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OBJECTIVES: We sought to determine whether bladder cuff excision and its technique influence outcomes after radical nephroureterectomy (RNU) for upper tract urothelial carcinoma (UTUC). METHODS AND MATERIALS: A multicenter, international, retrospective analysis using the ROBotic surgery for Upper tract Urothelial cancer Study (ROBUUST) 2.0 registry identified 1,718 patients undergoing RNU for UTUC between 2015 and 2023 at 17 centers across the United States, Europe, and Asia. Data was gathered on (1) whether bladder cuff excision was performed and (2) what technique was used, including formal excision or other techniques (pluck technique, stripping/intussusception technique) and outcomes. Multivariate and survival analyses were performed to compare the groups. RESULTS: Most patients (90%, 1,540/1,718) underwent formal bladder cuff excision in accordance with EAU and AUA guidelines. Only 4% (68/1,718) underwent resection using other techniques, and 6% (110/1,718) did not have a bladder cuff excised. Median follow up for the cohort was 24 months (IQR 9-44). When comparing formal bladder cuff excision to other excision techniques, there were no differences in oncologic or survival outcomes including bladder recurrence-free survival (BRFS), recurrence-free survival (RFS), metastasis-free survival (MFS), overall survival (OS), or cancer-specific survival (CSS). However, excision of any kind conferred a decreased risk of bladder-specific recurrence compared to no excision. There was no difference in RFS, MFS, OS, or CSS when comparing bladder cuff excision, other techniques, and no excision. CONCLUSIONS: Bladder cuff excision improves recurrence-free survival, particularly when considering bladder recurrence. This benefit is conferred regardless of technique, as long as the intramural ureter and ureteral orifice are excised. However, the benefit of bladder cuff excision on metastasis-free, overall, and cancer-specific survival is unclear.
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Robotic assisted partial nephrectomy (RPN) has emerged in urologic practice for the management of appropriately sized renal masses. We provide a 20-year comparison of the outcomes of open partial nephrectomy (OPN) versus RPN for renal cell carcinoma (RCC) at our institution. An IRB-approved retrospective review was conducted of RCC patients at a single institution from 2000 to 2022 who underwent RPN or OPN. In addition to demographics, procedural details including ischemia and operative time were collected. Oncologic outcomes were evaluated through Kaplan-Meier statistical analysis to determine recurrence-free survival (RFS), cancer-specific survival (CSS), and overall survival (OS) analysis. 849 patients underwent RPN while 385 underwent OPN. 61% were male with average age of 58.8 ± 12.8 years. Operative time was shorter in the open group (184 vs 200 min, p = 0.002), as was ischemia time (16 vs 19 min, p = 0.047). However, after 2012, RPN became more common than OPN with improving ischemia time. RPN patients had significantly improved RFS (HR 0.45, p = 0.0004) and OS (HR 0.51, p = 0.0016) when controlled for T-stage and margin status. More > pT1 masses were managed with OPN than RPN (11.2 vs 5.4%, p < 0.0001). At our institution, RPN had an increasing incidence with reduced ischemia time compared to OPN over the last 10 years. While higher stage renal masses were more often managed with OPN, selective use of RPN does offer improved oncologic outcomes. Further investigation is needed to evaluate optimization of the selection of RPN versus OPN in the nephron-sparing management of renal masses.
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Carcinoma de Células Renais , Neoplasias Renais , Nefrectomia , Procedimentos Cirúrgicos Robóticos , Humanos , Nefrectomia/métodos , Procedimentos Cirúrgicos Robóticos/métodos , Masculino , Pessoa de Meia-Idade , Neoplasias Renais/cirurgia , Feminino , Carcinoma de Células Renais/cirurgia , Resultado do Tratamento , Estudos Retrospectivos , Idoso , Duração da CirurgiaRESUMO
This study aimed to evaluate the utilization of drugs with pharmacogenomic guidelines (PGx-drugs) for personalized dosing in pediatric leukemia. A retrospective observational study of pediatric leukemia patients admitted between 2009-2019 at a single-center academic children's hospital was conducted to determine PGx-drug exposure within 3 years of diagnosis. Along with baseline demographic and clinical characteristics of these patients, data regarding dates of diagnosis, relapse, death were collected. During the study period, inclusion criteria were met by 714 patients. The most frequently given medications were ondansetron (96.1%), morphine (92.2%), and allopurinol (85.3%) during the study period. In this cohort, 82% of patients received five or more PGx-drugs. Patients diagnosed with acute myeloid leukemia and leukemia unspecified were prescribed more PGx-drugs than other types of leukemia. There was a significant relationship between age at diagnosis and the number of PGx-drugs prescribed. Adolescents and adults both received a median of 10 PGx-drugs, children received a median of 6 PGx-drugs, and infants received a median of 7 PGx-drugs (p < 0.001). Patients with recurrent leukemia had significantly more PGx-drugs prescribed compared to those without recurrent disease, 10 drugs and 6 drugs, respectively (p < 0.001). Patients diagnosed with childhood leukemia are high utilizers of PGx-drugs. There is a vital need to understand how PGx testing may be utilized to optimize treatment and enhance quality of life. Preemptive PGx testing is a tool that aids in optimization of drug therapy and decreases the need for later treatment modifications. This can result in financial savings from decreased health-care encounters.
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OBJECTIVE: A diverse physician workforce ensures equitable care. The holistic review of residency applications is one strategy to enhance physician diversity; however, little is known about current adoption and the factors that facilitate/impede the adoption of holistic recruitment practices (HRPs) by graduate medical education (GME) residency, and fellowship program directors (PDs). To describe the current state and explore, the barriers/facilitators to the adoption of HRPs at our institution. METHODS: We disseminated information about HRP within our program between 2021 and 2022. In May 2022, a survey of 73 GME PDs assessed current recruitment practices and self-reported barriers to holistic recruitment. Holistic Recruitment Scores (HRSs) reflecting the adoption of best practices were tabulated for each program and compared to identify predictors of adoption. RESULTS: 73/80 (92%) of PDs completed the survey. Programs whose PDs had higher academic rank, total number of trainees, and female trainees in the past 3 years had higher HRSs. Program size was directly correlated with HRS. Most (93%) PDs felt their current efforts were aligned to increase diversity and 58% felt there were no barriers to the adoption of holistic review. The most reported barriers were lack of time and knowledge/expertise in diversity, equity, and inclusion (DEI), both reported by 16 out of 73 PDs (22%). CONCLUSION: While most PDs implemented some HRP, institutional and departmental support of program directors through the commitment of resources (eg, staffing help and subject matter experts/coaches hiring) are crucial to overcome barriers.
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RATIONALE: Lung T1 MRI is a potential method to assess cystic fibrosis (CF) lung disease that is safe, quick, and widely available, but there are no data in children with mild CF lung disease. OBJECTIVE: Assess the ability of lung T1 MRI to detect abnormalities in children with mild CF lung disease. METHODS: We performed T1 MRI, multiple breath washout (MBW), chest computed tomography (CT), and spirometry in a cohort of 45 children with mild CF lung disease (6-11 years of age). MAIN RESULTS: Despite mean normal ppFEV1 values, the majority of children with CF in this study exhibited mild lung disease evident in lung clearance index (LCI) measured by MBW, chest CT Brody scores, and percent normal lung perfusion (%NLP) measured by T1 MRI. The %NLP correlated with chest CT Brody scores, as did LCI, but %NLP and LCI did not correlate with each other. Analysis of the Brody subscores showed that %NLP and LCI largely correlated with different Brody subscores. CONCLUSIONS: T1 MRI can detect mild CF lung disease in children and correlates with chest CT findings. The %NLP from T1 MRI and LCI correlate with different chest CT Brody subscores, suggesting they provide complementary information about CF lung disease.
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Humans living at high-altitude (HA) have adapted to this environment by increasing pulmonary vascular and alveolar growth. RNA sequencing data from a novel murine model that mimics this phenotypical response to HA suggested estrogen signaling via estrogen receptor alpha (ERα) may be involved in this adaptation. We hypothesized ERα was a key mediator in the cardiopulmonary adaptation to chronic hypoxia and sought to delineate the mechanistic role ERα contributes to this process by exposing novel loss-of-function ERα mutant (ERαMut) rats to simulated HA. ERα mutant or wild-type (wt) rats were exposed to normoxia or hypoxia starting at conception and continued postnatally until 6 wk of age. Both wt and ERαMut animals born and raised in hypoxia exhibited lower body mass and higher hematocrits, total alveolar volumes (Va), diffusion capacities of carbon monoxide (DLCO), pulmonary arteriole (PA) wall thickness, and Fulton indices than normoxia animals. Right ventricle adaptation was maintained in the setting of hypoxia. Although no major physiologic differences were seen between wt and ERαMut animals at either exposure, ERαMut animals exhibited smaller mean linear intercepts (MLI) and increased PA total and lumen areas. Hypoxia exposure or ERα loss-of-function did not affect lung mRNA abundance of vascular endothelial growth factor, angiopoietin 2, or apelin. Sexual dimorphisms were noted in PA wall thickness and PA lumen area in ERαMut rats. In summary, in room air-exposed rats and rats with peri- and postnatal hypoxia exposure, ERα loss-of-function was associated with decreased alveolar size (primarily driven by hypoxic animals) and increased PA remodeling.NEW & NOTEWORTHY By exposing novel loss-of-function estrogen receptor alpha (Erα) mutant rats to a novel model of human high-altitude exposure, we demonstrate that ERα has subtle but inconsistent effects on endpoints relevant to cardiopulmonary adaptation to chronic hypoxia. Given that we observed some histologic, sex, and genotype differences, further research into cell-specific effects of ERα during hypoxia-induced cardiopulmonary adaptation is warranted.
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Adaptação Fisiológica , Receptor alfa de Estrogênio , Hipóxia , Animais , Receptor alfa de Estrogênio/metabolismo , Receptor alfa de Estrogênio/genética , Feminino , Hipóxia/metabolismo , Hipóxia/fisiopatologia , Ratos , Masculino , Pulmão/metabolismo , Pulmão/patologia , Altitude , Modelos Animais de Doenças , Ratos Sprague-Dawley , Fator A de Crescimento do Endotélio Vascular/metabolismo , Fator A de Crescimento do Endotélio Vascular/genéticaRESUMO
BACKGROUND: Research from across the United States has shown that rurality is associated with worse melanoma outcomes. In Indiana, nearly a quarter of all residents live in rural counties and an estimated 2180 cases of melanoma will be diagnosed in 2023. AIMS: This study examines how geographical location affects the stage of melanoma diagnosis in Indiana, aiming to identify and address rural health disparities to ultimately ensure equitable care. METHODS AND RESULTS: Demographics and disease characteristics of patients diagnosed with melanoma at Indiana University Health from January 2017 to September 2022 were compared using Students t-tests, Wilcoxon tests, chi-squared or Fisher's exact tests. Patients from rural areas presented with more pathological stage T3 melanomas (15.0% vs. 3.5%, p < 0.001) in contrast to their urban counterparts. Additionally, rural patients presented with fewer clinical stage I melanomas (80.8% vs. 89.3%) and more clinical stage II melanomas (19.2% vs. 8.1%), compared to urban patients, with no stage III (p = 0.028). Concerningly, a significantly higher percentage of the rural group (40.7%) had a personal history of BCC compared to the urban group (22.6%) (p = 0.005) and fewer rural patients (78.0%) compared to urban patients (89.4%) received surgical treatment (p = 0.016). CONCLUSION: Patients from rural counties in Indiana have higher pathological and clinical stage melanoma at diagnosis compared to patients from urban counties. Additionally fewer rural patients receive surgical treatment and may be at higher risk of developing subsequent melanomas.
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Melanoma , Neoplasias Cutâneas , Humanos , Estados Unidos , Melanoma/diagnóstico , Melanoma/epidemiologia , Indiana/epidemiologia , Estudos Retrospectivos , Neoplasias Cutâneas/diagnóstico , Neoplasias Cutâneas/epidemiologia , Neoplasias Cutâneas/terapia , População RuralRESUMO
OBJECTIVE: To examine long-term ileal ureter replacement results at over 32 years at our institution. Long segment or proximal ureteral strictures pose a challenging reconstructive problem. Ureteroureterostomy, psoas hitch, Boari flap, buccal ureteroplasty, and autotransplantation are common reconstructive techniques. We show that ileal ureter remains a lasting option. METHODS: We performed a retrospective review of patients undergoing open ileal ureter creation from 1989-2021. Patient demographics, operative history, and complications were examined. All patients were followed for changes in renal function. Demographic data were analyzed and Cox proportional hazard models were performed. RESULTS: One hundred and fifty-eight patients were identified with median follow-up time of 40 months. Eighty-one percent had a unilateral ileal ureter creation. Fifty percent were female, median age was 53.3. Twenty-seven percent of patients had radiation-induced strictures. Preoperatively, 56.3% of patients were chronic kidney disease stage 1-2 and 43.7% were stage 3-5. Post-operatively, 54% were stage 1-2 and 46% were stage 3-5. Cox proportional hazard models demonstrated no significant correlation between worsening renal function and stricture cause, bilateral repair, complications, or sex (biologically male or female). Seventy-seven percent had no 30-day complications. Clavien complications included grade 1 (18), grade 2 (4), grade 3 (9), and grade 4 (5). Long-term complications included worsening renal function (3%), incisional hernia (8.2%), and small bowel obstruction (6.9%). Five (3.1%) patients ultimately required dialysis and 5 (3.1%) patients developed metabolic acidosis. CONCLUSION: Ileal ureteral reconstruction is often a last resort for patients with complex ureteral injuries. Clinicians can be reassured by our long-term data that ileal ureteral creation is a safe treatment with good preservation of renal function and low risk of hemodialysis and metabolic acidosis.
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Íleo , Complicações Pós-Operatórias , Ureter , Obstrução Ureteral , Humanos , Feminino , Masculino , Estudos Retrospectivos , Pessoa de Meia-Idade , Íleo/transplante , Íleo/cirurgia , Ureter/cirurgia , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Obstrução Ureteral/cirurgia , Obstrução Ureteral/etiologia , Adulto , Rim/cirurgia , Fatores de Tempo , Idoso , Seguimentos , Procedimentos Cirúrgicos Urológicos/métodos , Procedimentos Cirúrgicos Urológicos/efeitos adversos , Procedimentos de Cirurgia Plástica/métodos , Procedimentos de Cirurgia Plástica/efeitos adversosRESUMO
BACKGROUND: Offspring born to mothers with pre-eclampsia (Pre-E) suffer higher risks of adult cardiovascular diseases, suggesting that exposure to an antiangiogenic environment in-utero has a lasting impact on the development of endothelial function. The goal of this study is to test the hypothesis that in-utero exposure to Pre-E results in alterations of angiogenic factors/cytokines that negatively impact vascular development during infancy. METHODS: Infants born from mothers with and without Pre-E were recruited and followed up at 6 months. Plasma cytokines, blood pressure, microvessel density, and vascular reactivity were assessed. RESULTS: 6-month-old infants born to mothers with Pre-E had unchanged blood pressure (p = 0.86) and microvessel density (p = 0.57). Vascular reactivity was decreased in infants born to mothers with Pre-E compared to infants born to healthy mothers (p = 0.0345). Interleukin 8 (IL-8) (p = 0.03) and Angiopoeitin-2 (Ang-2) (p = 0.04) were increased in infants born to mothers with Pre-E. We observed that higher IL-8 was associated with lower vascular reactivity (rho = -0.14, p < 0.0001). CONCLUSION: At 6 months of age, infants born to mothers with Pre-E had impaired vascular reactivity and higher IL-8 and Ang-2, but similar blood pressure and microvessel density compared to infants born to non-Pre-E mothers. IMPACT STATEMENT: Changes in cord blood antiangiogenic factors are documented in infants of mothers with pre-eclampsia and may contribute to offspring risks of adult cardiovascular disease. How these factors evolve during early infancy and their correlation with offspring vascular development have not been studied. This study found that 6-month-old infants born to mothers with pre-eclampsia had decreased vascular reactivity, which was correlated with higher IL-8. These findings underscore the lasting impact of maternal pre-eclampsia on offspring vascular development and highlight the need for long-term follow-up in children born to mothers with pre-eclampsia.
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Detecção Precoce de Câncer , Melanoma , Estadiamento de Neoplasias , Neoplasias Cutâneas , Humanos , Neoplasias Cutâneas/patologia , Neoplasias Cutâneas/diagnóstico , Melanoma/patologia , Melanoma/diagnóstico , Melanoma/epidemiologia , Detecção Precoce de Câncer/métodos , Masculino , Feminino , Pessoa de Meia-Idade , Idoso , AdultoRESUMO
OBJECTIVES: Lung cancer screening is a complex and individualized decision. To understand how best to support patients in this decision, we must understand how shared decision-making is associated with both decisional and behavioral outcomes. METHODS: Observational cohort study combining patient survey data with electronic health record data of lung screening-eligible patients who recently engaged in a shared decision-making discussion about screening with a primary care clinician. RESULTS: Using multivariable analysis (n = 529), factors associated with higher lung cancer screening decisional quality include higher knowledge (OR = 1.33, p < .0001), lower perceived benefits (OR = 0.90, p = .0004), higher perceived barriers (OR = 1.07, p < .0001), higher self-efficacy (OR = 1.13, p < .0001), and higher levels of perceiving the discussion was shared (OR = 1.04, p < .0001). Factors associated with the patient's decision to screen include older age (OR = 1.12, p = .0050) and higher self-efficacy (OR = 1.11, p = .0407). Factors associated with screening completion included older age (OR = 1.05, p = .0050), higher knowledge (OR = 1.24, p = .0045), and higher self-efficacy (OR = 1.12, p = .0003). CONCLUSIONS: Shared decision-making in lung cancer screening is a dyadic process between patient and clinician. As we continue to strive for high-quality patient-centered care, patient decision quality may be enhanced by targeting key factors such as high-quality knowledge, self-efficacy, and fostering a shared discussion to support patient engagement in lung cancer screening decisions.
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Tomada de Decisões , Neoplasias Pulmonares , Humanos , Detecção Precoce de Câncer , Neoplasias Pulmonares/diagnóstico , Tomada de Decisão Compartilhada , Participação do PacienteRESUMO
BACKGROUND AND AIMS: Little is known about the clinical characteristics and prognosis of hospitalized patients with moderate alcohol-associated hepatitis (mAH) as compared to severe alcohol-associated hepatitis (sAH). Therefore, we aimed to describe the clinical characteristics and risk factors associated with mortality in hospitalized mAH patients. METHODS: Patients hospitalized with alcohol-associated hepatitis (AH) from 1 January 2010 to 31 December 2020 at a large US healthcare system [11 hospitals, one liver transplant centre] were retrospectively analysed for outcomes. Primary outcome was 90-day mortality. AH and mAH were defined according to NIAAA Alcoholic Hepatitis Consortia and Model for End-stage Liver Disease Score ≤ 20 respectively. Multivariable Cox regression analysis was performed to identify independent risk factors associated with 90-day mortality. RESULTS: 1504 AH patients were hospitalized during the study period, of whom 39% (n = 590) had mAH. Compared to sAH patients, mAH patients were older (50 vs. 48 years, p < 0.001) and less likely to have underlying cirrhosis (74% vs. 83%, p < 0.001). There were no differences between the two groups for median alcohol intake g/day (mAH 140.0 vs. sAH 112.0, p = 0.071). The cumulative proportion surviving at 90 days was 88% in mAH versus 62% in sAH (p < 0.001). On multivariable analysis, older age [HR 1.03 (95% CI 1.00-1.06), p = 0.020], corticosteroid use [HR 1.80 (95% CI 1.06-3.06), p = 0.030] and acute kidney injury (AKI) [HR 2.43 (95% CI 1.33-4.47), p = 0.004] were independently associated with 90-day mortality. CONCLUSIONS: mAH carries a 12% mortality rate at 90 days. Age, AKI and corticosteroid use were associated with an increased risk for 90-day mortality. Avoidance of corticosteroids and strategies to reduce the risk of AKI could improve outcomes in mAH patients.
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Injúria Renal Aguda , Doença Hepática Terminal , Hepatite Alcoólica , Humanos , Hepatite Alcoólica/complicações , Estudos Retrospectivos , Doença Hepática Terminal/complicações , Índice de Gravidade de Doença , Prognóstico , Corticosteroides/uso terapêuticoRESUMO
BACKGROUND & AIMS: Patients with acute liver failure (ALF) awaiting liver transplantation (LT) may develop multiorgan failure, but organ failure does not impact waitlist prioritization. The aim of this study was to examine the impact of organ failure on waitlist mortality risk and post LT outcomes in patients with ALF. METHODS: We studied adults waitlisted for ALF in the United Network for Organ Sharing (UNOS) database (2002-2019). Organ failures were defined using a previously described Chronic Liver Failure modified sequential organ failure score assessment adapted to UNOS data. Regression analyses of the primary endpoints, 30-day waitlist mortality (Competing risk), and post-LT mortality (Cox-proportional hazards), were performed. Latent class analysis (LCA) was used to determine the organ failures most closely associated with 30-day waitlist mortality. RESULTS: About 3212 adults with ALF were waitlisted, for hepatotoxicity (41%), viral (12%) and unspecified (36%) etiologies. The median number of organ failures was three (interquartile range 1-3). Having ≥3 organ failures (vs. ≤2) was associated with a sub hazard ratio (HR) of 2.7 (95%CI 2.2-3.4)) and a HR of 1.5 (95%CI 1.1-2.5)) for waitlist and post-LT mortality, respectively. LCA identified neurologic and respiratory failure as most impactful on 30-day waitlist mortality. The odds ratios for both organ failures (vs. neither) were higher for mortality 4.5 (95% CI 3.4-5.9) and lower for delisting for spontaneous survival .5 (95%CI .4-.7) and LT .6 (95%CI .5-.7). CONCLUSION: Cumulative organ failure, especially neurologic and respiratory failure, significantly impacts waitlist and post-LT mortality in patients with ALF and may inform risk-prioritized allocation of organs.
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Encefalopatia Hepática , Falência Hepática Aguda , Transplante de Fígado , Insuficiência Respiratória , Adulto , Humanos , Encefalopatia Hepática/etiologia , Respiração Artificial , Transplante de Fígado/efeitos adversos , Estudos Retrospectivos , Falência Hepática Aguda/cirurgia , Insuficiência Respiratória/etiologia , Listas de EsperaRESUMO
BACKGROUND: There is little known about the spectrum of cardiac injury in acute COVID-19 infection in children. METHODS: A single-centre, retrospective chart analysis was performed. The protocol was deemed IRB exempt. All patients under the age of 21 years admitted from 20 March, 2020 to 22 June, 2021 for acute symptomatic COVID-19 infection or clinical suspicion of multisystem inflammatory syndrome in children (MIS-C) associated with COVID-19 were included. Past medical history, lab findings, echocardiogram and electrocardiogram/telemetry findings, and clinical outcomes were reviewed. RESULTS: Sixty-six patients with MIS-C and 178 with acute COVID-19 were reviewed. Patients with MIS-C had more cardiac testing than those with acute COVID-19. Inflammatory markers were more likely elevated, and function was more likely abnormal on echocardiogram in those with MIS-C with testing performed. Among patients with MIS-C, 17% had evidence of coronary dilation versus 0% in the acute COVID-19 group. One (0.6%) patient with acute COVID-19 had clinically significant electrocardiogram or telemetry findings, and this was in the setting of prior arrhythmias and CHD. Four (6%) patients with MIS-C had clinically significant findings on electrocardiogram or telemetry. Among patients with acute COVID-19, extracorporeal membrane oxygenation support was required in 0.6% of patients with acute COVID-19, and there was a 2.8% mortality. There were no deaths in the setting of MIS-C. CONCLUSIONS: Patients with acute COVID-19 and clinical suspicion of cardiac injury had a lower incidence of abnormal laboratory findings, ventricular dysfunction, or significant arrhythmia than those with MIS-C.
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COVID-19 , Traumatismos Cardíacos , Síndrome de Resposta Inflamatória Sistêmica , Criança , Humanos , Adulto Jovem , Adulto , COVID-19/complicações , Estudos Retrospectivos , CoraçãoRESUMO
OBJECTIVES: The objective of this study was to compare plasma proteomes of patients with confirmed fracture-related infections (FRIs) matched to noninfected controls using liquid chromatography-mass spectrometry. DESIGN: This was a prospective case-control study. SETTING: The study was conducted at a single, academic, Level 1 trauma center. PATIENT SELECTION CRITERIA: Patients meeting confirmatory FRI criteria were matched to controls without infection based on fracture region, age, and time after surgery from June 2019 to January 2022. Tandem mass tag liquid chromatography-mass spectrometry analysis of patient plasma samples was performed. OUTCOME MEASURES AND COMPARISONS: Protein abundance ratios in plasma for patients with FRI compared with those for matched controls without infection were calculated. RESULTS: Twenty-seven patients meeting confirmatory FRI criteria were matched to 27 controls. Abundance ratios for more than 1000 proteins were measured in the 54 plasma samples. Seventy-three proteins were found to be increased or decreased in patients with FRI compared with those in matched controls (unadjusted t test P < 0.05). Thirty-two of these proteins were found in all 54 patient samples and underwent subsequent principal component analysis to reduce the dimensionality of the large proteomics dataset. A 3-component principal component analysis accounted for 45.7% of the variation in the dataset and had 88.9% specificity for the diagnosis of FRI. STRING protein-protein interaction network analysis of these 3 PCs revealed activation of the complement and coagulation cascades through the Reactome pathway database (false discovery rates <0.05). CONCLUSIONS: Proteomic analyses of plasma from patients with FRI demonstrate systemic activation of the complement and coagulation cascades. Further investigation along these lines may help to better understand the systemic response to FRI and improve diagnostic strategies using proteomics. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Fraturas Ósseas , Proteômica , Humanos , Estudos de Casos e Controles , Proteômica/métodos , Fraturas Ósseas/diagnóstico , Fraturas Ósseas/cirurgiaRESUMO
INTRODUCTION: The purpose of this study was to determine whether it is safe to use a conservative packed red blood cell transfusion hemoglobin threshold (5.5 g/dL) compared with a liberal transfusion threshold (7.0 g/dL) for asymptomatic patients with musculoskeletal-injured trauma out of the initial resuscitative period. METHODS: This was a multicenter, prospective, nonblinded, randomized study done at three level 1 trauma centers. One hundred patients were enrolled. One patient was inappropriately enrolled, withdrawn from the study, and excluded from analysis leaving 99 patients (49 liberal and 50 conservative) with 30-day follow-up. After initial resuscitation, patients were enrolled and randomized to either a liberal or a conservative transfusion strategy. This strategy was followed throughout the index hospitalization. The primary outcome of the study was infection. Superficial infection was defined as clinical diagnosis of cellulitis or other superficial infection treated with oral antibiotics only. Deep infection was defined as clinical diagnosis of fracture-related infection requiring IV antibiotics and/or surgical débridement. RESULTS: Ninety-nine patients were successfully followed for 30 days with 100% follow-up during this time. Seven infections (14%) occurred in the liberal group and none in the conservative group ( P < 0.01). Five deep infections (10%) occurred in the liberal group and none in the conservative group ( P = 0.03). Three superficial infections (6%) occurred in the liberal and none in the conservative group, which was not a significant difference ( P = 0.1). No difference was observed in length of stay between groups. DISCUSSION: Transfusing young healthy asymptomatic patients with orthopaedic trauma for hemoglobin <7.0 g/dL increases the risk of infection. No increased risk of anemia-related complications was identified with a conservative transfusion threshold of 5.5 g/dL. DATA AVAILABILITY AND TRIAL REGISTRATION NUMBERS: Data are available on request. IRB protocol number is 1402557771. This study was registered with Clinicaltrials.gov identifier NCT02972593. LEVEL OF EVIDENCE: Level 2, unblinded prospective randomized multicenter study.
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Anemia , Ortopedia , Humanos , Anemia/etiologia , Anemia/terapia , Antibacterianos , Hemoglobinas , Estudos Prospectivos , Sistema Musculoesquelético/lesões , Ferimentos e Lesões/terapia , Transfusão de SangueRESUMO
OBJECTIVE: The aims of this study were to determine the prevalence of positive mental health (MH) screens in a pediatric high-risk asthma (HRA) clinic population, and to determine the success rate of engagement in MH services before and after adding a clinical psychologist to our multidisciplinary clinic. HYPOTHESIS: We hypothesized that the HRA population would have a higher prevalence of anxiety/depression symptoms than that previously reported for the general pediatric asthma population. We anticipated that the presence of an embedded psychologist in HRA clinic would facilitate successful connection to MH services. METHODS: Pediatric patients in the HRA clinic were prospectively screened for anxiety and depression using validated screening instruments. Positive scores were referred for MH services. Time to MH service engagement was recorded before and after the addition of a clinical psychologist. RESULTS: A total of 186 patients were screened; 60% had a positive MH screen. Female sex was associated with higher median scores on both screening tools and higher likelihood of engagement in MH services. After addition of a clinical psychologist, new engagement in MH services increased (20% vs. 80%, p < 0.0001), and median time to engagement decreased (14.5 vs. 0.0 months, p = 0.003). CONCLUSION: There is a high prevalence of anxiety and depression in this pediatric HRA population. Success of engagement in MH services improved after a clinical psychologist joined our multidisciplinary team, suggesting access to care as a primary barrier to engagement.
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Asma , Serviços de Saúde Mental , Humanos , Criança , Feminino , Depressão/diagnóstico , Depressão/epidemiologia , Depressão/terapia , Ansiedade/diagnóstico , Ansiedade/epidemiologia , Transtornos de Ansiedade , Asma/diagnóstico , Asma/epidemiologia , Asma/terapiaRESUMO
OBJECTIVES: To determine whether it is safe to use a conservative packed red blood cell transfusion hemoglobin (Hgb) threshold (5.5 g/dL) compared with a liberal transfusion threshold (7.0 g/dL) for asymptomatic musculoskeletal injured trauma patients who are no longer in the initial resuscitative period. METHODS: Design: Prospective, randomized, multicenter trial. SETTING: Three level 1 trauma centers. PATIENT SELECTION CRITERIA: Patients aged 18-50 with an associated musculoskeletal injury with Hgb less than 9 g/dL or expected drop below 9 g/dL with planned surgery who were stable and no longer being actively resuscitated were randomized once their Hgb dropped below 7 g/dL to a conservative transfusion threshold of 5.5 g/dL versus a liberal threshold of 7.0 g/dL. OUTCOME MEASURES AND COMPARISONS: Postoperative infection, other post-operative complications and Musculoskeletal Functional Assessment scores obtained at baseline, 6 months, and 1 year were compared for liberal and conservative transfusion thresholds. RESULTS: Sixty-five patients completed 1 year follow-up. There was a significant association between a liberal transfusion strategy and higher rate of infection (P = 0.01), with no difference in functional outcomes at 6 months or 1 year. This study was adequately powered at 92% to detect a difference in superficial infection (7% for liberal group, 0% for conservative, P < 0.01) but underpowered to detect a difference for deep infection (14% for liberal group, 6% for conservative group, P = 0.2). CONCLUSIONS: A conservative transfusion threshold of 5.5 g/dL in an asymptomatic young trauma patient with associated musculoskeletal injuries leads to a lower infection rate without an increase in adverse outcomes and no difference in functional outcomes at 6 months or 1 year. LEVEL OF EVIDENCE: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.
Assuntos
Anemia , Ortopedia , Humanos , Estudos Prospectivos , Anemia/diagnóstico , Anemia/epidemiologia , Anemia/terapia , Hemoglobinas/análise , Transfusão de Sangue , Complicações Pós-OperatóriasRESUMO
OBJECTIVE: To compare rates of reduction loss, nonunion, and infection in intra-articular distal tibia fractures (IADTF) treated with limited open reduction internal fixation and intramedullary nailing (IMN) as compared to open reduction internal fixation with plate and screws (plate fixation [PF]). DESIGN: Retrospective review. SETTING: Level-I academic trauma center. PATIENT SELECTION CRITERIA: Patients age ≥ 18 with OTA/AO 43C1 and C2 IADTF treated with IMN or PF between 2013-2021. OUTCOME MEASURES AND COMPARISONS: Loss of reduction, surgical site infection (SSI), nonunion, and patient-reported outcomes (PROs) were compared for IMN versus PF treatments. RESULTS: One hundred ten patients met the inclusion criteria (IMN 33 and PF 77). There was no loss of reduction found. Seventeen nonunions (15% overall; IMN 4/33 and PF 13/77) and 13 SSIs (12% overall; IMN 2/33 and PF11/77) were identified. Despite several risk factors being identified for nonunion and SSI in bivariate analysis, only open fracture remained significant as a risk factor for both nonunion (odds ratio 0.09 for closed fracture, 95% confidence interval, 0.02-0.56, P = 0.009) and SSI (odds ratio 0.07 for closed fracture, 95% confidence interval, 0.06-0.26, P = 0.012) in the multivariate model. Propensity scoring based on presurgical variables was significantly different between patients who received IMN versus PF ( P = 0.03); however, logistic regression incorporating the propensity score revealed no significant association with nonunion and SSI. Adjusting for the propensity score, there remained no association comparing IMN versus PF with nonunion and SSI ( P = 0.54 and P = 0.17, respectively). There was also no difference in PROs between IMN and PF (physical function: P = 0.25 and pain interference: P = 0.21). CONCLUSIONS: Overall nonunion and SSI prevalence was 15% and 12%, respectively, in operatively treated OTA/AO 43C1 and C2 IADTF. An open fracture was a significant risk factor for nonunion and SSI. Metaphyseal fixation through IMN or PF did not affect loss of reduction, nonunion, SSI, or PROs. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
Assuntos
Fraturas do Tornozelo , Fixação Intramedular de Fraturas , Fraturas Fechadas , Fraturas Expostas , Fraturas da Tíbia , Humanos , Fixação Intramedular de Fraturas/efeitos adversos , Tíbia/cirurgia , Fraturas Expostas/etiologia , Pontuação de Propensão , Fraturas da Tíbia/cirurgia , Fraturas da Tíbia/etiologia , Estudos Retrospectivos , Análise Multivariada , Infecção da Ferida Cirúrgica/epidemiologia , Infecção da Ferida Cirúrgica/etiologia , Fraturas do Tornozelo/etiologia , Resultado do TratamentoRESUMO
BACKGROUND: Alcohol relapse occurs frequently in alcohol-associated hepatitis (AH) survivors, but data on the frequency and course of recurrent alcohol-associated hepatitis (rAH) are sparse. We investigated the incidence, risk factors, and outcomes of rAH. METHODS: Hospitalized patients with AH from 2010 to 2020 at a large health care system were followed until death/liver transplant, last follow-up, or end of study (December 31, 2021). AH was defined by NIAAA Alcoholic Hepatitis Consortium criteria; rAH was defined a priori as a discrete AH episode >6 months from index AH hospitalization with interim >50% improvement or normalization of total bilirubin. Multivariable competing risk analysis was performed to identify factors associated with rAH. Landmark Kaplan-Meier analysis was performed to compare survival between patients who did versus those who did not develop rAH. RESULTS: Of 1504 hospitalized patients with AH, 1317 (87.6%) survived and were analyzed. During a 3055 person-year follow-up, 116 (8.8%) developed rAH at an annual incidence rate of 3.8% (95% CI: 2.8-4.8). On multivariable competing risk analysis, marital status [sub-HR 0.54 (95% CI: 0.34, 0.92), p=0.01] and medications for alcohol use disorder [sub-HR 0.56 (95% CI: 0.34, 0.91), p=0.02] were associated with a lower risk for rAH. On landmark Kaplan-Meier analysis, the cumulative proportion surviving at 1 year (75% vs. 90%) and 3 years (50% vs. 78%) was significantly lower in patients who developed rAH compared to those who did not develop rAH (log-rank p<0.001). CONCLUSIONS: rAH develops in ~1 in 10 AH survivors and is associated with lower long-term survival. Medications for alcohol use disorder lower the risk for rAH and, therefore, could be a key preventative strategy to improve outcomes.