Search

Background: Vertebral body tethering (VBT) is a well-recognized, non-fusion alternative for idiopathic scoliosis in children with growth remaining. To date, there have been almost no published outcome studies with postoperative follow-up of >2 years. We aimed to fill this gap by evaluating mid-term outcomes in our first 31 consecutive patients. Methods: We retrospectively assessed additional clinical and radiographic data (mean, 5.7 ± 0.7 years) from our first 31 consecutive patients. Assessments included standard deformity measures, skeletal maturity status, and any additional complications (e.g., suspected broken tethers or surgical revisions). Using the same definition of success (i.e., all residual deformities, instrumented or uninstrumented, £30° at maturity; no posterior spinal fusion), we revisited the success rate, revision rate, and suspected broken tether rate. Results: Of our first 31 patients treated with VBT, 29 (of whom 28 were non-Hispanic White and 1 was non-Hispanic Asian; 27 were female and 2 were male) returned for additional follow-up. The success rate dropped to 64% with longer follow-up as deformity measures increased, and the revision rate increased to 24% following 2 additional surgical revisions. Four additional suspected broken tethers were identified, for a rate of 55%, with only 1 occurring beyond 4 years. No additional patients had conversion to a posterior spinal fusion. We observed a mean increase of 4° (range, 2° to 8°) in main thoracic deformity measures and 8° (range, 6° to 12°) in thoracolumbar deformity measures. Conclusions: With >5 years of follow-up, we observed a decrease in postoperative success, as progression of the deformity was observed in most subgroups, and an increase in the revision and suspected broken tether rates. No additional patients had conversion to a posterior spinal fusion, which may indicate long-term survivorship. [ABSTRACT FROM AUTHOR]

BACKGROUND: It is established that the immune system, namely T cells, plays a role in the development of hypertension and renal damage in male Dahl salt-sensitive (SS) rats, but far less is known about this relationship in females. Rats with genetically deleted T cells via CD247 gene mutation on the Dahl SS background (SSCD247−/−) were utilized to interrogate the effect of sex and T cells on salt sensitivity. METHODS: We assessed the hypertensive and kidney injury phenotypes in male versus female SS and SSCD247−/− rats challenged with 3 weeks of high salt (4. 0% NaCl). Differences in T cell activation genes were examined in renal T cells from male and female SS rats, and a sex-specific adoptive transfer was performed by injecting male or female splenocytes into either male or female SSCD247−/− recipients to determine the potential contribution of T cell sex. RESULTS: The lack of functional T cells in SSCD247−/− rats significantly reduced salt-induced hypertension and proteinuria in both sexes, although SSCD247−/− females exhibited greater protection from kidney damage. Adoptive transfer of either Dahl SS male or female splenocytes into SSCD247−/− male recipients exacerbated hypertension and proteinuria compared with controls, while in SSCD247−/− female recipients, exacerbation of disease occurred only upon transfer of male, but not female, SS splenocytes. CONCLUSIONS: The absence of T cells in the SSCD247−/− normalized sex differences in blood pressure, though sex differences in renal damage persisted. Splenocyte transfer experiments demonstrated that salt sensitivity is amplified if the sex of the T cell or the recipient is male. [ABSTRACT FROM AUTHOR]

Background: Many medications are low-risk but must undergo the same ordering process as high-risk medications in the inpatient setting. Nurses identify the need for supportive medications and notify providers. An order panel and policy were developed to allow nurses to order low-risk, supportive medications. Purpose: The aim of this study was to increase order panel utilization from a 6% to a goal of 15%. Methods: This was a quality improvement study at a 1000-bed academic medical center. Five plan-do-study-act (PDSA) cycles were implemented. The primary end point was order panel utilization, and secondary end points were individual nursing unit utilization and the number of orders for each medication on the panel. Results: After each PDSA cycle, order panel utilization improved to 7.8%, 13.2%, 7.5%, 10.2%, and 10.6%, respectively. The units using the order panel most often were general medicine (n = 95, 28%), medical intensive care (n = 71, 21%), and inpatient oncology (n = 40, 12%). The medication most frequently ordered was lanolin alcohols–mineral oil with petrolatum (Eucerin) cream (n = 220, 28%). Conclusions: Order panel utilization improved from a baseline of 6% to an average of 9.9%. Increasing awareness of the order panel and adding medications will contribute to improvement in order panel utilization in the long-term. [ABSTRACT FROM AUTHOR]

Background: The evidence base for the benefits of β-blockers in heart failure with reduced ejection fraction (HFrEF) suggests that higher doses are associated with better outcomes. Objectives: The aim of this study was to report the proportion of patients receiving optimized doses of β-blockers, outcomes, and factors associated with suboptimal dosing. Methods: This was a prospective cohort study of 390 patients with HFrEF undergoing clinical and echocardiography assessment at baseline and at 1 year. Results: Two hundred thirty-seven patients (61%) were receiving optimized doses (≥5-mg/d bisoprolol equivalent), 72 (18%) could not be up-titrated (because of heart rate < 60 beats/min or systolic blood pressure <100 mm Hg), and the remaining 81 (21%) should have been. Survival was similarly reduced in those who could not and should have been receiving 5 mg/d or greater, and patient factors did not explain the failure to attain optimized dosing. Conclusions: Many patients with HFrEF are not receiving optimal dosing of β-blockers, and in around half, there was no clear contraindication in terms of heart rate or blood pressure. [ABSTRACT FROM AUTHOR]

The high-dimensional propensity score is a semiautomated variable selection algorithm that can supplement expert knowledge to improve confounding control in nonexperimental medical studies utilizing electronic healthcare databases. Although the algorithm can be used to generate hundreds of patient-level variables and rank them by their potential confounding impact, it remains unclear how to select the optimal number of variables for adjustment. We used plasmode simulations based on empirical data to discuss and evaluate data-adaptive approaches for variable selection and prediction modeling that can be combined with the high-dimensional propensity score to improve confounding control in large healthcare databases. We considered approaches that combine the high-dimensional propensity score with Super Learner prediction modeling, a scalable version of collaborative targeted maximum-likelihood estimation, and penalized regression. We evaluated performance using bias and mean squared error (MSE) in effect estimates. Results showed that the high-dimensional propensity score can be sensitive to the number of variables included for adjustment and that severe overfitting of the propensity score model can negatively impact the properties of effect estimates. Combining the high-dimensional propensity score with Super Learner was the most consistent strategy, in terms of reducing bias and MSE in the effect estimates, and may be promising for semiautomated data-adaptive propensity score estimation in high-dimensional covariate datasets. [ABSTRACT FROM AUTHOR]

Objective: The aim of this study is to compare surgical outcomes of international medical graduates (IMGs) and United States medical graduates (USMGs). Summary of Background Data: IMGs represent 15% of practicing surgeons in the United States (US), and their training pathways often differ substantially from USMGs. To date, differences in the clinical outcomes between the 2 cohorts have not been examined. Methods: Using a unique dataset linking AMA Physician Masterfile data with hospital discharge claims from Florida and New York (2008-2011), patients who underwent 1 of 32 general surgical operations were stratified by IMG and USMG surgeon status. Mortality, complications, and prolonged length of stay were compared between IMG and USMG surgeon status using optimal sparse network matching with balance. Results: We identified 972,718 operations performed by 4581 surgeons (72% USMG, 28% IMG). IMG and USMG surgeons differed significantly in demographic (age, gender) and baseline training (years of training, university affiliation of training hospital) characteristics. USMG surgeons performed complex procedures (13.7% vs 11.1%, P < 0.01) and practiced in urban settings (79.4% vs 75.6%, P < 0.01) more frequently, while IMG surgeons performed a higher volume of studied operations (50.7 ± 5.1 vs 57.8 ± 8.4,P < 0.01). In the matched cohort analysis of 396,810 patients treated by IMG and USMG surgeons, rates of mortality (USMG: 2.2%, IMG: 2.1%; P < 0.001), complications (USMG: 14.5%, IMG: 14.3%; P = 0.032), and prolonged length of stay (pLOS) (USMG: 22.7%, IMG: 22.8%; P = 0.352) were clinically equivalent. Conclusion: Despite considerable differences in educational background, surgical training characteristics, and practice patterns, IMG and USMG-surgeons deliver equivalent surgical care to the patients whom they treat. [ABSTRACT FROM AUTHOR]

The article presents a study which carried out large-scale gene expression analysis of human atherosclerotic lesions. The examination of plaques from patients with peripheral artery disease identified a robust gene signature that is dominated by processes related to Toll-like receptor signaling, T-cell activation, and cholesterol efflux, among others. The researchers also developed an inflammatory composite score.