Search

Background Current treatment of vulvovaginal candidiasis (VVC) is largely limited to azole therapy. Ibrexafungerp is a first-in-class triterpenoid antifungal with broad-spectrum anti-Candida fungicidal activity. The objective of this study was to evaluate the efficacy and safety of ibrexafungerp compared with placebo in patients with acute VVC. Methods Patients were randomly assigned 2:1 to receive ibrexafungerp (300 mg twice for 1 day) or placebo. The primary endpoint was the percentage of patients with a clinical cure (complete resolution of vulvovaginal signs and symptoms [VSS] = 0) at test-of-cure (day 11 ± 3). Secondary endpoints included the percentage of patients with mycological eradication, overall success (clinical cure and mycological eradication), clinical improvement (VSS ≤ 1) at test-of-cure, and symptom resolution at follow-up (day 25 ± 4). Results Patients receiving ibrexafungerp had significantly higher rates of clinical cure (50.5% [95/188] vs 28.6% [28/98]; P = .001), mycological eradication (49.5% [93/188] vs 19.4% [19/98]; P < .001), and overall success (36.0% [64/178] vs 12.6% [12/95]; P < .001) compared with placebo. Symptom resolution was sustained and further increased with ibrexafungerp compared with placebo (59.6% [112/188] vs 44.9% [44/98]; P = .009) at follow-up. Post hoc analysis showed similar rates of clinical cure and clinical improvement at test-of-cure for Black patients (54.8% [40/73] and 63.4% [47/73], respectively) and patients with a body mass index >35 (54.5% [24/44] and 68.2% [30/44], respectively) compared with overall rates. Ibrexafungerp was well tolerated. Adverse events were primarily gastrointestinal and mild in severity. Conclusions Ibrexafungerp provides a promising safe and efficacious oral treatment that mechanistically differs from current azole treatment options for acute VVC.

The quality of life literature revealed the role that natural resources and local consumption amenities play in household preferences for cities and their growing importance in determining the success of cities. As women's control over household resources has increased, a growing body of consumer behavior literature has been documenting gender differences in preferences for consumer goods. Yet, the quality of life literature does not seem to make any distinction along gender lines in determining preferences for local consumption amenities. We estimate the quality of life across US cities separately for unmarried men and women, and using a rich set of location‐specific amenities, examine which amenities cause preferences to differ between men and women. Our results suggest that men and women's valuations of cities are correlated, suggesting commonality in preferences for many location‐based amenities, most notably natural resources, but there are also important deviations in valuations especially for local public goods and gender role attitudes.

Cholangiocarcinoma is the second most common primary hepatic malignancy which accounts for 13% of total cancer mortality worldwide. Surgical resection is the only curative treatment for localized disease; however, the majority of patients present when the tumor is unresectable. The incidence of the intrahepatic subtype of cholangiocarcinoma is increasing worldwide. Current standard of care in patients with unresectable intrahepatic cholangiocarcinoma is systemic chemotherapy; however, yttrium-90 transarterial radioembolization (Y90-TARE) is under investigation for the treatment of intrahepatic cholangiocarcinoma with promising trials and published clinical experience. This review critically evaluates the role of Y90-TARE in the management of intrahepatic cholangiocarcinoma.

To prospectively validate electromagnetic hand motion tracking in interventional radiology to detect differences in operator experience using simulation.Sheath task: Six attending interventional radiologists (experts) and 6 radiology trainees (trainees) placed a wire through a sheath and performed a "pin-pull" maneuver, while an electromagnetic motion detection system recorded the hand motion. Radial task: Eight experts and 12 trainees performed palpatory radial artery access task on a radial access simulator. The trainees repeated the task with the nondominant hand. The experts were classified by their most frequent radial artery access technique as having either palpatory, ultrasound, or overall limited experience. The time, path length, and number of movements were calculated. Mann-Whitney U tests were used to compare the groups, and P.05 was considered significant.Sheath task: The experts took less time, had shorter path lengths, and used fewer movements than the trainees (11.7 seconds ± 3.3 vs 19.7 seconds ± 6.5, P.01; 1.1 m ± 0.3 vs 1.4 m ± 0.4, P.01; and 19.5 movements ± 8.5 vs 31.0 movements ± 8.0, P.01, respectively). Radial task: The experts took less time, had shorter path lengths, and used fewer movements than the trainees (24.2 seconds ± 10.6 vs 33.1 seconds ± 16.9, P.01; 2.0 m ± 0.5 vs 3.0 m ± 1.9, P.001; and 36.5 movements ± 15.0 vs 54.5 movements ± 28.0, P.001, respectively). The trainees had a shorter path length for their dominant hand than their nondominant hand (3.0 m ± 1.9 vs 3.5 m ± 1.9, P.05). The expert palpatory group had a shorter path length than the ultrasound and limited experience groups (1.8 m ± 0.4 vs 2.0 m ± 0.4 and 2.3 m ± 1.2, respectively, P.05).Electromagnetic hand motion tracking can differentiate between the expert and trainee operators for simulated interventional tasks.

Fibrolamellar hepatocellular carcinoma (FL-HCC) is a rare primary liver tumor that typically presents at an advanced stage in early adolescents and adults with no underlying liver disease. Surgical resection is the first-line treatment, and patients who are not surgical candidates face limited treatment options with poor long-term outcomes. Herein we report the first documented, technically successful treatment of FL-HCC with extrahepatic spread using transarterial radioembolization (TARE) in a 16-year-old male patient with surgically unresectable disease. Subsequent imaging revealed tumor necrosis and a 20% reduction in size, and the patient survived 20 months post-treatment, a marked improvement relative to historical data in the literature. Further research should examine the potential role of yttrium-90 TARE in the treatment of FL-HCC patients with metastatic disease.

To review the technical feasibility of resin microsphere (SIR-Spheres®) yttrium-90 radioembolization prescribed using the medical internal radiation dose (MIRD) model. All radioembolization procedures for hepatic malignancies using resin microspheres with MIRD model between November 2015 and February 2019 were included in this IRB-approved study (n = 60). Student’s T test was used to compare prescribed activity based on MIRD and BSA models. Adverse events were assessed immediately, 30 days, and 6 months post-treatment. Sixty radioembolizations were performed in 54 patients (age 68 ± 9 years, 48–87 years, 35% female). Mean prescribed activity calculated by the MIRD model (target absorbed dose 120–200 Gy for primary and 80–200 Gy for metastatic liver cancers) was 1.7 GBq (0.3–6.4) compared with 0.6 GBq (0.12–2.1) if BSA had been used (p

Retrospective. Utilize three-dimensional (3D) measurements to assess the relationship between thoracic scoliosis severity and thoracic kyphosis in a large, multicenter cohort, and determine impact of 3D measurements on adolescent idiopathic scoliosis (AIS) curve classification. Research has demonstrated differences in two-dimensional (2D) and 3D assessment of the sagittal plane deformity in AIS. A prior smaller, single-institution study demonstrated an association between scoliosis severity and loss of 3D thoracic kyphosis. Data included retrospective compilation of prospectively enrolled bracing candidates and prospectively enrolled surgical candidates with thoracic AIS. Analysis included two groups based on thoracic curve magnitude: moderate (20–45°) and severe (> 45°). Imaging was performed using 2D radiographs. 3D thoracic kyphosis was calculated using a 2D to 3D conversion formula. Kyphosis was categorized according to the Lenke classification sagittal plane modifier. Analysis included 3032 patients. 2D kyphosis was significantly less in the moderate group (21 ± 12 vs 23 ± 14, p = 0.028). However, estimated 3D kyphosis was significantly greater in the moderate group (13 ± 10 vs 5 ± 12, p

Summary Background Data on patients with COVID-19 who have cancer are lacking. Here we characterise the outcomes of a cohort of patients with cancer and COVID-19 and identify potential prognostic factors for mortality and severe illness. Methods In this cohort study, we collected de-identified data on patients with active or previous malignancy, aged 18 years and older, with confirmed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection from the USA, Canada, and Spain from the COVID-19 and Cancer Consortium (CCC19) database for whom baseline data were added between March 17 and April 16, 2020. We collected data on baseline clinical conditions, medications, cancer diagnosis and treatment, and COVID-19 disease course. The primary endpoint was all-cause mortality within 30 days of diagnosis of COVID-19. We assessed the association between the outcome and potential prognostic variables using logistic regression analyses, partially adjusted for age, sex, smoking status, and obesity. This study is registered with ClinicalTrials.gov, NCT04354701, and is ongoing. Findings Of 1035 records entered into the CCC19 database during the study period, 928 patients met inclusion criteria for our analysis. Median age was 66 years (IQR 57–76), 279 (30%) were aged 75 years or older, and 468 (50%) patients were male. The most prevalent malignancies were breast (191 [21%]) and prostate (152 [16%]). 366 (39%) patients were on active anticancer treatment, and 396 (43%) had active (measurable) cancer. At analysis (May 7, 2020), 121 (13%) patients had died. In logistic regression analysis, independent factors associated with increased 30-day mortality, after partial adjustment, were: increased age (per 10 years; partially adjusted odds ratio 1·84, 95% CI 1·53–2·21), male sex (1·63, 1·07–2·48), smoking status (former smoker vs never smoked: 1·60, 1·03–2·47), number of comorbidities (two vs none: 4·50, 1·33–15·28), Eastern Cooperative Oncology Group performance status of 2 or higher (status of 2 vs 0 or 1: 3·89, 2·11–7·18), active cancer (progressing vs remission: 5·20, 2·77–9·77), and receipt of azithromycin plus hydroxychloroquine (vs treatment with neither: 2·93, 1·79–4·79; confounding by indication cannot be excluded). Compared with residence in the US-Northeast, residence in Canada (0·24, 0·07–0·84) or the US-Midwest (0·50, 0·28–0·90) were associated with decreased 30-day all-cause mortality. Race and ethnicity, obesity status, cancer type, type of anticancer therapy, and recent surgery were not associated with mortality. Interpretation Among patients with cancer and COVID-19, 30-day all-cause mortality was high and associated with general risk factors and risk factors unique to patients with cancer. Longer follow-up is needed to better understand the effect of COVID-19 on outcomes in patients with cancer, including the ability to continue specific cancer treatments. Funding American Cancer Society, National Institutes of Health, and Hope Foundation for Cancer Research.

Surgical correction for AIS has evolved from all hooks to hybrids or all screw constructs. Limited literature exists reporting outcomes using PHDS for posterior spinal fusion (PSF). This is the largest series in evaluating results of PHDS technique. A retrospective review of consecutive AIS patients undergoing PSF by a single surgeon between 2006 and 2015 was performed. All eligible patients met a minimum 2-year follow-up. Patient demographics and radiographical parameters (radiographic shoulder height (RSH), T1 tilt, clavicle angle) at baseline, 6-week and 2-year post-operation were recorded. The primary outcome was difference in RSH from baseline measurements evaluated using repeated measures one-way analysis of variance with Bonferroni correction. A total of 219 patients (mean age at surgery: 13.68 years; 82% female) were included. The mean follow-up was 41.2 months (range 24–108 months). The RSH was significantly improved from − 14.7 ± 10.38 mm to 8.0 ± 6.9 mm (P

Background Despite widespread use of single-stage open reduction and pelvic osteotomy for treatment of developmental dysplasia of the hip (DDH) after walking age, this aggressive strategy remains controversial. We directly compared dislocated hips treated with closed reduction (CR) to those treated with open reduction and Salter innominate osteotomy (OR/IO) to estimate the relative hazard of total hip arthroplasty (THA) and the THA-free survival time. Methods In a series of patients 18 to 60 months of age, 45 patients (58 hips) underwent CR and 58 patients (78 hips) were treated with OR/IO and followed to a minimum 40 years post-reduction. Observations in the survival analysis were censored if no THA had occurred by 48 years. Multivariate Cox regression analysis was used to estimate the hazard of THA given treatment, age, and bilaterality. Complications and additional procedures were noted. Results At 48 years of follow-up, 29 (50%) of the hips survived after CR compared with 54 (69%) after OR/IO. At 45 years, the survival probability after OR/IO was 0.63 (95% confidence interval [CI] = 0.50 to 0.78) compared with 0.55 (95% CI = 0.43 to 0.72) after CR. The hazard ratio (HR) of THA was modeled as a function of treatment, age at reduction, and bilaterality. The effect of age and treatment on the outcome of hips in patients with unilateral involvement was minimal. However, age did significantly alter the relationship between treatment and outcome in bilateral cases. In the bilateral group, the predicted HR of THA was lower after CR in hips that were reduced at the age of 18 months (HR = 0.16, 95% CI = 0.04 to 0.64) but higher in those that were reduced at 36 months (HR = 4.23, 95% CI = 2.00 to 8.95). Additional procedures were indicated for 17% and 22% of hips after CR and OR/IO, respectively. Conclusions Osteoarthritis and THA was more likely after CR than OR/IO, but the data do not indicate a difference in unadjusted hip-survival time. In patients with bilateral disease, an older age at reduction was associated with an increased hazard of THA after CR than after OR/IO. Both treatments provided substantial benefit relative to the natural history of DDH, but THA is the expected outcome in middle adulthood. Level of evidence Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Background There are increased options to deliver thrombolytic treatment for acute, high-risk pulmonary embolism (PE). The goals of this study were to examine practice patterns of systemic thrombolysis and catheter-directed thrombolysis (CDT) and to compare outcomes following CDT with ultrasound facilitation (CDT-ultrasound) and CDT alone. Methods The study analyzed adults aged > 18 years with hospitalizations associated with acute PE and thrombolysis in the 2016 Nationwide Readmissions Database. The study identified characteristics associated with the use of systemic thrombolysis and CDT. Comparisons of CDT-ultrasound vs CDT alone were then made by evaluating in-hospital events and readmissions. The primary outcomes were in-hospital mortality and 30-day readmission rates. Results Among 5,436 hospitalizations, systemic thrombolysis was used more often (n = 3,376; 62.1%) than CDT (n = 2,060; 37.9%). Compared with CDT, systemic thrombolysis was used more frequently in patients with higher rates of vasopressor use (4.3% vs 1.0%), shock (15.8% vs. 6.9%), cardiac arrest (12.7% vs 3.4%), and mechanical ventilation (19.0% vs 5.9%). Among patients who underwent CDT, 417 (20.2%) received CDT-ultrasound, and 1,643 (79.8%) received CDT alone. Rates of bleeding events, vasopressor use, and mechanical ventilation were similar between therapeutic strategies. Following adjustment, in-hospital mortality (OR, 1.19; 95% CI, 0.63-2.26; P = .59) and 30-day readmission rates (OR, 0.75; 95% CI, 0.47-1.22; P = .25) were not significantly different between CDT-ultrasound and CDT alone. Conclusions Systemic thrombolysis is used more often than CDT in patients with acute PE, in particular among those with a greater prevalence of high-risk features. Among patients treated with CDT, there were no differences in events between CDT-ultrasound and CDT alone.

BACKGROUND Congenital myopathies (CMs) are complex conditions often associated with early-onset scoliosis (EOS). The purpose of this study was to investigate radiographic outcomes in CM patients undergoing EOS instrumentation as well as complications. Secondarily, we sought to compare these patients to a population with higher prevalence, cerebral palsy (CP) EOS patients. METHODS This is a retrospective study of a prospectively collected multicenter registry. The registry was queried for EOS patients with growth-sparing instrumentation (vertical expandable prosthetic titanium ribs, magnetically controlled growing rods, traditional growing rod, or Shilla) and a CM or CP diagnosis with minimum 2 years follow-up. Outcomes included major curve magnitude, T1-S1 height, kyphosis, and complications. RESULTS Sixteen patients with CM were included. Six (37.5%) children with CM experienced 11 complications by 2 years. Mean major curve magnitude for CM patients was improved postoperatively and maintained at 2 years (P 0.05). Ninety-seven patients with CP EOS were included as a comparative cohort. Fewer CP patients required baseline respiratory support compared with CM patients (20.0% vs. 92.9%, P

Venous leg ulcers (VLUs) affect as many as 20% of patients with advanced chronic venous insufficiency and are associated with significant morbidity and health care costs. VLUs are the most common cause of leg ulcers; however, other etiologies of lower extremity ulcerations should be investigated, most notably arterial insufficiency, to ensure appropriate therapy. Careful clinical examination, standardized documentation, and ultrasound evaluation are needed for diagnosis and treatment success. Reduction of edema and venous hypertension through compression therapy, local wound care, and treatment of venous reflux or obstruction is the foundation of therapy. As key providers in venous disease, interventional radiologists should be aware of current standardized disease classification and scoring systems as well as treatment and wound care guidelines for venous ulcers.

In a traditional view, the natural history of a condition or a disease tells us of the adult consequences of that entity, be it benign or otherwise. This knowledge then provides guidance as to who needs treatment, and allows us to assess whether our treatments alter an otherwise adverse natural history in a positive way without introducing iatrogenic complications. However, in the new paradigm for health care delivery of value-based care, we need to be able to express natural history in additional terms of burden of disease. This is something that lawmakers and people who pay for health care can understand and has a comparative value. It also serves as a benchmark to show the effectiveness of interventions aimed at reducing disease burden. In this paper, I will discuss why this POSNA symposium is important and make some recommendations on directions where we as individuals and as a professional society should be putting in our efforts and resources.

We examine the geographical and temporal effects of the technological changes that led to the U.S. shale oil and gas boom. We assess changes in U.S. county rates of entrepreneurship and survival rates of existing businesses across different industries in response to the innovations that led to energy development in counties with shale resources. We employ a panel difference-in-differences approach and rely on the geological determination of the location of shale resources and the unexpected innovation in shale extraction as our source of exogeneity. We find that temporal impacts obscure effects that would look small if we only examined average effects. Namely, new firm formation and sales initially decrease in boom regions, followed by a positive trend after the initial disruption. While new firm formation eventually recovers after many years, the overall impact on business dynamism is negative, suggesting that the areas most affected by this technological change may not benefit.

Purpose To investigate rates and causes of 30-day readmission for patients who undergo percutaneous transhepatic biliary drainage (PTBD) procedures. Materials and Methods In this retrospective study, PTBD procedures performed at a tertiary care institution (June 2008 to May 2013) were reviewed. For each patient, the first 30-day readmission was used to determine cause of readmission. Two interventional radiologists independently categorized causes for readmission as planned or unplanned, and unplanned causes as related to or unrelated to interventional radiology. Interventional radiology-related readmissions were categorized as potentially preventable or unpreventable. Factors associated with higher odds for 30-day readmission were identified with univariable and multivariable analysis. Results There were 266 procedures in 266 patients (mean age, 67 years; interquartile range, 57-76 years; 53.4% men). The cause of obstruction was malignant in 50.0% of patients (133 of 266). There were 122 of 266 patients (45.9%) readmitted within 30 days. Of these readmissions, 44 of 122 (36.1%) were planned and 78 of 122 (63.9%) were unplanned. A majority of unplanned readmissions (57 of 78; 73%) were related to interventional radiology. Of unplanned interventional radiology-related readmissions, 16% (nine of 57) were related to periprocedural complications and 51% (29 of 57) were considered preventable. At multivariable analysis, Medicaid insurance (odds ratio, 3.68; 95% confidence interval: 1.52, 9.99; P = .009) and bilateral PTBDs (odds ratio, 5.81; 95% confidence interval: 1.79, 18.90; P = .003) were associated with 30-day readmission. Conclusion Thirty-day readmissions after primary biliary drainage are common and a majority of unplanned readmissions are drain-related. Nearly half of unplanned interventional radiology-related readmissions are potentially preventable. © RSNA, 2018 See also the editorial by Nikolic in this issue.

Graduate medical education is predominantly based on a time-based apprenticeship model, with implied acquisition of proficiency after a pre-set amount of clinical exposure. While motion metrics have been used previously to measure skill performance indicators, these assessments have largely been performed on a summative scale to describe the performance of complete tasks or procedures. By segmenting performances of interest and assessing the essential elements individually, a more comprehensive understanding of the aspects in need of improvement for a learner can be obtained. The purpose of this review is to discuss technologies applicable to motion tracking, their benefits and limitations, approaches to data processing, and potential applications based on recent improvements in this technology. Objective analysis of motion metrics may improve educational standards of learning and efficiency by both standardizing the feedback process for trainees and reducing the volume of instructors required to facilitate practice sessions. With rigorous validation and standardization, motion metric assessment may also prove useful to demonstrate competency in technical procedures as part of a comprehensive certification process.

Introduction: Parents often access online resources to educate themselves when a child is diagnosed with developmental dysplasia of the hip (DDH). In order to be fully understood by the average adult American, online health information must be written at an elementary school reading level. It was hypothesized that current available online resources regarding DDH would score poorly on objective measures of readability (syntax reading grade-level), understandability (ability to process key messages), and actionability (providing actions the reader may take). It was additionally hypothesized that the readability, understandability, and actionability would not correlate with search rank. Methods: Patient education materials were identified utilizing two independent online searches of the term “DDH” utilizing a commonly used search ending. From the top 50 search results, websites were included if directed at educating patients/parents regarding DDH. News articles, non-text material (video), research and journal articles, industry websites, and articles not related to DDH were excluded. The readability of included resources was quantified using the Flesch-Kincaid Grade Level Index. The Patient Education Materials Assessment Tool (PEMAT) was used to assess understandability and actionability using a 0-100% scale for both measures of interest. Spearman’s rho was used to examine the association between a website’s average search rank (from first to last) and its readability, understandability, and actionability. Statistical significance was defined as p

PURPOSE To evaluate outcomes of patients with intrahepatic cholangiocarcinoma (iCCA) undergoing neoadjuvant yttrium-90 (90Y) transarterial radioembolization (TARE) with resin microspheres prescribed using the Medical Internal Radiation Dose (MIRD) model. MATERIALS AND METHODS This retrospective institutional review board-approved study included 37 patients with iCCA treated with 90Y-TARE from October 2015 to September 2020. The primary outcome was overall survival (OS) from 90Y-TARE. The secondary outcomes were progression-free survival (PFS), Response Evaluation Criteria In Solid Tumors 1.1 imaging response, and downstaging to resection. Patients with tumor proximity to the middle hepatic vein (

Much of the literature on cross-border migration has focused on the impact of immigration on receiving countries with less attention paid to the impact of emigration on sending countries. Ghosh and Weinstein provide an overview of the push and pull factors that play a role in the decision to emigrate. The chapter draws attention to the linkages between the underlying factors that cause emigration and the impact of emigration on sending countries. Though the global impact of international migration may be positive, the efficiency gains from labor mobility are not shared equally across countries or across regions within sending countries. By specifically examining provinces across China, Ghosh and Weinstein find that, while there are short-term effects from the loss of labor and brain drain, the long-term effects accrue via emigrant networks that can promote trade, foreign direct investment and entrepreneurial activities, remittances and possibly brain gain, if emigrants return to their native country. Still, emigration in China likely exacerbates inequality between wealthier coastal provinces and inland areas. The chapter concludes with a brief discussion of the policy implications of emigration.

When the COVID-19 pandemic began, formal frameworks to collect data about affected patients were lacking. The COVID-19 and Cancer Consortium (CCC19) was formed to collect granular data on patients with cancer and COVID-19 at scale and as rapidly as possible. CCC19 has grown from five initial institutions to 125 institutions with >400 collaborators. More than 5,000 cases with complete baseline data have been accrued. Future directions include increased electronic health record integration for direct data ingestion, expansion to additional domestic and international sites, more intentional patient involvement, and granular analyses of still-unanswered questions related to cancer subtypes and treatments.

Purpose: Surgery within radiated tissue is associated with increased complication rates. It is hypothesized that impaired wound healing may result from aberrant inflammatory responses that occur in previously radiated tissues. Previous work has demonstrated that the topical application of naturally occurring antigen α-gal (Galα1-3Galβ1-(3)4GlcNAc-R) nanoparticles (AGNs) within wounds accelerates macrophage recruitment and subsequent healing in both normal and diabetic wounds. Herein, we hypothesize that application of this antigen would similarly enhance wound healing in irradiated tissues. Methods: To simulate human physiology, α-1,3-galactosyltransferase knockout (KO) mice were exposed to the antigen to produce anti-α-gal antibodies (anti-Gal). Ten days prior to wounding, the dorsal skin was irradiated with 1 session of 40 Gy. Bilateral dorsal 6-mm splinted full-thickness wounds were created within the radiated skin and treated with 50 µL of AGNs (50 mg/mL) immediately after wounding and again on postoperative day 1. A control KO group underwent similar irradiation and wounding protocols but was treated with phosphate-buffered saline (PBS) vehicle. Wild-type (WT) mice, which do not produce anti-Gal, went through the same irradiation and wounding. Results: Histologic analysis demonstrated enhanced epithelial migration in the radiated/AGN-treated KO wounds, which was significantly elevated in comparison to radiated/PBS-treated KO wounds beginning by day 15 and continuing until the end of the study (p < 0.01). In WT mice, treatment with AGNs showed no effect on epithelial migration. Conclusions: Topical application of AGNs onto irradiated wounds significantly ameliorates the delayed wound healing classically seen in radiated skin and results in faster wound closure with only transient application.

BACKGROUND Capsular contracture following breast augmentation is prone to recurrence with conventional surgical therapy. Adding acellular dermal matrix improves results but significantly increases operating time and cost. This study tested a new treatment algorithm that uses acellular dermal matrix selectively to optimize success rates while minimizing its drawbacks. METHODS All patients surgically treated by the authors for Baker grade III/IV capsular contracture between 2007 and 2018 were included in this retrospective cohort study. Data were collected on patient, breast augmentation, capsular contracture, and surgical treatment characteristics, in addition to follow-up findings. Treatment success was defined as Baker grade II or better. RESULTS One hundred eighty patients underwent 217 surgical treatments for capsular contracture. Conventional treatment was used in 185 cases and acellular dermal matrix in 32. Twenty-six patients were treated for a second occurrence and four were treated for a third. The average follow-up was 2.4 years. Conventional treatment was successful in 72.5 percent of first occurrences, 62.5 percent of second occurrences, and 50.0 percent of third occurrences. Acellular dermal matrix was successful in 96.9 percent of cases. The odds of failure were increased by bilateral capsular contracture (3.9 times) and previous treatment failure (3.5 times). When acellular dermal matrix was used selectively for bilateral capsular contracture or in unilateral cases with a previous treatment failure, the overall treatment success rate improved to 85.6 percent compared with 64.2 percent when this algorithm was not followed (p < 0.001). CONCLUSION This study demonstrates that selective acellular dermal matrix use can increase success rate to over 85 percent in the overall treatment of capsular contracture, and to nearly 100 percent in individual cases.

Objective: To describe the outcomes with use of a combination of tocilizumab and methylprednisolone administered around the time of endotracheal intubation in patients with confirmed coronavirus disease 2019-associated hypoxemic respiratory failure requiring mechanical ventilation. Data Sources: Retrospective chart review. Study Selection/Data Extraction: Twenty-one consecutive patients with confirmed coronavirus disease 2019-associated hypoxemic respiratory failure requiring mechanical ventilation. Initial ventilator parameters were positive end-expiratory pressure 14 cm H2o and target plateau pressure 29 cm H2o to maximize lung recruitment. Methylprednisolone (125 mg every 6hr for 24 hr with tapering to 60 mg every 12 hr) was administered shortly after patients were intubated (median 11 hr after intubation). Data Synthesis: No patient in the cohort died while hospitalized (mortality, 0%; 95% CI, 0%–18%) and 18 patients have been discharged from the acute care setting. Twenty of 21 patients (95%) have been liberated from mechanical ventilation after a median duration of 8 days (range, 4–30 d). Following 48 hours of methylprednisolone, the A-a o2 gradient decreased from 455 ± 103 to 228 ± 109 mm Hg (difference 227 ± 108 mm Hg; p < 0.01). Conclusions: Our positive experience with tocilizumab in combination with methylprednisolone started early after endotracheal intubation may be one avenue for reducing the morbidity and mortality seen with severe coronavirus disease 2019 and merits further exploration in clinical studies.

OBJECTIVE. The purpose of this study was to investigate the causes and rates of 30-day readmission after transjugular intrahepatic portosystemic shunt (TIPS) at a single liver transplant center. MATERIALS AND METHODS. We reviewed 165 TIPS procedures performed between 2003 and 2013. After excluding patients who died during the index admission (n = 16), any readmission within 30 days of discharge was identified, and cause of readmission was determined. Causes were categorized as planned or unplanned and interventional radiology (IR)-related or IR-unrelated. Unplanned readmissions were independently categorized as preventable or unpreventable by two interventional radiologists. Discrepant opinions were resolved by consensus. Factors predictive of 30-day readmission were identified by univariate and multivariate analysis. RESULTS. The reviewed TIPS procedures were performed in 165 patients (mean age ± SD, 56 ± 11 years; 69% male, 31% female). TIPS were placed for ascites or hydrothorax in 82 patients (50%) and variceal bleeding in 83 patients (50%). The 30-day readmission rate was 21% (31/149). The most common causes for readmissions were ascites or hydrothorax (23%, 7/31) and hepatic encephalopathy (23%, 7/31). All 30-day readmissions were unplanned; 17 (55%) of them were potentially preventable. Of the 17 potentially preventable readmissions, five (29%) were IR-related and 12 (71%) were IR-unrelated. In IR-related readmissions, all patients presented with a recurrence of symptoms (rebleeding or ascites) and were found to have TIPS stenosis or occlusion. Mortality rates were similar between patients who were and were not readmitted (p = 0.23). On multivariate analysis, spontaneous bacterial peritonitis during the index admission was the only variable associated with 30-day readmission (odds ratio = 4.81, p = 0.02). CONCLUSION. Over half of 30-day readmissions after TIPS could have been prevented by early outpatient follow-up and intraprocedural technique to optimize stent landing zones.

STUDY DESIGN Comparative effectiveness study OBJECTIVE.: To evaluate factors leading to higher percentage of brace failures in a cohort of North American patients with adolescent idiopathic scoliosis relative to their peers in Italy. SUMMARY OF BACKGROUND DATA Studies of bracing in United States have shown worse outcomes than studies from European centers, possibly due to sample characteristics or treatment approaches. METHODS Sample: Braced patients, aged 10 to 15, Risser

Survey. Bracing is the mainstay of conservative treatment in Adolescent Idiopathic Scoliosis (AIS). The purpose of this study was to establish best practice guidelines (BPG) among a multidisciplinary group of international bracing experts including surgeons, physiatrists, physical therapists, and orthotists utilizing formal consensus building techniques. Currently, there is significant variability in the practice of brace treatment for AIS and, therefore, there is a strong need to develop BPG for bracing in AIS. We utilized the Delphi process and the nominal group technique to establish consensus among a multidisciplinary group of bracing experts. Our previous work identified areas of variability in brace treatment that we targeted for consensus. Following a review of the literature, three iterative surveys were administered. Topics included bracing goals, indications for starting and discontinuing bracing, brace types, brace prescription, radiographs, physical activities, and physiotherapeutic scoliosis-specific exercises. A face-to-face meeting was then conducted that allowed participants to vote for or against inclusion of each item. Agreement of 80% throughout the surveys and face-to-face meeting was considered consensus. Items that did not reach consensus were discussed and revised and repeat voting for consensus was performed. Of the 38 experts invited to participate, we received responses from 32, 35, and 34 for each survey, respectively. 11 surgeons, 4 physiatrists, 8 physical therapists, 3 orthotists, and 1 research scientist participated in the final face-to-face meeting. Experts reached consensus on 67 items across 10 domains of bracing which were consolidated into the final best practice recommendations. We believe that adherence to these BPG will lead to fewer sub-optimal outcomes in patients with AIS by reducing the variability in AIS bracing practices, and provide a framework future research. Level IV.

Background Proximal femoral growth disturbance (PFGD) can be the most devastating complication of the treatment of development dysplasia of the hip. The reported incidence ranges from 0% to 73%. The condition involves varying degrees of growth disturbances of the femoral capital epiphysis, the physeal plate or both. Purpose This manuscript will discuss normal growth and development of the hip, the blood supply to the upper end of the femur, pathological and radiographic changes, classifications used to describe PFGD and, most importantly, the potential causes of these growth disturbances and the authors’ strategies for avoiding PFGD.

The purpose of this article is to discuss the use, comparative efficacy, and general technical considerations of percutaneous ablation, alone or in combination with other therapies, for the treatment of hepatocellular carcinoma (HCC).Percutaneous ablation is a mainstay treatment for early-stage HCC, offering survival comparable to that of surgical resection for small lesions. It can act as a primary curative therapy or bridge therapy for patients waiting to undergo liver transplant. New ablation modalities and combining tumor ablation with other therapies, such as transarterial chemoembolization, can improve clinical outcomes and allow treatment of larger lesions. Combining thermal ablation with systemic chemotherapy, including immunotherapy, is an area of future development.

Many U.S. towns reportedly boomed after new technologies in oil and gas extraction led to rapid development of shale resources. Recent research on the expected economic impact mainly focused on the employment effects associated with new oil and gas jobs. Instead, our focus is on the impact of oil and gas industry growth on local earnings while paying attention to the spatial and sectoral effects and assessing whether an increase in earnings due to energy development seeps out due to the peculiarities of the industry. Our estimation results suggest that oil and gas earnings multipliers are modest and similar to oil and gas employment multipliers, with relatively large shares of the earnings leaving the county on average. Likewise, oil and gas multipliers tend to be smaller or comparable to the estimated multipliers for equal-sized shocks in the rest of the economy, suggesting that oil and gas is not a special industry case. Given the high wages in the sector (and potentially large royalty payments), these results may be surprising.

This review summarizes evidence developed at the University of Iowa concerning the management and outcomes of developmental dysplasia of the hip beginning with the observations and analyses of Dr Arthur Steindler in the early 1900s. The strong evidence-based practice tradition established by Steindler 100 years ago continues as we critically evaluate our procedures and patient outcomes, only altering approaches when warranted by strong personal and research evidence. Our practice continues to be conservative in that we strive to produce the best environment possible for the hip to develop on its own and operate only when less invasive methods have failed.

IMPORTANCE: It is unclear whether the timing of second stage pushing efforts affects spontaneous vaginal delivery rates and reduces morbidities. OBJECTIVE: To evaluate whether immediate or delayed pushing results in higher rates of spontaneous vaginal delivery and lower rates of maternal and neonatal morbidities. DESIGN, SETTING, AND PARTICIPANTS: Pragmatic randomized clinical trial of nulliparous women at or beyond 37 weeks’ gestation admitted for spontaneous or induced labor with neuraxial analgesia between May 2014 and December 2017 at 6 US medical centers. The interim analysis suggested futility for the primary outcome and recruitment was terminated with 2414 of 3184 planned participants. Follow-up ended January 4, 2018. INTERVENTIONS: Randomization occurred when participants reached complete cervical dilation. Immediate group participants (n = 1200) began pushing immediately. Delayed group participants (n = 1204) were instructed to wait 60 minutes. MAIN OUTCOMES AND MEASURES: The primary outcome was spontaneous vaginal delivery. Secondary outcomes included total duration of the second stage, duration of active pushing, operative vaginal delivery, cesarean delivery, postpartum hemorrhage, chorioamnionitis, endometritis, perineal lacerations (≥second degree), and a composite outcome of neonatal morbidity that included neonatal death and 9 other adverse outcomes. RESULTS: Among 2414 women randomized (mean age, 26.5 years), 2404 (99.6%) completed the trial. The rate of spontaneous vaginal delivery was 85.9% in the immediate group vs 86.5% in the delayed group, and was not significantly different (absolute difference, −0.6% [95% CI, −3.4% to 2.1%]; relative risk, 0.99 [95% CI, 0.96 to 1.03]). There was no significant difference in 5 of the 9 prespecified secondary outcomes reported, including the composite outcome of neonatal morbidity (7.3% for the immediate group vs 8.9% for the delayed group; between-group difference, −1.6% [95% CI, −3.8% to 0.5%]) and perineal lacerations (45.9% vs 46.4%, respectively; between-group difference, −0.4% [95% CI, −4.4% to 3.6%]). The immediate group had significantly shorter mean duration of the second stage compared with the delayed group (102.4 vs 134.2 minutes, respectively; mean difference, −31.8 minutes [95% CI, −36.7 to −26.9], P

Electrical storm (ES) is a potentially lethal syndrome defined as three or more sustained episodes of ventricular tachycardia or ventricular fibrillation within 24 h. There are multiple inciting factors for ES, one of which involves excess catecholamine (endogenous and exogenous) effects. Exogenous catecholamines used for hemodynamic support can paradoxically engender or exacerbate an underling arrhythmia leading to ES. We report on an 63-year-old man who presented for repair of an ascending aortic dissection. After cardiopulmonary bypass separation assisted with high-dose epinephrine, ES developed requiring over 40 defibrillatory shocks. The epinephrine infusion was held and within 5 min, the ES self-terminated. ES in the context of cardiovascular surgery with the use of epinephrine for hemodynamic support has not be previously reported. Clinicians need to be cognizant of the seemingly paradoxical effect of epinephrine to induce ES. Initial ES treatment involves acute stabilization (treating or removing exacerbating factors (i.e., excess catecholamines)).

In the presence of large bone defects, delayed bone union, or nonunion and fractures, bone reconstruction may be necessary. Different strategies have been employed to enhance bone healing among which the use of autologous platelet concentrates (APCs). Due to the high content of platelets and platelet-derived bioactive molecules (e.g., growth factors, antimicrobial peptides), they are promising candidates to enhance bone healing. However, both preclinical and clinical studies produced contrasting results, mainly due to a high heterogeneity in study design, objectives, techniques adopted, and outcomes assessed. The aim of the present systematic review was to evaluate the efficacy of APCs in animal models of bone regeneration, considering the possible factors that might affect the outcome. An electronic search was performed on MEDLINE and Scopus databases. Comparative animal studies with a minimum follow up of 2 weeks, at least five subjects per group and using APCs for regeneration of bone defects were included. Articles underwent risk of bias assessment and quality evaluation. Fifty studies performed on six animal species (rat, rabbit, dog, sheep, goat, mini-pig) were included. The present part of the review considers studies performed on small ruminants, dogs, and mini-pigs (14 articles). The majority of the studies were considered at low risk of bias. In general, APCs' adjunct positively affected bone regeneration. Animal species, platelet and growth factors concentration, type of bone defect and of platelet concentrate used seemed to influence their efficacy in bone healing. However, sound conclusions were not drawn since too few studies for each large-size animal model were included. In addition, characterization of APCs' content was performed only in a few studies. Further studies with a standardized protocol including characterization of the final products will provide useful information for translating the results to clinical application of APCs in bone surgery.

Background: Spinal muscular atrophy (SMA) is a progressive neuromuscular disease commonly including progressive scoliosis resulting in severe deformity and negatively affecting pulmonary function. Surgical correction and stabilization of this progressive deformity is generally recommended; however, the timing and method of surgical fixation remains controversial. Methods: Retrospective review of clinical, radiographic, and pulmonary function data from 16 children with SMA and surgically treated scoliosis between 1985 and 2013. Radiographic data included direct measures of major curve, coronal balance, pelvic obliquity, T1-T12 height, T1-S1 height, and T1-rod length. Estimations of rib collapse, thoracic cavity shape, and space-available-for-lung (T6:T12, width ratio; T6:T10, rib-vertebral-angle difference ratios; and lung height) were determined. Eleven patients were able to complete pulmonary function testing. Results were compared with published outcomes for growing rod constructs. Results: Posterior spinal fusion was performed at an average age of 9.8±3.6 years. The mean age at most recent follow-up was 19.4 years (range, 10 to 37 y), with a mean follow-up of 10.1 years (range, 3.1 to 26 y). Radiographic measurements improved from preoperative to latest follow-up as follows: major curve, 78±20 degrees to 27±24 degrees; coronal balance, 4.1±4.0 cm to 1.9±2.2 cm; pelvic obliquity (median), 23 to 5 degrees; T1-T12 height, 19±3 cm to 22±3 cm; T1-S1 height, 31±7 cm to 36±6 cm; T1-rod length, 0.8±1.1 cm (postop) to 2.8±1.6 cm (final); and space-available-for-lung ratio, 0.88±0.26 to 0.95±0.25. Rib collapse continued throughout the follow-up period in all but 1 patient. Pulmonary function testing demonstrated a decrease in rate of decline in forced vital capacity and forced expiratory volume when comparing preoperative with postoperative rates. Mean length of stay was 7.8±4.4 days. Complications included reintubation for low tidal volumes (n=1), pneumonia (n=1), superficial wound breakdown (n=1), and superficial infection (n=1). Conclusions: Definitive posterior spinal fusion for treatment of scoliosis associated with SMA is effective at controlling curve progression and pelvic obliquity without negatively impacting the space-available-for-lung ratio, trunk height, or pulmonary function at 10 years follow-up. Level of Evidence: Therapeutic Level IV.

Many chemical and physical modifications of titanium surfaces were introduced, aiming at improving surface bioactivity, but few comparative evidence exists.To evaluate histologically in minipigs the osseointegration of implants made of commercially pure (CP) titanium or titanium alloy, treated by different roughening procedures.Three sandblasted acid-etched (SA) surfaces, 2 anodized (AN), and 1 double acid-etched (DAE) were compared. Surface microtopography was characterized with scanning electron microscope; surface element composition was also assessed. One implant per group was inserted in each proximal tibia of 2 minipigs. Three months after healing, block biopsies were taken for histomorphometric analysis. Implant stability quotient (ISQ) was measured at insertion and before harvesting.The highest amount of cortical bone-implant contact was observed around SA implants and showed positive correlation with surface roughness. The greatest increase in ISQ was observed in CP-AN implants. In the medullary region, SA implants showed the best osteogenic response, whereas inflammatory cells were found around DAE and alloy-AN implants.SA surfaces were more osteogenic than anodized or dual acid-etched ones, although not significantly. Surface roughness affected osseointegration.

BACKGROUND Understanding national trends in the treatment of pediatric supracondylar humeral fractures will provide important insight into variations in regional treatment and identify areas for improving value and quality in care delivery in the U.S. METHODS U.S. national trends in the treatment of supracondylar humeral fractures were evaluated through query of the Humana (2007 to 2014) and ING (2007 to 2011) administrative claims databases. Geographic variation and changes in surgical and transfer rates over time were further explored through the Nationwide Emergency Department Sample (NEDS) database (2006 to 2011). Hospital characteristics impacting treatment decisions were identified. RESULTS A total of 29,642 pediatric patients with supracondylar humeral fractures were identified in the administrative claims databases and a projected 63,348 encounters for supracondylar humeral fracture were identified in the NEDS database. The majority of the patients (76.1%; 22,563 of 29,642) were treated definitively with cast immobilization. Operative treatment was performed in 23.9% of the patients (7,079 of 29,642), with no change observed in the operative rate over time (p = 0.055). Of patients undergoing operative treatment, closed reduction and percutaneous pinning (CRPP) was performed in 87.3%, with a significant increase noted in the rate of CRPP over time (p = 0.0001); open reduction was performed in 12.7%, with a significant decrease noted in the rate of open reduction over time (p < 0.0001). Regional surgical rates generally showed significant variation from 2006 to 2010, followed by a convergence in the surgical rate among all geographic regions in 2011. These trends occurred simultaneous to a significant increase in transfer rates nationwide, from 5.6% in 2006 to 9.1% in 2011 (p = 0.0011). Transfer rates were significantly higher (p < 0.0001) for nontrauma, nonteaching, and nonmetropolitan centers while surgical rates were significantly higher (p < 0.0001) for trauma, teaching, and metropolitan centers when rates were analyzed by hospital designation. CONCLUSIONS Operative treatment was performed in 24% of pediatric patients with supracondylar humeral fractures from 2007 to 2014. There was a convergence of surgical rates across geographic regions, suggesting that a "standard of care" in the treatment of supracondylar humeral fractures is being established nationally. CLINICAL RELEVANCE Cases of pediatric supracondylar humeral fracture are increasingly being transferred to and, when managed surgically, receiving care at metropolitan facilities designated as trauma centers or teaching hospitals, with a corresponding decrease observed in the rate of open reduction. The optimization of nationwide referral and treatment patterns may improve value in care delivery.

More than 100 MRIs per 1000 inhabitants are performed in the United States annually, more than almost every other country. Little is known regarding the cost of obtaining an MRI and factors associated with differences in cost. By surveying all hospital-owned and independent imaging centers in Iowa, we wished to determine (1) the cost to the consumer of obtaining a noncontrast shoulder MRI, (2) the frequency and magnitude of discounts provided, and (3) factors associated with differences in cost including location (hospital-owned or independent) and Centers for Medicare & Medicaid Services designation (rural, urban, and critical access). There were 71 hospitals and 26 independent imaging centers that offered MRI services in Iowa. Each site was contacted via telephone and posed a scripted request for the cost of the technical component of a noncontrast shoulder MRI. Radiologists’ reading fees were not considered. Statistical analysis was performed using standard methods and significance was defined as a probability less than 0.05. The mean technical component cost to consumers for an MRI was USD 1874 ± USD 694 (range, USD 500-USD 4000). Discounts were offered by 49% of imaging centers, with a mean savings of 21%. Factors associated with increased cost include hospital-owned imaging centers (USD 2062 ± USD 664 versus USD 1400 ± USD 441 at independent imaging centers; p