyV-Ab plasma and tumor titers, as well as patient and treatment factors, were collected. Two-year overall survival (OS) and disease-free survival (DFS) were examined based on MCPyV-Ab presence in tumor. RESULTS: Forty patients were identified, with a median follow-up of 27.6 months. Patients were stratified into four groups based on the presence of MCPyV-Ab in plasma (P+, P-) and tumor (T+, T-). Most patients (60.0%) were P-/T-. Of the remaining patients, 22.5% were P+/T+, 12.5% were P-/T+, and 5.0% were P+/T-. Two-year DFS of the P-/T- group was 16.6 months, which was not different from the other groups (p = 0.79). Two-year OS of P-/T- was 18.3 months, and 2-year OS of P-/T+ was 28.1 months, which was similar between groups (p = 0.80). CONCLUSIONS: Most patients P+ for MCPyV had antibody-positive tumors (T+), and P- patients were also T-; however, there was a subset of patients where plasma and tumor antibody findings were incongruent. Patients with MCPyV-Ab in either plasma or tumor had a trend toward improved 2-year DFS and OS, but was limited by a small cohort. This study offers an exploratory investigation into the relationship between plasma and tumor antibodies to MCPyV on which to base future work.

Diagnostic utility of nasal methicillin-resistant Staphylococcus aureus polymerase chain reaction testing in head and neck infection.

In this retrospective study of adult inpatients who underwent an ear, nose, and throat (ENT) surgery with operative cultures and collection of nasal methicillin-resistant Staphylococcus aureus (MRSA) polymerase chain reaction (PCR), we found that MRSA nasal PCR demonstrated 100% sensitivity and a negative predictive value (NPV) of 100% when compared to operative cultures.

Implementing Change Through an Outpatient Antibiotic Stewardship Program.

INTRODUCTION: We sought to implement a multipronged behavioral intervention to reduce and tailor antibiotic use for 2 common urologic outpatient procedures. METHODS: This study was a nonblinded intervention study that consisted of a preintervention phase (November 2018-January 2019), an intervention phase (January 2020-December 2020) in which a multipronged behavioral intervention was implemented, and a postintervention phase (January 2021-March 2021). We examined antibiotic use for cystoscopy and transrectal prostate biopsy at 3 separate urologic outpatient clinics. A multipronged behavioral intervention consisted of formal physician education, modification of the electronic health order sets, clinic staff education, literature review, development and introduction of patient questionnaires, and individual audit feedback. The primary outcome was 30-day infections. Secondary outcomes were adherence to the recommended antibiotic protocols, questionnaire completion, and Escherichia coli outpatient antibiograms. RESULTS: A total of 2374 patients underwent 3047 cystoscopies, and 547 patients underwent 559 prostate biopsies. The proportions of cystoscopy patients receiving antibiotic prophylaxis and prostate biopsy patients receiving augmented antibiotic prophylaxis decreased 33% and 35%, respectively. The odds of postcystoscopy infection were not different between the preintervention and intervention phases and were lower in the postintervention phase. The odds of postbiopsy infection were not changed between the preintervention and intervention phases or between the preintervention and postintervention phases. CONCLUSIONS: Implementing a multipronged behavioral intervention reduced and tailored antibiotic use without an increase in 30-day infections. These findings suggest that outpatient antibiotic stewardship and facilitating rapid adoption of guidelines can be accomplished via this approach.

Assessing Pain and Functional Outcomes of Percutaneous Stabilization of Metastatic Pelvic Lesions via Photodynamic Nails: A Bi-Institutional Investigation of Orthopaedic Outcomes.

Background: Minimally invasive surgical interventions for metastatic invasion of the pelvis have become more prevalent and varied. Our group hypothesized that the use of percutaneous photodynamic nails (PDNs) would result in decreased pain, improved functional outcomes and level of ambulation, and decreased use of opioid pain medication. Methods: We performed a retrospective chart review of patients with metastatic pelvic bone disease undergoing stabilization with PDNs (IlluminOss Medical) at 2 institutions. Functional outcome measures assessed include the Combined Pain and Ambulatory Function (CPAF), Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function, and PROMIS Global Health-Physical. Pain was assessed using a visual analog scale (VAS). Outcomes were assessed preoperatively and at 6 weeks, 3 months, 6 months, and 1 year following surgery. Results: A total of 39 patients treated with PDNs were included. No cases of surgical site infection or implant failure were identified. The median pain VAS score decreased from 8 preoperatively to 0 at the 6-week time point (p < 0.0001). The median CPAF score improved from 5.5 points preoperatively to 7 points at the 3-month mark (p = 0.0132). A significant improvement in physical function was seen at 6 months in the PROMIS Physical Function (p = 0.02) and at both 6 months (p = 0.01) and 1 year (p < 0.01) for the PROMIS Global Health-Physical. The rate of patients prescribed opioid analgesia dropped from 100% preoperatively to 20% at 6 months following surgery (p < 0.001). By 6 weeks, all patients were fully weight-bearing and able to walk independently with or without assistive devices. Conclusions: Percutaneous stabilization of metastatic periacetabular defects using PDNs is a safe and effective palliative procedure that has been shown to improve patient mobility and provide early pain relief. Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Early Metabolomic and Immunologic Biomarkers as Prognostic Indicators for COVID-19.

This prospective study in Hong Kong aimed at identifying prognostic metabolomic and immunologic biomarkers for Coronavirus Disease 2019 (COVID-19). We examined 327 patients, mean age 55 (19-89) years, in whom 33.6% were infected with Omicron and 66.4% were infected with earlier variants. The effect size of disease severity on metabolome outweighed others including age, gender, peak C-reactive protein (CRP), vitamin D and peak viral levels. Sixty-five metabolites demonstrated strong associations and the majority (54, 83.1%) were downregulated in severe disease (z score: -3.30 to -8.61). Ten cytokines/chemokines demonstrated strong associations (p < 0.001), and all were upregulated in severe disease. Multiple pairs of metabolomic/immunologic biomarkers showed significant correlations. Fourteen metabolites had the area under the receiver operating characteristic curve (AUC) > 0.8, suggesting a high predictive value. Three metabolites carried high sensitivity for severe disease: triglycerides in medium high-density lipoprotein (MHDL) (sensitivity: 0.94), free cholesterol-to-total lipids ratio in very small very-low-density lipoprotein (VLDL) (0.93), cholesteryl esters-to-total lipids ratio in chylomicrons and extremely large VLDL (0.92);whereas metabolites with the highest specificity were creatinine (specificity: 0.94), phospholipids in large VLDL (0.94) and triglycerides-to-total lipids ratio in large VLDL (0.93). Five cytokines/chemokines, namely, interleukin (IL)-6, IL-18, IL-10, macrophage inflammatory protein (MIP)-1b and tumour necrosis factor (TNF)-a, had AUC > 0.8. In conclusion, we demonstrated a tight interaction and prognostic potential of metabolomic and immunologic biomarkers enabling an outcome-based patient stratification.

Does surgical sequencing influence the accuracy of maxillary positioning in bimaxillary cleft orthognathic surgery?

PURPOSE: To evaluate whether the sequence of osteotomies influences the accuracy of maxillary positioning in patients with cleft palate ± cleft lip undergoing bimaxillary orthognathic surgery (OGS). METHODS: This was a prospective study of patients with Veau 2-4 clefts who underwent bimaxillary OGS at tertiary-care children's hospital over a 3-year period. The primary predictor variable was the sequence of osteotomies (maxilla-first versus mandible-first). The primary outcome of interest was the concordance between the planned and achieved maxillary position, as assessed using linear and angular measurements. Secondary study predictors were demographic and surgical variables. Differences between groups were compared using non-parametric independent samples tests for continuous measures (data reported as median and interquartile range, IQR) and chi-squared tests for categorical measures. For all analyses, p≤ 0.05 was considered significant. RESULTS: Subjects who underwent maxilla-first (n=15) and mandible-first (n=16) operations were comparable with regard to age, gender, cleft type, skeletal classification, segmental maxillary osteotomy, and magnitude of maxillary movement (p ≥ 0.09). The planned sagittal and vertical positions of the maxilla were similarly accurate between the two groups (p ≥ 0.68). Angular accuracy was also comparable (p ≥ 0.56) between the study groups. CONCLUSION: In patients with CP ± CL undergoing bimaxillary orthognathic surgery, use of mandible-first sequencing, when compared to maxilla-first sequencing, does not impact accuracy of maxillary positioning in the immediate post-operative period in well-selected patients.

In-hospital outcomes following surgery versus conservative therapy in elderly patients with C2 fractures: a propensity score-matched analysis.

OBJECTIVE: Second cervical vertebrae (C2) fractures are a common traumatic spinal injury in the elderly population. Surgical fusion and nonoperative bracing are two primary treatments for cervical instability, but the former is often withheld in the elderly due to concerns for poor postoperative outcomes arising from patient frailty. This study sought to evaluate the in-hospital differences in mortality, outcomes, and discharge disposition in elderly patients with C2 fractures undergoing surgical intervention compared with conservative therapy. METHODS: The National Trauma Data Bank was queried from 2017 to 2019 for all patients aged ≥ 65 years with C2 fractures undergoing either surgical stabilization or conservative therapy. Propensity score matching was performed using k-nearest neighbors with replacement based on patient demographics, comorbidities, insurance type, injury severity, and fracture type. Group differences were compared using Student t-tests and Pearson's chi-square tests with Benjamini-Hochberg multiple comparisons correction. Subgroup analyses were performed in the 65-74, 75-79, and 80+ year age subgroups. RESULTS: Six thousand forty-nine patients were identified, of whom 2156 underwent surgery and 3893 received conservative treatment. Following matching, the surgery group had significantly lower mortality rates (5.52% vs 9.6%, p < 0.001), a longer mean hospital length of stay (LOS; 12.64 vs 7.49 days p < 0.001), and slightly higher rates of several complications (< 3% difference), as well as lower rates of discharge home (14.56% vs 23.52%, p < 0.001) and to hospice (1.07% vs 2.09%, p = 0.02) and a higher rate of discharge to intermediate care (68.83% vs 48.28%, p < 0.001). Similar trends in mortality and LOS were noted in all 3 subgroups. CONCLUSIONS: In elderly patients with C2 fractures, surgical stabilization confers a small survival advantage with a slightly higher in-hospital complication rate compared to conservative therapy. The increased rate of discharge to rehabilitation may represent better long-term prognosis following surgery. The increased risk of short-term complications is present but relatively small, thus surgery should not be withheld in patients with good long-term prognosis.

Treatment-emergent cefiderocol resistance in carbapenem-resistant Acinetobacter baumannii is associated with insertion sequence ISAba36 in the siderophore receptor pirA.

We report the emergence of cefiderocol resistance in a blaOXA-72 carbapenem-resistant Acinetobacter baumannii isolate from a sacral decubitus ulcer. Cefiderocol was initially used; however, a newly approved sulbactam-durlobactam therapy with source control and flap coverage was successful in treating the infection. Laboratory investigation revealed cefiderocol resistance mediated by ISAba36 insertion into the siderophore receptor pirA.

Financial Interventions to Improve Screening in Primary Care: A Systematic Review.

INTRODUCTION: Although health screenings offer timely detection of health conditions and enable early intervention, adoption is often poor. How might financial interventions create the necessary incentives and resources to improve screening in primary care settings? This systematic review aimed to answer this question. METHODS: Peer-reviewed studies published between 2000 and 2023 were identified and categorized by the level of intervention (practice or individual) and type of intervention, specifically alternative payment models (APMs), fee-for-service (FFS), capitation, and capital investments. Outcomes included frequency of screening, performance/quality of care (e.g., patient satisfaction, health outcomes), and workflow changes (e.g., visit length, staffing). RESULTS: Of 51 included studies, a majority focused on practice-level interventions (n=32), used APMs (n=41) that involved payments for achieving key performance indicators (KPIs; n=31) and were of low or very low strength of evidence based on GRADE criteria (n=42). Studies often included screenings for cancer (n=32), diabetes care (n=18), and behavioral health (n=15). KPI payments to both practices and individual providers corresponded with increased screening rates, whereas capitation and provider-level FFS models yielded mixed results. A large majority of studies assessed changes in screening rates (n=48) with less focus on quality of care (n=11) or workflow changes (n=4). DISCUSSION: Financial mechanisms can enhance screening rates with evidence strongest for KPI payments to both practices and individual providers. Future research should explore the relationship between financial interventions and quality of care, in terms of both clinical processes and patient outcomes, as well as the role of these interventions in shaping care delivery.

The current state of autonomous suturing: a systematic review.

BACKGROUND: Robotic technology is an important tool in surgical innovation, with robots increasingly being used in the clinical setting. Robots can be used to enhance accuracy, perform remote actions, or to automate tasks. One such surgical task is suturing, a repetitive, fundamental component of surgery that can be tedious and time consuming. Suturing is a promising automation target because of its ubiquity, repetitive nature, and defined constraints. This systematic review examines research to date on autonomous suturing. METHODS: A systematic review of the literature focused on autonomous suturing was conducted in accordance with PRISMA guidelines. RESULTS: 6850 articles were identified by searching PubMed, Embase, Compendex, and Inspec. Duplicates and non-English articles were removed. 4389 articles were screened and 4305 were excluded. Of the 84 remaining, 43 articles did not meet criteria, leaving 41 articles for final review. Among these, 34 (81%) were published after 2014. 31 (76%) were published in an engineering journal9 in a robotics journal, and 1 in a medical journal. The great majority of articles (33, 80%) did not have a specific clinical specialty focus, whereas 6 (15%) were focused on applications in MIS/laparoscopic surgery and 2 (5%) on applications in ophthalmology. Several suturing subtasks were identified, including knot tying, suture passing/needle insertion, needle passing, needle and suture grasping, needle tracking/kinesthesia, suture thread detection, suture needle shape production, instrument assignment, and suture accuracy. 14 articles were considered multi-component because they referred to several previously mentioned subtasks. CONCLUSION: In this systematic review exploring research to date on autonomous suturing, 41 articles demonstrated significant progress in robotic suturing. This summary revealed significant heterogeneity of work, with authors focused on different aspects of suturing and a multitude of engineering problems. The review demonstrates increasing academic and commercial interest in surgical automation, with significant technological advances toward feasibility.

Motor seizures confer overall survival benefit in who grade 2 glioma.

OBJECTIVE: The prevalence of epilepsy in World Health Organization (WHO) grade 2 glioma is high, with seizures being the presenting symptom in 60%-90%. We explore the epidemiology of seizures in this patient population in a regional neurosurgical center. METHODS: Electronic health records of patients with histologically-proven WHO grade 2 glioma (n = 228) were reviewed between 1997 and 2021, with data collected including patient demographics, epilepsy prevalence, and seizure semiology. The influence of seizure type on overall survival was calculated using a Cox proportional hazards model. RESULTS: Overall, 197 of 228 patients (86.4%) were diagnosed with epilepsy-either at presentation or during the course of their disease. Male patients were more likely than female patients to be diagnosed with epilepsy (91.1% vs 77.1%, p = .003) and, in those with epilepsy, more likely to experience at least one focal to bilateral tonic-clonic seizure (69.4% vs 54.1%, p = .05). Patients with left-sided tumors were twice as likely to have experienced a focal to bilateral tonic-clonic seizure (p = .02, odds ratio [OR] = .47). Predominantly experiencing seizures with motor activity appeared to confer better overall survival, with a 65% decrease in the risk of death 10 years post diagnosis (hazard ratio [HR] = .35, p = .02). This is despite accounting for previously described prognostic markers including tumor histology/genetics, time from diagnosis to surgery, and the extent of tumor resection. SIGNIFICANCE: Motor seizure activity is a frequent feature in WHO grade 2 glioma and appears to confer a survival benefit regardless of histology or surgical factors. Seizures due to dominant hemisphere tumors may be more likely to propagate and cause bilateral tonic-clonic activity.

Further Distance From Treating Facility is Associated With Advanced Colon Cancer at Presentation and Increased Mortality.

BACKGROUND: Colon cancer outcomes in the United States have improved over the last thirty years. However, there remain significant outcome disparities, especially in rural regions. It is unclear if distance to the treating facility has an independent effect on colon cancer mortality and outcomes. We sought to evaluate whether distance from a treating facility impacts stage at diagnosis and mortality. METHODS: The National Cancer Database (NCDB) was utilized to identify a cohort of adult patients with colon cancer between the years 2013 and 2017 in all regions of the United States. Outcomes measured included colon cancer TNM stage, time to surgery, time to chemotherapy, and overall survival. RESULTS: A total of n = 356,189 patients met inclusion criteria. When controlling for race, education status, insurance status, comorbidities, and income, distance from the treating facility was a significant predictor of stage at presentation with more advanced clinical TNM stage as distance increased (AORs 1.12-1.62, P < .001 for all groups). Longer distance significantly increased the time to surgery (between 5.06 and 14.46 days, P < .001) and overall mortality (HR 1.11-1.28, P < .001). Median survival was 82.4 months for the closest group, versus 75.1 months for the farthest group (P < .001). CONCLUSIONS: Increased distance from the treating facility resulted in a significantly higher stage at presentation, increased time to surgery, and increased mortality. These results suggest that there are significant disparities in access to cancer care for patients who live in rural areas. Targeted interventions by treating facilities are needed to improve screening and timely treatment for rural colon cancer patients.

Prevalence of oral human papillomavirus infection among the general adult population in Hong Kong.

A cross-sectional study in 2021-23 collected oral rinse gargle samples from an human papillomaviruses (HPV) vaccine-naïve general adult population in Hong Kong. HPV was detected by a PCR using SPF10 primers, and genotyped by a linear array covering 25 genotypes. Epidemiologic information including sociodemographics, medical history, oral health, and sexual behavior were collected by a self-administered questionnaire. Altogether, 2323 subjects aged 18-75 (median 47) years with 50.1% male were recruited. The prevalence for oral HPV infection with all genotypes combined, high-risk, and low-risk genotypes was 1.5%, 0.7%, and 0.7%, respectively; and with no statistically significant difference between participant gender. The prevalence increased with age and was highest in women at 45-54 years (2.7% for all genotypes combined), and highest in men aged >64 years (4.1% for all genotypes combined). HPV52 was the most common genotype among all participants. Univariate analysis suggested more lifetime sexual or oral sexual partners as risk factors, but they did not reach statistical significance upon multivariate analysis; whereas higher educational level had an independent protective effect. To conclude, oral HPV prevalence increased with age in Hong Kong. Strategies to prevent oral HPV infection and the associated cancers are urgently needed.

Free flap jaw reconstruction with dental implantation: A single-institution experience.

BACKGROUND: We sought to review our institution's experience with dental implant placement in free flap jaw reconstruction to determine factors impacting restoration of dental occlusion. METHODS: Exactly 48 patients underwent free flap jaw reconstruction with or without dental restoration from 2017 to 2022. Primary outcome was achievement of restored dental occlusion after jaw free flap reconstruction. RESULTS: A total of 48 patients with a mean age of 59.8 ± 16.4 years underwent jaw reconstruction from 2017 to 2022. Ten patients (20.8%) received osteointegrated dental implants. Two patients received a temporary dental prosthesis, 12 ± 4 months after initial reconstruction. Three patients received a final prosthesis, with a mean time to final prosthesis of 17.7 ± 12.4 months. Five patients did not receive any prosthesis despite placement of implants. CONCLUSION: A minority of patients received dental implant placement with free flap jaw reconstruction and only a small subset of these received a definitive dental prosthesis.

Preoperative CA 19-9 Predicts Disease Progression in Colorectal Peritoneal Metastases Treated with Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy: An Analysis from the US HIPEC Collaborative.

INTRODUCTION: Patients with colorectal peritoneal metastases (CRPM) are increasingly treated with cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS/HIPEC). Unfortunately, data identifying preoperative risk factors for poor oncologic outcomes after this procedure are limited. We aimed to determine the prognostic value of preoperative CEA, CA 125, and CA 19-9 on disease progression after CRS/HIPEC. METHODS: Patients with CRPM treated with curative intent CRS/HIPEC from 12 participating sites in the United States from 2000 to 2017 were identified. Progression-free survival (PFS), defined as disease progression or recurrence, was the primary outcome. RESULTS: In 279 patients who met inclusion criteria, the rate of disease progression was 63.8%, with a median PFS of 11 months (interquartile range [IQR] 5-20). Elevated CA 19-9 was associated with dismal PFS at 2 years (8.9% elevated vs. 30% not elevated, p < 0.01). In 113 patients who underwent upfront CRS/HIPEC, CA 19-9 emerged as the sole tumor marker independently predictive of worse PFS (hazard ratio [HR] 2.88, p = 0.048). In the subgroup of patients who had received neoadjuvant therapy (NAT), no variable was independently predictive of PFS. CA 19-9 levels over 37 U/ml were highly specific for accelerated disease progression after CRS/HIPEC. Lastly, there was no association between PFS and elevated CEA or CA 125. CONCLUSIONS: Elevated CA 19-9 is associated with decreased PFS in patients with CRPM. While traditionally CEA is the main tumor marker assessed in colon cancer, we found that CA 19-9 may better inform preoperative risk stratification for poor oncologic outcomes in patients with CRPM. However, prospective studies are required to confirm this association.

Safety and Efficacy Outcomes in Immune Checkpoint Inhibitor-Treated Patients With Metastatic Urothelial Carcinoma Requiring Treatment Interruption or Discontinuation Due to Immune-Related Adverse Events.

INTRODUCTION: As most patients with metastatic urothelial carcinoma (mUC) will be treated with immune checkpoint inhibitors (ICI), familiarity with their associated immune-related adverse events (irAEs) is critical. We describe the characteristics and outcomes of ICI-treated mUC patients who experienced irAEs requiring treatment interruption (TI) or permanent discontinuation. MATERIALS AND METHODS: ICI-treated mUC patients who developed grade ≥2 irAEs were reviewed. Clinical-, treatment-, and toxicity-related data were evaluated. Toxicity was graded per common terminology for categorization of adverse events v5.0. Cohorts were divided into patients who underwent ICI rechallenge and those who required permanent ICI discontinuation. Time to treatment interruption (TTI), time to next treatment, and duration of clinical benefit were assessed descriptively. Progression-free survival and overall survival (OS) were estimated using Kaplan-Meier methodology. RESULTS: Of 200 ICI-treated mUC patients at Cleveland Clinic between October 2015 and October 2020, 16 (8%) experienced ≥ grade 2 irAEs necessitating TI. Median TTI among all patients was 6.5 months (range, 1-19). Eleven patients (69%) required corticosteroids. ICI were held and rechallenged in 10 patients (62%) and permanently discontinued in 6 patients (38%). Of the 10 ICI-rechallenged patients, 7 (70%) experienced another irAE upon rechallenge with median time to irAE recurrence of 2.9 months (range, 0.1-10.9); 3 (30%) eventually discontinued ICI due to recrudescent irAEs. Four (40%) of the 10 ICI-rechallenged patients received subsequent therapy. Five (83%) of the 6 patients who permanently discontinued ICI demonstrated durable clinical benefit off therapy with median duration of clinical benefit 17.7 months (range, 14.2-55.2). Two-year OS was 40% (95% CI: 19%-86%) in the ICI rechallenge cohort and 67% (95% CI: 38%-100%) in the permanent discontinuation cohort. CONCLUSION: ICI-treated mUC patients who developed irAEs requiring TI had a high rate of subsequent irAEs upon ICI rechallenge. Importantly, patients who permanently discontinued ICI due to irAE demonstrated durable clinical benefit off treatment.

Impact of sex on Transcatheter aortic valve replacement outcomes: Results of a single-center study.

BACKGROUND: Early studies on transcatheter aortic valve replacement (TAVR) outcomes showed that female sex was associated with better survival. With increased use of new-generation valves, the impact of sex on contemporary TAVR outcomes is less well known. METHODS: Retrospective analysis using institutional National Cardiovascular Data Registry STS/ACC TVT data was performed on all patients undergoing TAVR at Yale New Haven Hospital from July 2012 to August 2019. New-generation valves were Evolut PRO, Evolut R, and SAPIEN 3. Old-generation valves were CoreValve, SAPIEN, and SAPIEN XT. Log-rank test and Kaplan-Meier curves were used to compare sex differences in survival up to 1 year after TAVR. Cox modeling was used to adjust for baseline and procedural characteristic differences. RESULTS: 927 consecutive patients (41.4% women) underwent TAVR. Women were older (82.8 vs 80.6 years old; p < 0.001) with higher STS mortality scores compared with men (7.6% vs 6.4%; p < 0.001) despite lower prevalence of cardiovascular comorbidities including coronary artery disease, peripheral artery disease, and smoking. Most cases used transfemoral access (90.5%) and new-generation devices (72.3%). Women received smaller valves compared with men (20-26 mm: 78.0% vs 32.9%; 29-34 mm: 22.1% vs 67.1%; overall p < 0.0001). There were no statistically significant differences between sexes in both unadjusted and adjusted 1-year mortality. CONCLUSION: Our data show no significant difference in 1-year survival between sexes using primarily new generation valves. Further studies should reassess the impact of sex on TAVR outcomes and whether newer technologies like new valve design and sizes, and CT imaging may have eliminated sex-based disparities.

Next Level of Care Protocols in Radiology: Improving Patient Access to Care.

OBJECTIVE: To introduce a novel next level of care (NLC) protocol used in our breast imaging practice to bypass additional imaging and image-guided biopsy orders and to examine the impact of NLC on breast biopsy wait times compared with thyroid biopsy wait times, which do not use NLC. METHODS: Our institutional review board deemed this retrospective analysis to be exempt. NLC was implemented for breast imaging in late 2014. Two 6-month periods before and after the COVID-19 shutdown were sampled and compiled. Data were queried from departmental database and electronic health record for all breast and thyroid biopsies during this time. Time to biopsy (TTB) was defined as the number of days from the diagnostic imaging evaluation recommending the biopsy to the completion of the biopsy. To determine the effect of NLC, TTB was compared between breast and thyroid biopsies. RESULTS: Of the 1,114 breast biopsies and 154 thyroid biopsies included, the mean TTB was 9 days (95% confidence interval 8.4-9.3) for breast and 23 days (95% confidence interval 20.5-25.0) for thyroid. There was a 61% reduction in the mean TTB for patients in the breast group compared with patients in the thyroid group. The effect of the NLC was comparable among different races and ethnicities in the breast group, but a significantly higher mean TTB (24% higher, P = .025) was observed for thyroid biopsies in Black patients compared with thyroid biopsies in Hispanic patients. CONCLUSION: NLC protocol facilitates imaging evaluations and reduces the time interval to image-guided biopsies.

The Chalcidoidea bush of life: evolutionary history of a massive radiation of minute wasps.

Chalcidoidea are mostly parasitoid wasps that include as many as 500 000 estimated species. Capturing phylogenetic signal from such a massive radiation can be daunting. Chalcidoidea is an excellent example of a hyperdiverse group that has remained recalcitrant to phylogenetic resolution. We combined 1007 exons obtained with Anchored Hybrid Enrichment with 1048 ultra-conserved elements (UCEs) for 433 taxa including all extant families, >95% of all subfamilies, and 356 genera chosen to represent the vast diversity of the superfamily. Going back and forth between the molecular results and our collective knowledge of morphology and biology, we detected bias in the analyses that was driven by the saturation of nucleotide data. Our final results are based on a concatenated analysis of the least saturated exons and UCE datasets (2054 loci, 284 106 sites). Our analyses support an expected sister relationship with Mymarommatoidea. Seven previously recognized families were not monophyletic, so support for a new classification is discussed. Natural history in some cases would appear to be more informative than morphology, as illustrated by the elucidation of a clade of plant gall associates and a clade of taxa with planidial first-instar larvae. The phylogeny suggests a transition from smaller soft-bodied wasps to larger and more heavily sclerotized wasps, with egg parasitism as potentially ancestral for the entire superfamily. Deep divergences in Chalcidoidea coincide with an increase in insect families in the fossil record, and an early shift to phytophagy corresponds with the beginning of the "Angiosperm Terrestrial Revolution". Our dating analyses suggest a middle Jurassic origin of 174 Ma (167.3-180.5 Ma) and a crown age of 162.2 Ma (153.9-169.8 Ma) for Chalcidoidea. During the Cretaceous, Chalcidoidea may have undergone a rapid radiation in southern Gondwana with subsequent dispersals to the Northern Hemisphere. This scenario is discussed with regard to knowledge about the host taxa of chalcid wasps, their fossil record and Earth's palaeogeographic history.