Blood pressure elevation in erenumab-treated patients with migraine: A retrospective real-world experience.

BACKGROUND: Erenumab is a monoclonal antibody that targets the calcitonin gene-related peptide (CGRP) receptor and is approved for the preventative treatment of migraine in adults. CGRP is involved in the regulation of vasomotor tone under physiologic and pathologic conditions, including hypertension. While there has not been evidence of hypertension in preclinical models or clinical trials, post-marketing data suggest erenumab may be associated with hypertension. This led to a warning in the United States Food and Drug Administration prescribing information for erenumab. OBJECTIVE: To determine the frequency of worsening blood pressure (BP) after initiation of erenumab in patients with migraine and how this is associated with hypertension. METHODS: This is an observational retrospective cohort study evaluating patients at a tertiary headache or neurology department. Systolic and diastolic BPs were compared between the initial visit prior to initiation of erenumab, and follow-up visit while on erenumab. Worsening BP was defined as moving from a lower stage to a higher stage of BP, as defined by the American Heart Association. Serious adverse vascular events were also recorded. RESULTS: A total of 335 patients were included in the final analysis (mean [SD] age of 45.7 [14.40] years, 83.9% [281/335] female). At baseline, 20.9% (70/335) of patients had a prior diagnosis of hypertension. The median (interquartile range) time to follow-up appointment from initial appointment was 20.5 (13.3-35.3) weeks. The mean (SD) BP at baseline was systolic 124.7 (15) mmHg and diastolic 77 (11) mmHg, and at follow-up was systolic 124.0 (15) mmHg and diastolic 77.8 (9) mmHg. Overall, 23.3% (78/335) of all patients had worsening BP, whereas 13/225 (3.9%) patients had improvement in their BP. Patients with atrial fibrillation were more likely to develop worsening BP (odds ratio, 4.9, 95% confidence interval 1.12-21.4; p = 0.035). There was no association between worsening BP and pre-existing hypertension, sex, body mass index, or age. One patient had non-ST elevation myocardial infarction attributed to a hypertensive emergency while on erenumab. CONCLUSION: We found that 23.3% of patients initiated on erenumab may have developed worsening BP, suggesting the need for BP monitoring in patients initiated on erenumab.

Evaluating the Need for Simultaneous Carpal Tunnel Release With Forearm Fasciotomy.

PURPOSE: The need to include simultaneous carpal tunnel release (sCTR) with forearm fasciotomy for acute compartment syndrome (ACS) or after vascular repair is unclear. We hypothesized that sCTR is more common when: 1) fasciotomies are performed by orthopedic or plastic surgeons, rather than general or vascular surgeons; 2) ACS occurred because of crush, blunt trauma, or fractures rather than vascular/reperfusion injuries; 3) elevated compartment pressures were documented. We also sought to determine the incidence of delayed CTR when not performed simultaneously. METHODS: Retrospective chart review identified patients who underwent forearm fasciotomy for ACS or vascular injury over a period of 10 years. Patient demographics, mechanism of ACS or indication for fasciotomy, surgeon subspecialty, compartment pressure measurements, inclusion of sCTR, complications, reoperations, and timing and method of definitive closure were analyzed. Logistic regression modeling was used to analyze predictors associated with delayed CTR. RESULTS: Fasciotomies were performed in 166 patients by orthopedic (63%), plastic (28%), and general/vascular (9%) surgeons. Orthopedic and plastic surgeons more frequently performed sCTR (67% and 63%, respectively). A total of 107 (65%) patients had sCTR. Fasciotomies for vascular/reperfusion injury were more likely to include sCTR (44%) compared with other mechanisms. If not performed simultaneously, 11 (19%) required delayed CTR at a median of 42 days. ACS secondary to fracture had the highest rate of delayed CTR (35%), and the necessity of late CTR for fractures was not supported by the logistic regression model. Residual hand paresthesias were less frequent in the sCTR group (6.5% vs 20%). Overall complication rates were similar in both groups (63% sCTR vs 70% without sCTR). CONCLUSION: When sCTR is excluded during forearm fasciotomy, 19% of patients required delayed CTR. This rate was higher (35%) when ACS was associated with fractures. Simultaneous CTR with forearm fasciotomy may decrease the incidence of residual hand paresthesias and the need for a delayed CTR. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognosis IV.

Safety of liver biopsy at the time of bariatric surgery: an analysis of the MBSAQIP database.

BACKGROUND: The majority of patients undergoing bariatric surgery have hepatic steatosis. Liver biopsy is not technically difficult to perform at the time of metabolic and bariatric surgery (MBS), but there may be concerns for bleeding complications. The safety of liver biopsy (LBx) at the time of MBS has been studied in single institutional studies but has not been studied on a national level. METHODS: The MBSAQIP database for 2015-2018 was examined. The codes for Roux-en-Y gastric bypass (RYGB) of 43644 and sleeve gastrectomy (SG) 43775 were used along with 47000 (percutaneous liver biopsy), 47001 (percutaneous liver biopsy at time of other procedure), and 47379 (unlisted laparoscopic procedure, liver). Outcomes such as operative time, complications, and length of stay were examined. Propensity-matched analysis was performed to evaluate for adjusted associations. RESULTS: There were 546,532 patients that met our inclusion criteria. Of those, 21,367 (3.9%) underwent LBx. Only 5.5% (8012) of patients undergoing RYGB had a LBx and 3.3% (13,355) of SG patients. Patients who underwent a LBx had a longer operative time before (103 min vs 84 min, p < 0.001) and after propensity matching [regression coefficient (RC): 10.7 (8.87, 12.5)]. There was no increase in length of stay. There was an increased risk in mortality in the unadjusted analysis (prevalence ratio = 1.61, p = 0.02), but when propensity-matched analysis was done, there was no statistically significant difference between the two groups. Concerning bleeding or transfusion, there was no difference in bleeding or rates of transfusion (p= 0.22, p = 0.21). CONCLUSION: Liver biopsy at the time of MBS is safe. It adds operative time, but there is no increase in length of stay, bleeding complications, morbidity, or death.

Is fundoplication necessary after paraesophageal hernia repair? A meta-analysis and systematic review.

INTRODUCTION: Paraesophageal hernias are often asymptomatic, but when symptomatic they should be fixed laparoscopically. A cruroplasty of the diaphragmatic pillars is performed and a fundoplication is usually performed at the time. However, there are times, especially in emergency cases, where it is not always possible to perform a fundoplication. We hypothesized there would be no difference in outcomes whether or not a fundoplication is performed as part of a paraesophageal hernia repair. METHODS: A literature review of available clinical databases was performed using PubMed, Clinical Key and Google Scholar. Our search terms were: "paraesophageal hernia" "paraesophageal hernia repair" "fundoplication" "emergency surgery" "no fundoplication" We excluded studies that were in languages other than English, abstracts and small case series. RESULTS: Our search criteria yielded a total of 22 studies published between 1997 and 2020. There were a total of 8600 subjects enrolled into this study. The overall pooled prevalence of fundoplication were estimated as 69% (95% CI: 59%-78%). In patients who underwent fundoplication, the risk of gastroesophageal reflux disease (GERD) was reduced as compared to patients who did not undergo fundoplication (RR: 0.64, 95% CI: 0.40-1.04, p = 0.069, I2 = 47.2%). A similar trend was also observed in recurrence (RR: 0.53, 95% CI: 0.27-1.03, p = 0.061, I2 = 0.0%) and reoperations (RR: 0.25, 95% CI: 0.02-2.69, p = 0.25, I2 = 56.7%). However, patients who underwent fundoplication had an increased risk of dysphagia (RR: 1.68, 95% CI: 0.59-4.81, p = 0.83, I2 = 42%). CONCLUSIONS: There is a higher rate of recurrence of gastroesophageal reflux disease, recurrence of hernia and reoperation when no fundoplication is performed during a paraesophageal hernia repair but a lower risk of dysphagia, but none of these reached statistical significance.(Comment 1) Paraesophageal hernia repair with fundoplication should be performed, but it is acceptable to not do it in certain situations.

Ethnic Differences Between Hispanics and Non-Hispanic Whites in Neuropsychiatric Symptoms Predict Conversion to Mild Cognitive Impairment.

The aim of the study is to ascertain the neuropsychiatric symptoms (NPS) subtypes significantly influencing progression to mild cognitive impairment (MCI) by ethnicity. In this retrospective cohort study, we included 386 cognitively normal individuals participating in the longitudinal Texas Alzheimer's Research and Care Consortium between February 2007 and August 2014. The primary outcome was time to incident MCI. Data driven NPS subtypes at baseline were identified and the effects of these subtypes on the outcome were obtained for Hispanic and non-Hispanic ethnic cohorts and summarized with a hazard ratio (HR). Three NPS subtypes were identified and internally validated: psychomotor apathy factor (including agitation, irritability, apathy), affective mood factor (including depression, anxiety), and physical behavior factor (including nighttime behavior, eating/appetite disturbances). In adjusted analysis, a psychomotor apathy score of NPS was the best predictor for MCI (HR = 2.19, p = 0.037) among non-Hispanics whereas physical behavior score was the most predictive of MCI (HR = 2.55, p = 0.029) among Hispanics. A high score of affective mood factor also tended to increase the risk of MCI (HR = 2.09, p = 0.06) in Hispanics. Progression from normal cognition to MCI was differentially predicted by NPS subtypes in Hispanics and non-Hispanic whites. These data may inform the allocation of efforts for monitoring individuals at-risk of MCI.

Associations between Combined Influenza and Pneumococcal Pneumonia Vaccination and Cardiovascular Outcomes.

BACKGROUND: In 2017, the CDC listed heart disease as the leading cause of death, with pneumonia and influenza being the eighth cause of death. Several studies have suggested the protective effects of influenza vaccination on myocardial infarction (MI). Available evidence supports the use of influenza vaccination in decreasing cardiovascular events, and the Joint Commission considers influenza vaccination a metric of quality care for hospitalized patients. Our specific aim was to evaluate the combined use of pneumococcal pneumonia vaccine (PPV) and influenza vaccine on cardiovascular outcomes and mortality. METHODS: A retrospective observational study was conducted using the 2012-2015 US National Inpatient Sample (NIS) database, to compare cardiovascular events in adult patients who did and did not receive vaccination during their hospitalization. ICD-9 codes were used to extract data for specific variables. The outcomes included MI, transient ischemic attacks, cardiac arrest, stroke, heart failure, and death. Adjusted relative risks (RR) were calculated using survey-weighted generalized linear models after adjusting for gender, race, socioeconomic status, diabetes, hypertension, hyperlipidemia, smoking status, prior coronary artery disease, and cerebrovascular disease. The effect of vaccination on in-hospital mortality was assessed in each subgroup of cardiovascular events using RR regressions. RESULTS: This study included 22,634,643 hospitalizations, of which 21,929,592 did not receive immunization. Vaccination solely against influenza was associated with lower MI (RR = 0.84, 95% CI: 0.82-0.87, p < 0.001), TIA (RR = 0.93, 95% CI: 0.9-0.96, p < 0.001), cardiac arrest (RR = 0.36, 95% CI: 0.33-0.39, p < 0.001), stroke (RR = 0.94, 95% CI: 0.91-0.97, p < 0.001), and mortality (RR = 0.38, 95% CI: 0.36-0.4, p < 0.001). Vaccination with PPV alone was associated with MI (RR = 1.13, 95% CI: 1.11-1.16, p < 0.001), TIA (RR = 1.28, 95% CI: 1.26-1.31, p < 0.001), stroke (RR = 1.21, 95% CI: 1.18-1.24, p < 0.001), and lower mortality (RR = 0.47, 95% CI: 0.45-0.49, p < 0.001). Combined PPV and influenza vaccine was associated with lower mortality (2.21% vs. 1.03%, p < 0.001) and lower cardiac arrest (0.61% vs. 0.51%, p < 0.001). In the adjusted analysis, the RR was 0.46 (95% CI: 0.43, 0.49) for mortality in the combined vaccinated cohort. The combined vaccination group also had a significantly reduced risk of mortality among those admitted with MI (RR = 0.46), transient ischemic attacks (RR = 0.58), and stroke (RR = 0.42) compared to the nonvaccinated group. CONCLUSIONS: Our study shows a significantly reduced risk of mortality with influenza vaccine and PPV and with combined pneumococcal and influenza vaccination. These data suggest that in-hospital administration of pneumonia and influenza vaccines appears safe and supports the use of combined vaccination during hospitalization due to their cardiovascular benefits.

The association between metabolic syndrome and Hepatitis C virus infection in the United States.

PURPOSE: Hepatitis C virus (HCV) infection is the prevalent risk factor for chronic hepatitis, cirrhosis, and hepatocellular carcinoma (HCC) worldwide. The association between metabolic syndrome (MetS) and HCV infection has not been studied effectively, particularly among different ethnic/racial groups in the US. METHODS: A retrospective cross-sectional study was conducted using data from the National Health and Nutrition Examination Survey (1999-2014). Unadjusted and adjusted associations were summarized using the prevalence ratio (PR) and 95% confidence interval (CI) after exploring possible interactions. RESULTS: In the overall population, MetS was significantly associated with HCV infection with an interaction of age. After adjusting for all potential confounders, MetS was found to be significantly associated with HCV among non-obese and younger adults of age less than 60 years (PR 1.67, 95% CI 1.21-2.30, p = 0.002). MetS was also associated with an increased prevalence of HCV in each racial/ethnic group, while the association was strongly modified by age and obesity status of the subjects in different ethnic/racial groups. CONCLUSIONS: MetS or its components are associated with an increased prevalence of HCV in some sub-populations of all ethnic/racial groups in the US. A better understanding of the pathophysiology of MetS associated with HCV is important as MetS may have a role in HCV infection treatment outcomes.

Segmental Withdrawal During Screening Colonoscopy Does Not Increase Adenoma Detection Rate.

OBJECTIVES: The aim of this study was to compare a standard versus segmental withdrawal during screening colonoscopy and its effect on the adenoma detection rate (ADR). METHODS: We performed a single-center clinical trial of average-risk patients 50 years of age and older undergoing screening colonoscopy. Patients were randomized into four groups: a standard withdrawal of at least 6 or 8 minutes and a segmental withdrawal, in which ≥3 or ≥4 minutes were dedicated to the right side of the colon, with a minimum withdrawal time of at least 6 or 8 minutes, respectively. RESULTS: There were 311 patients in the study. There was no difference in ADR between the standard and segmental groups (relative ratio [RR] 0.91, P = 0.50), even after stratifying for right-sided adenomas. During standard withdrawal, an increased continuous withdrawal time was associated with a higher ADR (RR 1.08, P <0.001) and total adenomas per patient (RR 1.12, P < 0.001). A binary analysis of ≥8 minutes or <8 minutes withdrawal was associated with an increased adenomas per colonoscopy (RR 1.86, P = 0.04). These differences were not observed in the segmental group. CONCLUSIONS: Overall, there was no benefit from a segmental withdrawal protocol on ADR, but this may have been the result of the inherent limitations in the study design. After sensitivity analysis, a segmental withdrawal protocol led to an improvement in the detection of adenomas per colonoscopy and polyps per colonoscopy. A larger sample size is needed to confirm these findings.

Differences in Prevalence of Large Polyps Between Hispanic Americans from Mexican- and Non-Mexican-Predominant States.

BACKGROUND: There have been conflicting reports comparing the prevalence of large polyps (>9 mm) between Hispanics and non-Hispanic whites (NHW). Differences between Hispanic subpopulations may account for these variations. AIMS: We aimed to assess the prevalence of large polyps (>9 mm) in Hispanics from Mexican- and non-Mexican-predominant states compared with NHW. As secondary outcome, we evaluated results by polyp location. METHODS: The 2010 U.S. Census Bureau was used to identify states with a predominantly Mexican Hispanic (West) versus non-Mexican Hispanic (East) populations. Average-risk colonoscopies in those states from 2001 to 2014 were accessed using the Clinical Outcomes Research Initiative database. Military and Veteran's Administration sites were excluded. Hispanics were compared with NHW in each geographical location using hierarchical logistic regression analysis. RESULTS: A total of 65,138 procedures were included with 33,425 procedures in the West (14.5% Hispanics) and 31,713 procedures in the East (44.0% Hispanics,). East Hispanics had significantly less odds of large polyps, OR 0.74, CI 0.58-0.94, p = 0.02, while West Hispanics exhibited no difference, OR 0.91, CI 0.76-1.10, p = 0.33, compared with NHW. Eastern Hispanics had less odds of large distal polyps, OR 0.69, CI 0.52-0.91, p = 0.01, and no difference in proximal polyps compared with NHW. Among Western Hispanics, no differences were seen in proximal, OR 1.06, CI 0.83-1.35, p = 0.66, or distal polyps, OR 0.83, CI 0.68-1.02, p = 0.08, compared with NHW. CONCLUSION: Using NHW as a reference, Hispanics from Mexican-predominant states have a similar prevalence of large polyps, while Hispanics from non-Mexican-predominant states have a lower prevalence. Differences in Hispanic subpopulations likely explain previous conflicting reports on the prevalence of large polyps in Hispanics and NHW.

Evaluation of the rate of marginal ulcer formation after bariatric surgery using the MBSAQIP database.

BACKGROUND: Marginal ulcer (MU) formation is a known problem after gastric bypass. The Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database contains data from all US and Canadian Centers of Excellence including complication rates. We hypothesized that the short-term rate of ulceration is low. METHODS: We queried the MBSAQIP database for the year 2015. We searched patients with primary gastric bypass who developed MU. We then compared preoperative, operative, and postoperative characteristics with patients who did not develop MU. RESULTS: The incidence of MU in the entire cohort of GB patients was 155 of 44,379 (0.35%, 95% CI 0.297%, 0.409%). Among the 155 patients with an ulcer, 88 (57%) patients had only one procedure, 69 had an intervention (therapeutic or diagnostic endoscopy), 16 had readmission, and 3 had reoperation. 65 patients (42%) had two procedures with the majority having both readmissions and endoscopy (n = 59); and two patients (1%) had three procedures. Ulcer formation was most common in the intervention group (11.4%). The occurrence of ulcer formation was associated with unplanned ICU admissions (6.45%), transfusions (5.16%), postoperative UTI (3.87%), sepsis (1.94%), and myocardial infarction (0.65%). Death occurred in 76 patients with no related cases to MUs. The risk of ulcer was associated with increased BMI (OR 1.02, p = 0.01), presence of percutaneous transluminal cardiac catheterization (PTC) (2.17, p = 0.038), histories of DVT (1.72, p = 0.085), and pulmonary embolism (2.84, p = 0.002). CONCLUSIONS: In a nationally reported database, symptomatic MUs rarely occur in the first month. The large majority are diagnosed and treated endoscopically with minimal need for surgical intervention. The risk of anastomotic ulcer was increased with increased BMI, need for PTC, and history of DVT/PE.

Cholangioscopy Is Safe and Feasible in Elderly Patients.

BACKGROUND & AIMS: Although cholangioscopy is widely used during endoscopic retrograde cholangiopancreatiography (ERCP), its safety and feasibility for elderly patients are not well established. We aimed to evaluate the safety and feasibility of cholangioscopy in elderly patients. METHODS: We performed a retrospective study of all ERCPs with single-operator cholangioscopy (SOC) performed at 3 tertiary referral hospitals from March 2012 through October 2015. We collected data on patient demographics, procedure indications, findings, complications, and success rates (complete success was achieved if all intended diagnostic and therapeutic procedures were performed, such as tissue sample collection or complete removal of stones). The cohort was divided into 3 groups: patients younger than 65 years (group 1, n = 178), patients 65-75 years old (group 2, n = 86), and patients older than 75 years (group 3, n = 77). We used 1-way ANOVA, the χ2 test, and the Wilcoxon sum rank test to compare study variables. The primary aim was to assess rates of complications from ERCP with SOC in elderly patients compared with younger patients. RESULTS: Baseline clinical features were similar among groups, except for a higher prevalence of co-morbidities in group 3. The indication for and findings from ERCP with SOC differed among the groups; stricture or tumor was the most common indication in groups 1 and 3-the most common findings were strictures and masses, respectively. In group 2, choledocholithiasis was the most common indication and finding. The success rate, analyzed in a subset of 209 patients, was 88.5% overall and did not differ significantly among groups. The overall rate of complication was 7.33% with no significant difference among groups (7.30% for group 1, 6.98% for group 2, and 7.79% for group 3) (P < .17). CONCLUSIONS: In a retrospective analysis of ERCPs with SOCs, we found this procedure to be safe for elderly patients (older than 75 years), who had rates of complications and hospital admission similar to those of younger patients.

Eradication Rate of Helicobacter pylori on the US-Mexico Border Using the Urea Breath Test.

OBJECTIVES: Helicobacter pylori is prevalent worldwide, especially in Latin America. Triple and quadruple antibiotic therapies have been relatively effective; however, resistance has emerged in recent years. The treatment success rate of these regimens on the border of the United States and Mexico is unknown. Our study attempted to determine eradication rates of two major regimens based on urea breath test (UBT) results in patients previously diagnosed as having H. pylori in a single center in El Paso, Texas, a city on the geographic border with Mexico. METHODS: This was a retrospective cohort study of adult patients with H. pylori who underwent UBT after being treated with triple therapy (amoxicillin/clarithromycin/proton pump inhibitor for 14 days), quadruple therapy (tetracycline/metronidazole/bismuth/proton pump inhibitor, usually for 10 days), or both for H. pylori from 2010 to 2015 in a county hospital. Patients were excluded if they did not complete therapy or if their treatment regimen was unknown. The Student t test and the χ2 test were used to analyze the data. The cumulative incidence and 95% confidence interval (CI) for treatment success were estimated. RESULTS: A total of 104 patients completed the treatment for H. pylori and had UBT. Mean age was 53 years, 76% were women, 85% were Hispanic, and mean body mass index was 30.5 kg/m2. Of the 104 patients diagnosed as having H. pylori, 88 received triple therapy (84.6%) and 16 received quadruple therapy: 12 (11.5%) standard quadruple therapy, 4 (3.9%) triple therapy plus metronidazole. There were no differences between groups regarding age, sex, body mass index, or ethnicity. Overall, 90 (86.5%, 95% CI 78-92) patients had negative UBT after initial treatment. Based on posttreatment UBT, the triple therapy group had a similar eradication rate compared with the quadruple therapy group (78/88, 88.6% vs 12/16, 75.0%, P = 0.22). Of the 14 patients with positive posttreatment UBT, 12 (85.7%) received retreatment (2 were lost to follow-up), 11 (91.7%) received quadruple therapy, and 1 (8.3%) received triple therapy. Eradication was successful in 9 of 12 (75%, 95% CI 43-95) patients at retreatment. As such, of the initial 104 patients, 99/104 (95.2%) achieved H. pylori eradication posttreatment (either initial or retreatment). CONCLUSIONS: In a predominantly Hispanic population on the US-Mexico border, H. pylori eradication rates based on UBT results were relatively high and were similar for triple therapy and quadruple therapy. Quadruple therapy was effective for those who failed the initial H. pylori treatment. This may have implications for cost-effective therapy in our region.

Examining patient demographics and major adverse cardiac events following noncardiac surgery: Applying a health equity lens.

BACKGROUND: Major adverse cardiac events (MACE) are a major contributor to postoperative complications. This study employed a health equity lens to examine rates of postoperative MACE by race and ethnicity. METHODS: This single-center, retrospective observational cohort study followed patients with and without pre-existing coronary artery stents from 2008 to 2018 who underwent non-cardiac surgery. MACE was the primary outcome (death, acute MI, repeated coronary revascularization, in-stent thrombosis) and self-reported race and ethnicity was the primary predictor. A propensity score model of a 1:1 cohort of non-Hispanic White (NHW) patients and all other racial and ethnic minority populations (Hispanic and Black) was used to compare the rate of perioperative MACE in this cohort. RESULTS: During the study period, 79,686 cases were included in the analytic sample; 950 patients (1.2 %) had pre-existing coronary artery stents. <1 % of patients experienced MACE within 30 days following non-cardiac surgery (0.8 %). After confounder adjustment and propensity score matching, there were no statistically significant differences in MACE among racial and ethnic minority patients compared to NHW patients (OR = 0.77; 95 % CI: 0.48, 1.25). In our sensitivity analyses, stratifying by sex, there were no differences in MACE by race and ethnicity. CONCLUSIONS: The study found no statistically significant differences in MACE by race and ethnicity among patients who underwent non-cardiac surgery. Access to a high-volume, high-quality hospital such as the one studied may reduce the presence of healthcare disparities and may explain why our findings are not consistent with previous studies.

Sharing Patient Praises With Radiology Staff: Workflow Automation and Impact on Staff.

OBJECTIVE: This study aims to develop and evaluate a semi-automated workflow using natural language processing (NLP) for sharing positive patient feedback with radiology staff, assessing its efficiency and impact on radiology staff morale. METHODS: The HIPAA-compliant, institutional review board-waived implementation study was conducted from April 2022 to June 2023 and introduced a Patient Praises program to distribute positive patient feedback to radiology staff collected from patient surveys. The study transitioned from an initial manual workflow to a hybrid process using an NLP model trained on 1,034 annotated comments and validated on 260 holdout reports. The times to generate Patient Praises e-mails were compared between manual and hybrid workflows. Impact of Patient Praises on radiology staff was measured using a four-question Likert scale survey and an open text feedback box. Kruskal-Wallis test and post hoc Dunn's test were performed to evaluate differences in time for different workflows. RESULTS: From April 2022 to June 2023, the radiology department received 10,643 patient surveys. Of those surveys, 95.6% contained positive comments, with 9.6% (n = 978) shared as Patient Praises to staff. After implementation of the hybrid workflow in March 2023, 45.8% of Patient Praises were sent through the hybrid workflow and 54.2% were sent manually. Time efficiency analysis on 30-case subsets revealed that the hybrid workflow without edits was the most efficient, taking a median of 0.7 min per case. A high proportion of staff found the praises made them feel appreciated (94%) and valued (90%) responding with a 5/5 agreement on 5-point Likert scale responses. CONCLUSION: A hybrid workflow incorporating NLP significantly improves time efficiency for the Patient Praises program while increasing feelings of acknowledgment and value among staff.

Kinetics of SARS-CoV-2 infection biomarkers in a household transmission study.

SARS-CoV-2 is the causative agent of COVID-19. Timely and accurate diagnostic testing is vital to contain the spread of infection, reduce delays in treatment and care, and inform patient management. Optimal specimen type (e.g. nasal swabs or saliva), timing of sampling, viral marker assayed (RNA or antigen), and correlation with viral infectivity and COVID-19 symptoms severity remain incompletely defined. We conducted a field study to evaluate SARS-CoV-2 viral marker kinetics starting from very early times after infection. We measured RNA and antigen levels in nasal swabs and saliva, virus outgrowth in cell culture from nasal swabs, and antibody levels in blood in a cohort of 30 households. Nine household contacts (HHC) became infected with SARS-CoV-2 during the study. Viral RNA was detected in saliva specimens approximately 1-2 days before nasal swabs in six HHC. Detection of RNA was more sensitive than of antigen, but antigen detection was better correlated with culture positivity, a proxy for contagiousness. Anti-nucleocapsid antibodies peaked one to three weeks post-infection. Viral RNA and antigen levels were higher in specimens yielding replication competent virus in cell culture. This study provides important data that can inform how to optimally interpret SARS-CoV-2 diagnostic test results.

Automated target placement for VMAT lattice radiation therapy: enhancing efficiency and consistency.

Objective. An algorithm was developed for automated positioning of lattice points within volumetric modulated arc lattice radiation therapy (VMAT LRT) planning. These points are strategically placed within the gross tumor volume (GTV) to receive high doses, adhering to specific separation rules from adjacent organs at risk (OARs). The study goals included enhancing planning safety, consistency, and efficiency while emulating human performance.Approach. A Monte Carlo-based algorithm was designed to optimize the number and arrangement of lattice points within the GTV while considering placement constraints and objectives. These constraints encompassed minimum spacing between points, distance from OARs, and longitudinal separation along thez-axis. Additionally, the algorithm included an objective to permit, at the user's discretion, solutions with more centrally placed lattice points within the GTV. To validate its effectiveness, the automated approach was compared with manually planned treatments for 24 previous patients. Prior to clinical implementation, a failure mode and effects analysis (FMEA) was conducted to identify potential shortcomings.Main results.The automated program successfully met all placement constraints with an average execution time (over 24 plans) of 0.29 ±0.07 min per lattice point. The average lattice point density (# points per 100 c.c. of GTV) was similar for automated (0.725) compared to manual placement (0.704). The dosimetric differences between the automated and manual plans were minimal, with statistically significant differences in certain metrics like minimum dose (1.9% versus 1.4%), D5% (52.8% versus 49.4%), D95% (7.1% versus 6.2%), and Body-GTV V30% (20.7 c.c. versus 19.7 c.c.).Significance.This study underscores the feasibility of employing a straightforward Monte Carlo-based algorithm to automate the creation of spherical target structures for VMAT LRT planning. The automated method yields similar dose metrics, enhances inter-planner consistency for larger targets, and requires fewer resources and less time compared to manual placement. This approach holds promise for standardizing treatment planning in prospective patient trials and facilitating its adoption across centers seeking to implement VMAT LRT techniques.

No difference in COVID-19 treatment outcomes among current methamphetamine, cannabis and alcohol users.

BACKGROUND: Poor outcomes of COVID-19 have been reported in older males with medical comorbidities including substance use disorder. However, it is unknown whether there is a difference in COVID-19 treatment outcomes between patients who are current cannabis users, excessive alcohol drinkers and those who use a known hazardous stimulant such as methamphetamine (METH). METHODS: Electronic medical records (EMR) of COVID-19 patients with current METH (n = 32), cannabis (n = 46), and heavy alcohol use (n = 44) were reviewed. COVID-19 infection was confirmed by positive SARS-CoV-2 PCR test, current drug use was confirmed by positive urine drug testing, and alcohol use was identified by a blood alcohol concentration greater than 11 mg/dl. Multivariate linear regression models as well as the firth logistic regression models were used to examine the effect of substance use group (METH, cannabis, or alcohol) on treatment outcome measures. RESULTS: A total of 122 patients were included in this analysis. There were no significant differences found between drug groups in regards to key SARS-CoV-2 outcomes of interest including ICU admission, length of stay, interval between SARS-CoV-2 positive test and hospital discharge, delirium, intubation and mortality after adjusting for covariates. About one-fifth (21.9% in METH users, 15.2% in cannabis users, and 20.5% in alcohol users) of all patients required ICU admission. As many as 37.5% of METH users, 23.9% of cannabis users, and 29.5% of alcohol users developed delirium (P = 0.4). There were no significant differences between drug groups in COVID-19 specific medication requirements. Eight patients in total died within 10 months of positive SARS-CoV-2 PCR test. Two patients from the METH group (6.3%), two patients from the cannabis group (4.3%), and four patients from the alcohol group (9.1%) died. DISCUSSION: The study outcomes may have been affected by several limitations. These included the methodology of its retrospective design, relatively small sample size, and the absence of a COVID-19 negative control group. In addition, there was no quantification of substance use and many covariates relied on clinical documentation or patient self-report. Finally, it was difficult to control for all potential confounders particularly given the small sample size. CONCLUSION: Despite these limitations, our results show that current METH, cannabis, and heavy alcohol users in this study have similar treatment outcomes and suffer from high morbidity including in-hospital delirium and high mortality rates within the first-year post COVID-19. The extent to which co-morbid tobacco smoking contributed to the negative outcomes in METH, cannabis, and alcohol users remains to be investigated.

Rates of Readmission and Emergency Department Visits of Publicly Versus Commercially Insured Patients in a Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program Accredited Center.

Background: Patients with governmental insurance are known to utilize the emergency department (ER) at a higher rate and have higher readmission rates than other patients. Twenty percent of our patients are publicly insured. Our objective was to determine if there was a higher rate of readmissions and ER visits within 30 days in publicly insured patients. Methods: Data was analyzed from a single center submitted to the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program Participant Use Data File from January 1, 2015 to December 31, 2018. We added insurance status and described quantitative variables using mean, and standard deviation (SD). These were reported as regression coefficients (RC) and prevalence ratio (PR), along with their 95% confidence interval (CI). P values of less than 5% were considered statistically significant. Results: The overall rate of ER visits, readmissions, and reoperations were 3.5%, 7.4%, and 2.2% respectively. Medicaid and Medicare patients were found to have longer operative times, 62.7 minutes vs 57.5 minutes (p = 0.35). Patients on public insurance had higher adjusted risk of ER visits (PR 1.43, 95% CI: 0.41-5.3; p = 0.58) and readmissions (PR 1.64, 95% CI: 0.76-3.55; p = 0.21) than patients on commercial/self-pay insurance. Re-operations were lower in the publicly insured group (PR 0.93, 95% CI: 0.2-4.7; p = 0.92) than patients on commercial/self-pay insurance. However, these outcomes were not statistically significant. Conclusions: Publicly insured patients tend to have a higher adjusted risk of ER visits and readmissions but was not statistically significant. The rate of re-operation was slightly lower in publicly insured patients.

Five-Year Analysis of the MBSAQIP Database: Are We Getting Better?

BACKGROUND: The MBSAQIP has been used to evaluate risk and create risk models. Previous studies have determined what complications matter most. STUDY DESIGN: This study was a registry-based analysis of patients who underwent laparoscopic Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) between January 1, 2015, and December 31, 2019, at centers participating in MBSAQIP. Cases were identified using Current Procedural Terminology. Patients less than 18 years old were excluded. A chi-square test was used to assess differences in the prevalence of complications and effects across years. Using a multivariable Poisson regression model with a link log and robust estimation, prevalence ratio estimates and 95% CI were obtained. RESULTS: A total of 690,770 observations met the inclusion criteria. Mean (SD) age was 44.5 (±12.0) years, and mean (SD) BMI was 45.2 kg/m2 (±7.9). SG cases accounted for 73.45% of all observations. There was a significant relative reduction in readmissions, end-organ dysfunction, and all-cause mortality from 2015 to 2019 in the SG subgroup. There were also noticeable reductions in 30-day readmission, ICU admission, and end-organ dysfunction in the RYGB subgroup. For complications, bleeding, postoperative pneumonia, and stroke were significantly decreased in the RYGB subgroup, but only bleeding was significantly decreased in the SG subgroup during the 5-year study period. CONCLUSIONS: There has been a continuous improvement in several (but not all) outcomes through the years that the MBSAQIP has been collecting data. Different outcomes were reduced between the SG and RYGB subgroups, and the decrease in all-cause mortality was only noted in the SG subgroup.

Latin Americans and US Hispanics show differences in IBD phenotype: a systematic review with meta-analysis.

Latin America has experienced a rise in the prevalence and incidence of inflammatory bowel disease (IBD). Differences in IBD phenotype between Hispanics in Latin America and those in the USA have not been described. We conducted a systematic review with meta-analysis of population-based and cohort studies comparing the phenotype of ulcerative colitis (UC) and Crohn's disease (CD) in Latin Americans and US Hispanics. A systematic search was conducted up to March 2019 using MEDLINE, EMBASE and Google Scholar. Inclusion criterion includes studies describing IBD phenotype in Latin Americans or in US Hispanics. Exclusion criterion includes prevalence or incidence studies not describing phenotype. A random effects model was chosen "a priori" for analysis of pooled proportions. A total of 46 studies were included from Latin America and 7 studies from the USA. The predominant IBD subtype in Latin America was UC with a more balanced UC:CD ratio noted in Puerto Rico (0.53) and Brazil (0.56). UC-related extensive colitis was more common in US Hispanics (0.64) than in Latin Americans (0.38), p<0.001. CD phenotype was similar between US Hispanics and Latin Americans. UC is the predominant IBD subtype in Latin America, with the exception of Puerto Rico and Brazil which demonstrate a more balanced UC:CD ratio. In UC, extensive colitis was more frequently seen in US Hispanics than in Latin Americans. CD phenotype was similar in both US Hispanics and Latin Americans.