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1.
Am J Transplant ; 2020 Apr 30.
Artigo em Inglês | MEDLINE | ID: mdl-32356368

RESUMO

Noninvasive biomarker profiles of acute rejection (AR) could affect the management of liver transplant (LT) recipients. Peripheral blood was collected following LT for discovery (Northwestern University [NU]) and validation (National Institute of Allergy and Infectious Diseases Clinical Trials in Organ Transplantation [CTOT]-14 study). Blood gene profiling was paired with biopsies showing AR or ADNR (acute dysfunction no rejection) as well as stable graft function samples (Transplant eXcellent-TX). CTOT-14 subjects had serial collections prior to AR, ADNR, TX, and after AR treatment. NU cohort gene expression (46 AR, 45 TX) was analyzed using random forest models to generate a classifier training set (36 gene probe) distinguishing AR vs TX (area under the curve 0.92). The algorithm and threshold were locked and tested on the CTOT-14 validation cohort (14 AR, 50 TX), yielding an accuracy of 0.77, sensitivity 0.57, specificity 0.82, positive predictive value (PPV) 0.47, and negative predictive value (NPV) 0.87 for AR vs TX. The probability score line slopes were positive preceding AR, and negative preceding TX and non-AR (TX + ADNR) (P ≤ .001) and following AR treatment. In conclusion, we have developed a blood biomarker diagnostic for AR that can be detected prior to AR-associated graft injury as well a normal graft function (non-AR). Further studies are needed to evaluate its utility in precision-guided immunosuppression optimization following LT.

2.
Mil Med ; 2020 May 12.
Artigo em Inglês | MEDLINE | ID: mdl-32395766

RESUMO

The measles-mumps-rubella (MMR) vaccine is generally well tolerated, and reports of anaphylaxis to the vaccine are rare. IgE-mediated reactions to vaccines are often caused by additives or residual vaccine components. An inability to obtain proper immunizations can be a disqualifying component to military service. We report a case of anaphylaxis to the MMR vaccine in a new military recruit sensitized to gelatin IgE.

3.
J Am Chem Soc ; 2020 May 20.
Artigo em Inglês | MEDLINE | ID: mdl-32431151

RESUMO

Accurately characterizing isoprene ozonolysis con-tinues to challenge atmospheric chemists. The reac-tion is believed to be a spontaneous, concerted cy-cloaddition. However, little information is available about the entrance channel and isoprene-ozone complexes thought to define the long-range por-tion of the reaction coordinate. Our coupled cluster and auxiliary field quantum Monte Carlo calcula-tions predict multiple stable isoprene-ozone van der Waals complexes for the trans-isoprene in the gas-phase with moderate association energies. These results indicate that long-range dynamics in the isoprene-ozone entrance channel can impact the overall reaction in the troposphere and provide the spectroscopic information necessary to extend microwave characterization of isoprene ozonolysis to pre-reactive complexes. At the air-water inter-face, Born-Oppenheimer Molecular Dynamics simulations indicate that the cycloaddition reaction between ozone and trans-isoprene follows a step-wise mechanism, which is quite distinct from our proposed gas-phase mechanism and occurs on a femtosecond time scale. The stepwise nature of isoprene ozonolysis on the aqueous surface is more consistent with the DeMore mechanism than with the Criegee mechanism suggested by the gas-phase calculations, suggesting that the reaction media may play an important role in the reaction. Over-all, these predictions aim to provide a missing fun-damental piece of molecular insight into isoprene ozonolysis, which has broad tropospheric implica-tions due to its critical role as a nighttime source of hydroxyl radical.

5.
World Neurosurg ; 2020 Apr 25.
Artigo em Inglês | MEDLINE | ID: mdl-32344145

RESUMO

A 76-year-old male whose brain MRI demonstrated an anterior right frontal broad dural based homogenously enhancing mass measuring 6.0x3.1x6.3cm. after presenting with a one year progressive cognitive dysfunction. A right sided pterional craniotomy and resection of mass was performed under general anesthesia with an uncomplicated intraoperative course. Postoperatively, the right eye was noted to have an afferent pupillary defect, complete ophthalmoplegia, ptosis, and significant resistance to retropulsion. Emergent ophthalmologic consultation confirmed the ocular exam and the diagnosis of right orbital compartment syndrome was suspected. A right lateral canthotomy and cantholysis was performed by the ophthalmologist at the bedside. The fundoscopic retinal evaluation was normal. Non-contrast CT of the head demonstrated expected postoperative changes and mild edema of the right frontal lobe without evidence of acute hemorrhage. There was no retro-orbital hematoma but the right extra-ocular muscles appeared edematous compared to the left. No light perception and opthalmoplegia continued in the right eye. This case demonstrates that although very rare, orbital compartment syndrome can occur without compression of the eye or an intra-orbital mass. Visual loss is a devastating complication and preoperative informed consent of this complication is imperative. Constant vigilance to ensure adequate arterial and venous supply to the orbit, with great care to prevent external compression on the eye, hopefully, will continue to make this complication rare.

6.
Surgery ; 2020 Apr 05.
Artigo em Inglês | MEDLINE | ID: mdl-32268937

RESUMO

BACKGROUND: Transjugular intrahepatic portosystemic shunt has been established as an effective treatment for complicated portal hypertension. This retrospective study investigated the effect of pretransplant transjugular intrahepatic portosystemic shunt placement on intraoperative graft hemodynamics and surgical outcomes after liver transplantation. METHODS: Of 1,081 patients who underwent liver transplantation between January 2007 and June 2017 at Cleveland Clinic (OH, USA), 130 patients had transjugular intrahepatic portosystemic shunt placement before liver transplant. We performed a 1:2 propensity score matching to compare intraoperative graft hemodynamics and surgical outcomes between the transjugular intrahepatic portosystemic shunt group (n = 130) and the no-transjugular intrahepatic portosystemic shunt group (n = 260). RESULTS: The transjugular intrahepatic portosystemic shunt did not increase operative time, the volume of blood transfusion, duration of hospital stay, or complication rates. Graft and patient survivals were similar between the groups. Mean intraoperative cardiac output and graft portal flow in the transjugular intrahepatic portosystemic shunt group were greater than in the no-transjugular intrahepatic portosystemic shunt group (P = .03 and P = .003, respectively). In multivariate analysis, male sex, younger age, low platelet count, absence of portal vein thrombosis, and pretransplant transjugular intrahepatic portosystemic shunt placement were independently associated with increased portal flow volume (P < or = 0.03 each). Transjugular intrahepatic portosystemic shunt malposition was observed in 17 patients (13.1%). The 1-year patient survival was 70.6% with transjugular intrahepatic portosystemic shunt malposition and 92.0% without transjugular intrahepatic portosystemic shunt malposition (P = .01). CONCLUSION: Our findings suggest that pretransplant transjugular intrahepatic portosystemic shunt placement increases graft portal flow but does not compromise surgical outcomes after liver transplantation. Transjugular intrahepatic portosystemic shunt malposition, however, is not uncommon and may increase the complexity of transplantation.

7.
Artigo em Inglês | MEDLINE | ID: mdl-32118809

RESUMO

PURPOSE: To demonstrate a novel approach to scleral fixation of posterior chamber intraocular lenses and capsular tension rings and segments in deep-set eyes using the Finesse FlexLoop (Alcon Laboratories). METHODS: The technique described herein, based on previous approaches to scleral fixation of posterior chamber intraocular lenses, uniquely employs the FlexLoop to "lasso" Gore-Tex sutures that have already been threaded through the eyelets of a CZ70BD (Alcon Laboratories) IOL and externalize them. RESULTS: All patients who underwent surgery with this technique experienced visual improvement. The only complication was of mild hyphema in the patient who had a capsular tension segment placed, which resolved with medical therapy. CONCLUSION: The advantages of this procedure include a smaller diameter instrument (FlexLoop) as compared to the 25-gauge forceps typically employed, an easier to perform surgical maneuver that alleviates the need for both precise placement and constant tension to be exerted by the surgeon to grasp the sutures, as well as an instrument that can function when bent up to 45° to help accommodate deep-set eyes requiring this procedure.

8.
Am J Obstet Gynecol ; 2020 Mar 07.
Artigo em Inglês | MEDLINE | ID: mdl-32151611

RESUMO

Uterus transplantation is the only known potential treatment for absolute uterine factor infertility. It offers a unique setting for the investigation of immunologic adaptations of pregnancy in the context of the pharmacologic-induced tolerance of solid organ transplants, thus providing valuable insights into the early maternal-fetal interface. Until recently, all live births resulting from uterus transplantation involved living donors, with only 1 prior birth from a deceased donor. The Cleveland Clinic clinical trial of uterus transplantation opened in 2015. In 2017, a 35 year old woman with congenital absence of the uterus was matched to a 24 year old parous deceased brain-dead donor. Transplantation of the uterus was performed with vaginal anastomosis and vascular anastomoses bilaterally from internal iliac vessels of the donor to the external iliac vessels of the recipient. Induction and maintenance immunosuppression were achieved and subsequently modified in anticipation of pregnancy 6 months after transplant. Prior to planned embryo transfer, ectocervical biopsy revealed ulceration and a significant diffuse, plasma cell-rich mixed inflammatory cell infiltrate, with histology interpreted as grade 3 rejection suspicious for an antibody-mediated component. Aggressive immunosuppressive regimen targeting both cellular and humoral rejection was initiated. After 3 months of treatment, there was no histologic evidence of rejection, and after 3 months from complete clearance of rejection, an uneventful embryo transfer was performed and a pregnancy was established. At 21 weeks, central placenta previa with accreta was diagnosed. A healthy neonate was delivered by cesarean hysterectomy at 34 weeks' gestation. In summary, this paper highlights the first live birth in North America resulting from a deceased donor uterus transplant. This achievement underscores the capacity of the transplanted uterus to recover from a severe, prolonged rejection and yet produce a viable neonate. This is the first delivery from our ongoing clinical trial in uterus transplantation, including the first reported incidence of severe mixed cellular/humoral rejection as well as the first reported placenta accreta.

9.
J Vasc Surg ; 2020 Feb 27.
Artigo em Inglês | MEDLINE | ID: mdl-32115317

RESUMO

BACKGROUND: Thoracic outlet syndrome (TOS) results from compression of the neurovascular structures in the thoracic outlet. Decompression provides relief of TOS symptoms. However, little is known about long-term function and quality of life (QoL) from a patient's perspective. The purpose of this study was to evaluate surgical and QoL outcomes after surgical decompression of the thoracic outlet using a paraclavicular approach. METHODS: A prospectively maintained database was used to conduct a retrospective review of patients who underwent thoracic outlet decompression between August 2004 and August 2018. We excluded patients without complete follow-up data. Functional outcomes were assessed by the Derkash classification (poor, fair, good, excellent) using contingency table methods, and QoL was assessed by the 12-Item Short Form Health Survey (SF-12) using general linear models. SF-12 was scored by published criteria, and scale-specific and aggregate mental and physical health-related QoL scores were computed. Aggregate QoL scores range from 0 (terrible) to 100 (perfect). Secondary outcomes included mortality, complications, and duration of hospital stay. RESULTS: We performed 105 operations for TOS, and 100 patients with complete follow-up data were included in the study. Five patients were lost to follow-up. Median age was 35 (interquartile range, 24-47) years, and 58 (58%) were female. The median duration of hospital stay was 4 (interquartile range, 3-5.5) days. Of these patients, 46 had venous etiology, 8 arterial, 42 neurogenic, and 4 mixed vascular and neurogenic. Good or excellent Derkash results were reported in 77 (77%) patients, 46 of 54 (85%) of those with vascular TOS vs 31 of 46 (67%) of those with neurogenic etiology (P < .036). SF-12 score was obtained in 93 of 100 (93%) with a median duration from surgery of 6.1 (3.3-9.3) years. Patients with neurogenic TOS (NTOS) reported significantly lower aggregate mental health QoL than patients with vascular-only TOS (57 vs 59; P < .016). This effect persisted across the entire duration of follow-up and was unaffected by time from surgery (regression P for time = .509). In contrast, aggregate physical function QoL was unaffected by neurogenic etiology (P = .303), and all patients improved linearly with time (0.5 scale unit/y; P < .009). Three patients with incomplete relief of symptoms after paraclavicular decompression for NTOS underwent pectoralis minor decompression. There were no deaths or injuries to the long thoracic nerve. Complications included pleural effusion or hemothorax requiring evacuation (n = 6), neurapraxia (n = 6), and lymph leak (n = 2) treated with tube thoracostomy. CONCLUSIONS: NTOS is associated with significantly worse functional outcome assessed by the Derkash classification. NTOS also demonstrated worse composite mental health QoL, which did not improve over time. In contrast, composite physical health QoL improved linearly with time from surgery regardless of etiology of TOS.

10.
J Minim Invasive Gynecol ; 27(1): 160-165, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-30926368

RESUMO

STUDY OBJECTIVE: To determine whether incorporation of operative hysteroscopy with biopsy of products of conception, in conjunction with a suction curettage for a first trimester missed abortion, affected the rate of maternal cell contamination when chromosomal analysis was performed on the products of conception, and to determine the rates of retained products of conception with incorporation of hysteroscopy after suction curettage. DESIGN: Retrospective chart study. SETTING: Private, minimally invasive surgery and infertility practice with academic-community hospital affiliation. PATIENTS: Infertility patients undergoing evacuation of products of conception for documented first trimester miscarriages between 2006 and 2017. INTERVENTIONS: Suction curettage or hysteroscopic biopsy and suction curettage, followed by chromosomal analysis of products of conception for determination of fetal genetics. MEASUREMENTS AND RESULTS: A total of 264 charts were analyzed. Patients were categorized into 2 groups based on surgical collection of products of conception: group 1 (N = 174), suction curettage only, and group 2 (N = 90), a single procedure consisting of operative hysteroscopy with biopsy of products of conception followed by suction curettage and then diagnostic hysteroscopy to look for retained products. Data for chromosome detection and retained products of conception were available for 246 and 239 patients, respectively. No significant differences were detected between the groups for age, body mass index, ethnicity, gravida, parity, primary infertility, secondary infertility, spontaneous conception, single or multiple gestation, and surgical complications. Fetal chromosome detection was significantly higher without maternal contamination in group 2 (88.5%) compared with group 1 (64.8%) (p < .001). There was no significant between-group difference in postoperative retained products of conception. CONCLUSION: Obtaining fetal genetics can be useful when planning for a future successful pregnancy. The addition of operative hysteroscopy to biopsy the gestational sac, chorionic villi, and/or fetus significantly decreases the risk of maternal contamination and increases the ability to detect fetal chromosomes for genetic analysis without an increased risk of surgical complications. Despite the low risk of surgical complications, immediate second-look hysteroscopy after the completion of suction evacuation does not reduce the risk of postoperative retained products of conception.

11.
Artigo em Inglês | MEDLINE | ID: mdl-31584320

RESUMO

There is a need for a broad study addressing different preservation conditions of anaerobic sludge and its activity after a prolonged storage. This study compared four different preservation methods of mesophilic anaerobic sludge for a period of up to 12 months: storage at 23 ± 2 °C, +4 °C, ‒20 °C, and freeze-dried. Anaerobic sludge was sampled from upper and bottom ports of an up flow anaerobic sludge blanket (UASB) reactor fed with microalgae and sodium acetate at organic loading rate of 5.4 gCOD/L·d. Specific methanogenic activity (SMA) tests were performed on the sludge samples after 2.5, 6, and 12 months of storage. Results demonstrated a statistically significant decrease in the SMA of the bottom port preserved sludge, but not of the upper port sludge, regardless of the method used for preservation. A varying susceptibility to the storage of the two types of the anaerobic sludge can be explained by the content of the methanogenic microorganisms, with bottom port sludge having a higher amount of the methane producing species. Interestingly, lyophilized samples were able to produce similar amounts of biogas when compared to the other three storage conditions, with the only difference of having a longer re-activation period.

12.
Ann Thorac Surg ; 109(1): 249-254, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31521592

RESUMO

BACKGROUND: We reviewed the efficacy of intraoperative intercostal nerve cryoanalgesia for pain control in patients undergoing descending and thoracoabdominal aortic aneurysm repairs. METHODS: During 2013 and 2017, 241 patients underwent descending and thoracoabdominal aortic aneurysm repair. Of those, 38 patients were treated with intraoperative cryoanalgesia to the intercostal nerves at the level of 4th to 10th under electromyography guidance and were compared with patients who did not receive cryoanalgesia. Both groups received multilevel paravertebral block and local infiltration with liposomal bupivacaine. Numerical pain scale scores and amount of opioid usage in morphine milligram equivalences on the first to fourth and eighth postoperative days were collected. We excluded patients from the study who were extubated after the third postoperative day or who were reintubated. RESULTS: One hundred twenty-six patients met the inclusion criteria: 28 in the cryoanalgesia group and 98 in the control group. Preoperative patient demographics were similar in both groups, except for more frequent chronic dissection in patients with cryoanalgesia (93% vs 65%, P = .004). Postoperative major complications, length of stay, and discharge to home were not significantly different in either group. However, median ventilation hours were significantly shorter in the cryoanalgesia group (5 vs 12 hours, P < .001). Opioid use was significantly less in the cryoanalgesia group after postoperative day 4. Indexed morphine milligram equivalences, adjusted with body surface area, and numerical pain scale scores were significantly lower in the cryoanalgesia group throughout the postoperative course. CONCLUSIONS: Intercostal nerve cryoanalgesia under electromyography guidance provided improved pain control and reduced narcotic use after descending and thoracoabdominal aortic aneurysm repairs compared with those who only received paravertebral block.

13.
J Clin Endocrinol Metab ; 105(3)2020 Mar 01.
Artigo em Inglês | MEDLINE | ID: mdl-31650182

RESUMO

CONTEXT: Elagolix is an oral gonadotropin-releasing hormone (GnRH) antagonist recently approved for the treatment of endometriosis-associated pain and being developed for heavy menstrual bleeding associated with uterine fibroids. OBJECTIVE: The objective was to evaluate the effects of elagolix on ovulation and ovarian sex hormones. DESIGN AND SETTING: This was a randomized, open-label, multicenter study. PARTICIPANTS: Participants were healthy ovulatory women aged 18 to 40 years. INTERVENTIONS: Elagolix was administered orally for 3 continuous 28-day dosing intervals at 100 to 200 mg once daily (QD), 100 to 300 mg twice daily (BID), and 300 mg BID plus estradiol/norethindrone acetate (E2/NETA) 1/0.5 mg QD. MAIN OUTCOME MEASURES: The main outcomes measures were ovulation rates measured by transvaginal ultrasound, progesterone concentrations, and hormone suppression. RESULTS: Elagolix suppressed ovulation in a dose-dependent manner. The percentage of women who ovulated was highest at 100 mg QD (78%), intermediate at 150 and 200 mg QD and 100 mg BID (47%-57%), and lowest at 200 and 300 mg BID (32% and 27%, respectively). Addition of E2/NETA to elagolix 300 mg BID further suppressed the ovulation rate to 10%. Elagolix also suppressed luteinizing hormone and follicle stimulating hormone in a dose-dependent manner, leading to dose-dependent suppression of estradiol and progesterone. Elagolix had no effect on serum biomarker of ovarian reserve, and reduced endometrial thickness compared to the screening cycle. CONCLUSION: Women being treated with elagolix may ovulate and should use effective methods of contraception. The rate of ovulation was lowest with elagolix 300 mg BID plus E2/NETA 1/0.5 mg QD.

14.
Liver Transpl ; 26(2): 215-226, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31642164

RESUMO

The primary aim of this single-center, phase 1 exploratory study was to investigate the safety, feasibility, and impact on intrahepatic hemodynamics of a fresh frozen plasma (FFP)-based perfusate in ex situ liver normothermic machine perfusion (NMP) preservation. Using an institutionally developed perfusion device, 21 livers (13 donations after brain death and 8 donations after circulatory death) were perfused for 3 hours 21 minutes to 7 hours 52 minutes and successfully transplanted. Outcomes were compared in a 1:4 ratio to historical control patients matched according to donor and recipient characteristics and preservation time. Perfused livers presented a very low resistance state with high flow during ex situ perfusion (arterial and portal flows 340 ± 150 and 890 ± 70 mL/minute/kg liver, respectively). This hemodynamic state was maintained even after reperfusion as demonstrated by higher arterial flow observed in the NMP group compared with control patients (220 ± 120 versus 160 ± 80 mL/minute/kg liver, P = 0.03). The early allograft dysfunction (EAD) rate, peak alanine aminotransferase (ALT), and peak aspartate aminotransferase (AST) levels within 7 days after transplantation were lower in the NMP group compared with the control patients (EAD 19% versus 46%, P = 0.02; peak ALT 363 ± 318 versus 1021 ± 999 U/L, P = 0.001; peak AST 1357 ± 1492 versus 2615 ± 2541 U/L, P = 0.001 of the NMP and control groups, respectively). No patient developed ischemic type biliary stricture. One patient died, and all other patients are alive and well at a follow-up of 12-35 months. No device-related adverse events were recorded. In conclusion, with this study, we showed that ex situ NMP of human livers can be performed safely and effectively using a noncommercial device and an FFP-based preservation solution. Future studies should further investigate the impact of an FFP-based perfusion solution on liver hemodynamics during ex situ normothermic machine preservation.

15.
Artigo em Inglês | MEDLINE | ID: mdl-31699416

RESUMO

OBJECTIVE: To review short-term outcomes and long-term survival and durability after open surgical repairs for chronic distal aortic dissections in patients whose anatomy was amenable to thoracic endovascular aortic repair (TEVAR). METHODS: Between February 1991 and August 2017, we repaired chronic distal dissections in 697 patients. Of those patients, we enrolled 427 with anatomy amenable to TEVAR, which included 314 descending thoracic aortic aneurysms (DTAAs) and 105 extent I thoracoabdominal aortic aneurysms (TAAAs). One hundred eighty-five patients (44%) had a history of type A dissection, and 33 (7.9%) had a previous DTAA/TAAA repair. Variables were assessed with logistic regression for 30-day mortality and Cox regression for long-term mortality. Time-to-event analysis was performed using Kaplan-Meier methods. RESULTS: Thirty-day mortality was 8.4% (n = 36). In all, 22 patients (5.2%) developed motor deficit (paraplegia/paraparesis), and 17 (4.0%) experienced stroke. Multivariable analysis identified low estimated glomerular filtration rate (eGFR; <60 mL/min/1.73 m2), previous DTAA/TAAA repair, and chronic obstructive pulmonary disease (COPD) as associated with 30-day mortality. Patients without all 3 risk factors had a 30-day mortality rate of 2.6%. During a median follow-up of 6.5 years, 160 patients died. The survival rate was 81% at 1 year and 61% at 10 years. Cox regression analysis identified preoperative aortic rupture, eGFR <60 mL/min/1.73 m2, previous DTAA/TAAA repair, COPD, and age >60 years as predictive of long-term mortality. Forty-five patients required subsequent aortic procedures, including 8 reinterventions to the treated segment. Freedom from any aortic procedures was 85% at 10 years, and aortic procedure-free survival was 45% at 10 years. Hereditary aortic disease was the sole predictor for any aortic interventions (hazard ratio, 3.2; P = .004). CONCLUSIONS: Open surgical repair provided satisfactory low neurologic complication rates and durable repairs in chronic distal aortic dissection. Patients without low eGFR, redo, and COPD are the low-risk surgical candidates and may benefit from open surgical repair at centers with similar experience to ours. Patients with hereditary aortic disease warrant close surveillance.

16.
PLoS One ; 14(11): e0225204, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31725810

RESUMO

OBJECTIVE: Delirium is associated with poor outcomes among critically ill patients. However, it is not well characterized among patients with ischemic or hemorrhagic stroke (IS and HS). We provide the population-level frequency of in-hospital delirium and assess its association with in-hospital outcomes and with 30-day readmission among IS and HS patients. METHODS: We analyzed Nationwide in-hospital and readmission data for years 2010-2015 and identified stroke patients using ICD-9 codes. Delirium was identified using validated algorithms. Outcomes were in-hospital mortality, length of stay, unfavorable discharge disposition, and 30-day readmission. We used survey design logistic regression methods to provide national estimates of proportions and 95% confidence intervals (CI) for delirium, and odds ratios (OR) for association between delirium and poor outcomes. RESULTS: We identified 3,107,437 stroke discharges of whom 7.45% were coded to have delirium. This proportion significantly increased between 2010 (6.3%) and 2015 (8.7%) (aOR, 95% CI: 1.04, 1.03-1.05). Delirium proportion was higher among HS patients (ICH: 10.0%, SAH: 9.8%) as compared to IS patients (7.0%). Delirious stroke patients had higher in-hospital mortality (12.3% vs. 7.8%), longer in-hospital stay (11.6 days vs. 7.3 days) and a significantly greater adjusted risk of 30-day-readmission (16.7%) as compared to those without delirium (12.2%) (aRR, 95% CI: 1.13, 1.11-1.15). Upon readmission, patients with delirium at initial admission continued to have a longer length of stay (7.7 days vs. 6.6 days) and a higher in-hospital mortality (9.3% vs. 6.4%). CONCLUSION: Delirium identified through claims data in stroke patients is independently associated with poor in-hospital outcomes both at index admission and readmission. Identification and management of delirium among stroke patients provides an opportunity to improve outcomes.

17.
Nature ; 575(7781): 180-184, 2019 11.
Artigo em Inglês | MEDLINE | ID: mdl-31695210

RESUMO

Methane is a powerful greenhouse gas and is targeted for emissions mitigation by the US state of California and other jurisdictions worldwide1,2. Unique opportunities for mitigation are presented by point-source emitters-surface features or infrastructure components that are typically less than 10 metres in diameter and emit plumes of highly concentrated methane3. However, data on point-source emissions are sparse and typically lack sufficient spatial and temporal resolution to guide their mitigation and to accurately assess their magnitude4. Here we survey more than 272,000 infrastructure elements in California using an airborne imaging spectrometer that can rapidly map methane plumes5-7. We conduct five campaigns over several months from 2016 to 2018, spanning the oil and gas, manure-management and waste-management sectors, resulting in the detection, geolocation and quantification of emissions from 564 strong methane point sources. Our remote sensing approach enables the rapid and repeated assessment of large areas at high spatial resolution for a poorly characterized population of methane emitters that often appear intermittently and stochastically. We estimate net methane point-source emissions in California to be 0.618 teragrams per year (95 per cent confidence interval 0.523-0.725), equivalent to 34-46 per cent of the state's methane inventory8 for 2016. Methane 'super-emitter' activity occurs in every sector surveyed, with 10 per cent of point sources contributing roughly 60 per cent of point-source emissions-consistent with a study of the US Four Corners region that had a different sectoral mix9. The largest methane emitters in California are a subset of landfills, which exhibit persistent anomalous activity. Methane point-source emissions in California are dominated by landfills (41 per cent), followed by dairies (26 per cent) and the oil and gas sector (26 per cent). Our data have enabled the identification of the 0.2 per cent of California's infrastructure that is responsible for these emissions. Sharing these data with collaborating infrastructure operators has led to the mitigation of anomalous methane-emission activity10.

18.
Transplantation ; 2019 Sep 18.
Artigo em Inglês | MEDLINE | ID: mdl-31568395

RESUMO

BACKGROUND: While portal flow (PF) plays an important role in determining graft outcomes in living donor liver transplantation, its impact in deceased donor whole liver transplantation (DDLT) is unclear. The aim of this study was to investigate the correlations between graft PF and graft outcomes in DDLT. METHODS: We retrospectively investigated 1,001 patients who underwent DDLT between January 2007 and June 2017 at our institution. The patients were divided into three groups according to hazard ratio for one-year graft loss at each PF value, which was standardized with graft weight. Graft and recipient outcomes were compared between the groups. RESULTS: The low-PF group (PF < 65 mL/min/100g, n = 210, P = 0.011) and the high-PF group (PF > 155 mL/min/100g, n = 159, P = 0.018) showed significantly poorer one-year graft survival compared with the intermediate-PF group (PF > 65 mL/min/100g and < 155 mL/min/100g, n = 632). The patients in the low-PF group had severe reperfusion injury and were more frequently complicated with primary nonfunction (P = 0.013) and early allograft dysfunction (P < 0.001) compared with the other groups. In contrast, the patients in the high-PF group had milder reperfusion injury, but had lower intraoperative hepatic artery flow with higher incidence of hepatic artery thrombosis (P = 0.043) and biliary complication (P = 0.041) compared with the other groups. CONCLUSIONS: These results suggest that intraoperative PF plays an important role in determining early graft outcomes after DDLT.

19.
Clin Transplant ; 33(11): e13723, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31583762

RESUMO

OBJECTIVE: Portal vein thrombosis (PVT) does not preclude liver transplantation (LT), but poor portal vein (PV) flow after LT remains a predictor of poor outcomes. Given the physiologic tendency of the hepatic artery (HA) to compensate for low PV flow via vasodilation, we investigated whether adequate HA flow would have a favorable prognostic impact among patients with low PV flow following LT. METHODS: This study included 163 patients with PVT who underwent LT between 2004 and 2015. PV and HA flow were categorized into quartiles, and their association with 1-year graft survival (GS) and biliary complication rates was assessed. For both the HA and the PV, patients at the lowest two quartiles were categorized as having low flow and the remainder as having high flow. RESULTS: The median MELD score was 22 and 1-year GS was 87.3%. As expected, GS paralleled PV flow with patients at the lowest flow quartile faring the worst. In combination of PV and HA flows, high HA flow was associated with improved 1-year GS among patients with low PV flow (P = .03). Similar findings were observed with respect to biliary complication rates. CONCLUSIONS: Sufficient HA flow may compensate for poor PV flow. Consequently, meticulous HA reconstruction may be central to achieving optimal outcomes in PVT cases.

20.
Clin Transplant ; 33(12): e13743, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31655000

RESUMO

OBJECTIVE: The objective of this retrospective study was to characterize the neutrophil to lymphocyte ratio (NLR) on the waitlist and determine its prognostic utility in liver transplantation (LT) for hepatocellular carcinoma (HCC) with special focus on longitudinal data. Biomarkers such as pre-operative NLR have been suggested to predict poor oncological outcomes for patients with HCC seeking LT. NLR's utility is thought to be related to tumor biology. However, recent studies have demonstrated that a high NLR conveys worse outcomes in non-HCC cirrhotics. This study investigated the relationship between NLR, liver function, tumor factors and patient prognosis. METHODS: Patients with HCC undergoing LT were identified between 2002 and 2014 (n = 422). Variables of interest were collected longitudinally from time of listing until LT. The prognostic utility of NLR was assessed using Kaplan-Meier and Cox Proportional Hazard regression. Associations between NLR and MELD-Na, AFP, and tumor morphology were also assessed. RESULTS: NLR demonstrated a positive correlation with MELD-Na at LT (R2 = 0.125, P < 0.001) and had parallel trends over time. The lowest NLR quartile had a median MELD-Na of 9 while the highest had a median MELD-Na of 19. There were minimal differences in AFP, tumor morphology, and rates of vascular invasion between quartiles. NLR was a statistically significant predictor of OS (HR = 1.64, P = 0.017) and recurrence (HR = 1.59, P = 0.016) even after controlling for important tumor factors. However, NLR lost its statistical significance when MELD-Na was added to the Cox regression model (OS: HR = 1.46, P = 0.098) (recurrence: HR = 1.40, P = 0.115). CONCLUSIONS: NLR is a highly volatile marker on the waitlist that demonstrates a significant correlation and collinearity with MELD-Na temporally and at the time of LT. These characteristics of NLR bring into question its utility as a predictive marker in HCC patients.

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