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Context: As blood flow restriction gains popularity across different populations (eg, young and older adults) and settings (eg, clinical and sports rehabilitation), the accuracy of blood flow restricted percentage becomes crucial. We aimed to compare manually measured arterial occlusion pressure (AOP) among young adults to understand whether lower limb composition affects the pressure required to achieve AOP. The results will shed light on the adequacy of published calculations used to estimate AOP in practical and research settings. Design: An observational cross-sectional study design was implemented to examine the relationship between lower limb composition, lower limb circumference, and measured AOP. Methods: Twenty-two participants (12 males, 26 [4] y, 1.74 [0.07] m, 73.2 [12.5] kg) underwent a whole-body Dual-energy X-ray Absorptiometry scan before AOP (in millimeters of mercury) and lower limb circumference (in centimeters) were determined. In a supine position, a 10-cm wide cuff was manually inflated on the dominant leg to the point where a pulse could no longer be detected by a Doppler ultrasound of the posterior tibial artery to determine AOP. Lower limb composition (fat, muscle, and bone mass [in grams]) was obtained from the Dual-energy X-ray Absorptiometry scan. Results: Lower limb muscle mass had a moderate negative relationship with AOP (r2 =.433, β = −0.004) and a moderate positive relationship with lower limb circumference (r2 =.497, β = 0.001). Lower limb circumference had the weakest relationship with AOP (r2 =.316, β = 0.050) of all measures. Conclusions: The reported relationships between lower limb muscle mass, lower limb circumference, and AOP suggest that as muscle mass increases, lower limb circumference also increases, yet AOP decreases. This implies that limb circumference should not be used as the primary measure for calculating AOP within the sampled population. We recommend individually measuring AOP when implementing blood flow restriction in all exercise modalities. [ABSTRACT FROM AUTHOR]

A total of 57 interproximal restorations invading the supracrestal tissue attachment were evaluated in terms of crestal bone loss over a mean period of 15 years (10 to 23 years). The distance from the cavity margin to the bone was measured at T0 (after the restoration; baseline) and controlled using radiographs and a measurable landmark. The mean vertical bone loss was 0.46 mm, with a 96.49% survival rate. Smoking habits (P = .02) and tooth type (P = .03) significantly affected bone loss. The proposed technique could help the clinician in adopting a minimally invasive approach in the treatment of heavily compromised teeth. Future research with rigorous study designs would be interesting to guide the clinical decision-making. [ABSTRACT FROM AUTHOR]

Purpose: To compute reference centiles for 5- and 30-m sprint times relative to chronological and skeletal age in youth soccer players. Subsequently, to compare individual's sprint performance scores derived from the chronological and skeletal age reference centiles. Methods: Sprint times were collected for a sample of male U11 to U19 soccer players (n = 1745 data points). Skeletal age data were available for a subsample (n = 776 data points). Reference centiles were fitted using generalized additive models for location, scale, and shape. Individual z scores relative to chronological and skeletal age reference centiles were computed and compared for each maturity group (late, on-time, early, and very early) using standardized mean differences (SMD). Results: Reference centiles for chronological age increased more rapidly between 10.5 and 15.5 years, while reference centiles for skeletal age increased more rapidly between 13.0 and 16.5 years. Differences in chronological and skeletal z scores for very early (SMD: −0.73 to −0.43) and late (SMD: 0.58 to 1.29) maturing players were small to large, while differences for early (SMD: −0.30 to −0.19) and on-time (SMD: 0.16 to 0.28) were trivial to small. Conclusion: Reference centiles provide a valuable tool to assist the evaluation of sprint performance in relation to chronological and skeletal age for talent identification purposes in youth soccer players. [ABSTRACT FROM AUTHOR]

Purpose: Travel fatigue impacts cognitive and physiologic systems, but its association with elite soccer match performance is unclear. In this retrospective observational study, we aimed to explore the association between travel and match outcomes in elite North American soccer. Methods: Travel data and match outcomes (team points or goals scored and conceded) and physical performance outcomes from 26 elite professional soccer teams and their players were analyzed (148 matches [team-based data] and 1252 player matches from 297 players; age 22.7 [4.5] y). Player- and match-level correlations between performance measures and both acute and cumulated travel metrics were analyzed. Results: Cumulative travel metrics were positively associated with team (travel distance [r =.20; 95% CI,.03–.25], travel time [r =.20;.06–.37], and time away [r =.20;.06–.37]) and individual player (travel distance, [r =.14;.08–.19], travel time [r =.17–.23], and time away [r =.13;.07–.18]) high-intensity running. Cumulative time away was negatively associated with team points (r = −.14; −.28 to −.001) and positively associated with goals conceded (r =.14;.01–.27); no clear association between acute travel metrics and match outcomes or physical performance was observed. Conclusions: As travel cumulated, away teams and their players ran more but for less reward (team points), although the magnitude of these associations was small. These data are exploratory and do not imply a causal relationship; however, further research should consider cumulation of travel. [ABSTRACT FROM AUTHOR]

Purpose: To compare designs of training sessions applied by world-class cross-country skiers during their most successful junior and senior season. Methods: Retrospective analysis of self-reported training characteristics (ie, training form, intensity, and exercise mode) among 8 male and 7 female world-class cross-country skiers was conducted. Results: Total number of sessions (441 [71] vs 519 [34], P <.001, large effect) and mean duration (1.5 [0.1] h vs 1.7 [0.1] h, P <.001, moderate effect) increased from junior to senior age. More double-session days were performed at senior age (124 [50] vs 197 [29] d, P <.001, large). The number (310 [64] vs 393 [64], P <.001, large effect) and duration (1.3 [0.1] h vs 1.5 [0.1] h, P <.001, moderate effect) of low-intensity training sessions increased from junior to senior age. Regarding intensive training, most emphasis was put on high-intensity training sessions lasting 20 to 39 minutes with <5-minute intervals at junior age, while 40 to 59 minutes of moderate-intensity training with 5- to 9-minute intervals was predominant at senior age. More MIXED (combined moderate- and high-intensity) sessions (9 [7] vs 14 [7], P =.023, moderate effect) and longer races (0.5 [0.1] h vs 0.6 [0.1] h, P = 0.29, moderate effect) compensated for fewer high-intensity training sessions at senior age (36 [17] vs 25 [10], P =.027, moderate effect). Duration of strength-training sessions increased significantly (0.6 [0.1] vs 0.8 [0.2] h, P = 0.30, moderate effect), while other training forms remained unchanged. Conclusions: World-class cross-country skiers increased their training volume from junior to senior age primarily by more and longer low-intensity training sessions and more often training twice per day. Concurrently, the most frequent intensive sessions were modified from high- to moderate-intensity training, lasted longer, and contained longer intervals. [ABSTRACT FROM AUTHOR]

This study compared the survival, marginal bone loss (MBL), and prosthetic complications of 4.5-mm extra-short implants and longer implants splinted to the short implants via the restoration. A retrospective controlled cohort study was performed. The 4.5-mm extra-short group (study group; SG) included 48 consecutively placed implants. The control group (CG) included 48 implants splinted to the extra-short implants. The same surgical team treated the 39 included patients, and all implants were restored with a screw-retained fixed restoration and intermediate abutments. Immediate and conventionally loaded implants were included. All implants were in function during the follow-up period (14 ± 3.4 and 17 ± 13 months for SG and CG, respectively). No differences in technical complications were observed between the groups (one and two cases of screw loosening for SG and CG, respectively; two provisional prosthesis fractures for SG; P = .310). Marginal bone stability was similar for SG and CG at the mesial level (-0.01 ± 0.28 mm for SG vs -0.18 ± 0.72 mm for CG; P = .270) and at the distal level (0.02 ± 0.39 mm for SG vs -0.18 ± 0.68 mm for CG; P = .076). The same good clinical performance could be observed for 4.5-mm implants and longer implants under the same prosthesis. [ABSTRACT FROM AUTHOR]

Objective: This study aimed to provide a comprehensive case analysis from a single center, with the objective of clarifying the optimal timing and recommendations for a preferred treatment strategy customized to the specific presentation of each type of supernumerary tooth identified in the research. Method and materials: A retrospective study was conducted on patients who presented with a supernumerary tooth and were treated interdisciplinarily at the clinic. Results: In total, 55 patients with 81 supernumerary teeth of the permanent dentition were analyzed, 30 males and 25 females. The dentition status of the patients was as follows: 31 patients with mixed dentition, no patients with primary dentition, and 24 patients with permanent dentition. The diagnosis of supernumerary tooth was primarily made by general or pediatric dental practitioners and/or orthodontists. Patients were then referred to maxillofacial surgeons for treatment decision. The timing of treatment was mainly determined by the oral surgeon, based on the recommendations of the other specialists involved. Cases involving maleruption or malalignment of permanent teeth required both surgical and orthodontic treatment. Patients over 9 years old were treated either under local anesthesia or sedation, whereas those under 9 years old were treated under deep sedation or general anesthesia. A comprehensive investigation of cases involved the utilization of CBCT at the supernumerary tooth site to facilitate treatment planning. There was a significant correlation between younger age and the preference for treatment under sedation or general anesthesia (P = .01, t test). Similarly, a strong association was found between younger age and the need for additional orthodontic treatment (P = .016, t test). Cases of surgical removal of a supernumerary tooth at a young age typically did not require orthodontic traction of the permanent tooth, in contrast to cases of late surgical intervention (patients over 11 years old), which often did necessitate such traction. There was a strong tendency for treating supernumerary teeth in the maxilla. The proximity of supernumerary teeth to vital anatomical landmarks significantly influenced treatment decisions. Patients with supernumerary teeth near the mental foramen or the inferior dental canal in the premolar area were exclusively placed under follow-up care (P = .002, Pearson chi-square test). However, in the maxilla, the proximity of supernumerary teeth to vital structures such as the floor of the nose and the incisive nerve did not affect the treatment approach, and those supernumerary teeth were mostly removed. Conclusions: A team approach for managing supernumerary teeth is recommended. The timing of treatment should carefully consider the advantages and disadvantages of early versus late intervention. Early surgical treatment in cases where eruption is disturbed might result in spontaneous eruption, eliminating the need for orthodontic traction of the permanent teeth. [ABSTRACT FROM AUTHOR]

Objective: Periodontal disease is caused by subgingival bacteria that adversely affect the host immune system and create and maintain unmitigated inflammation in gingival and periodontal tissues. The condition is also linked to systemic conditions including cardiovascular disease, diabetes, and arthritis. Periodontitis elevates the bacterial load and spreads systemic inflammation through infection and inflammation. The main radiographic sign of periodontitis is marginal bone loss. Risk factors, including medications, smoking, age, and sex, are known to influence periodontal health. However, there is little information about the impact of systemic conditions and medications on tooth wear. The aim of the present study was to assess the association between systemic conditions and medications and radiographic signs of tooth wear and marginal bone loss. Method and materials: This retrospective analysis was conducted on a group of 2,223 consecutive patients who came for dental treatment in the clinics of a large Health Maintenance Organization in Israel. Data available for the study included details of concomitant systemic diseases and medication and fullmouth radiographic surveys. Odds ratio and logistic regression analysis were used to detect associations between systemic conditions and medication, and marginal bone loss and tooth wear. Results: The results indicated an elevated odds ratio for tooth wear associated with age, sex, and smoking across all age groups. Among young patients, those using proton pump inhibitors and psychiatric medications had an elevated risk of tooth wear. Age, smoking, and diabetes conditions were associated with an increased odds ratio for marginal bone loss in all age groups. Psychiatric medications and sex elevated the odds ratio for marginal bone loss only among older patients. Conclusion: The results highlight the significant impact of age, sex, and smoking on tooth wear, and extend these risks to alveolar bone loss when combined with diabetes and psychiatric conditions. [ABSTRACT FROM AUTHOR]

Purpose: To explore how the change-point method can be used to analyze complex longitudinal data and detect when meaningful changes (change points) have occurred during rehabilitation. Method: This design is a prospective single-case observational study of a football player in a professional club who sustained an acute lower-limb muscle injury during high-speed running in training. The rehabilitation program was entirely completed in the football club under the supervision of the club's medical team. Four wellness metrics and 5 running-performance metrics were collected before the injury and until the player returned to play. Results: Data were collected over 130 days. In the univariate analysis, the change points for stress, sleep, mood, and soreness were located on days 30, 47, 50, and 50, respectively. The change points for total distance, acceleration, maximum speed, deceleration, and high-speed running were located on days 32, 34, 37, 41, and 41, respectively. The multivariate analysis resulted in a single change point for the wellness metrics and running-performance metrics, on days 50 and 67, respectively. Conclusions: The univariate approach provided information regarding the sequence and time point of the change points. The multivariate approach provided a common change point for multiple metrics, information that would benefit clinicians to have a broad overview of the changes in the rehabilitation process. Clinicians may consider the change-point method to integrate and visualize data from multiple sources to evaluate athletes' progression along the return-to-sport continuum. [ABSTRACT FROM AUTHOR]

Context: The hip adductor and abductor muscles play vital roles as stabilizers in the lower-extremity. Their activation during soccer-specific actions is essential, but local muscular fatigue can hinder athletic performance and increase the risk of injury. Design: This study aimed to observe the variations in frontal plane hip strength in female college soccer players before and after a high-workload soccer-specific training session. Furthermore, the study sought to compare the relative changes in hip strength with the internal and external load measures obtained during that session. Methods: Twenty female college soccer players participated in a retrospective observational study. Isometric hip adductor and abductor strength were measured before and after a training session in the college spring season. Measurements were taken with a handheld dynamometer (MicroFET 2) while the players were supine. Global positioning system sensors (Catapult Vector S7), commonly worn by players during training sessions and competitive matches, were used to measure external and internal loads. Statistical analyses were performed using paired samples t test to assess hip adductor and abductor strength changes before and after the training session. Spearman rank was used to identify correlation coefficients between global positioning system data and isometric hip strength. Results: The findings revealed significant decreases in the strength of the right hip adduction (P =.012, −7% relative change), right abduction (P =.009, −7.6% relative change), and left abduction (P =.016, −4.9% relative change) after the training session. Furthermore, relative decreases in hip isometric adduction and abduction strength are related to the distance covered at high speeds. Conclusion: The results of this study highlight that hip isometric adduction and abduction strength tend to decrease after exposure to high workloads during soccer-specific training. [ABSTRACT FROM AUTHOR]

Purpose: To compare the standard Yo-Yo intermittent recovery (IR) test and an agility Yo-Yo IR test with a higher number of change-of-direction movements to cardiorespiratory match performance. Methods: The study included 11 professional male handball players (age 24.5 [4.6] y) of a German second-league team. The performance parameters of the players of the seasons 2016–17 to 2018–19 were analyzed. The Yo-Yo IR test was compared to a Yo-Yo IR test with multiple multidirectional changes of direction in response to visual stimuli, which was conducted on a SpeedCourt (Yo-Yo SC IR). Peak oxygen uptake (VO2peak) and maximum heart rate (HRmax) were measured. Between-methods differences of individual athletes were quantified with Bland–Altman plots. Results: HRmax was not statistically different during the Yo-Yo SC IR test compared to the Yo-Yo IR test (181 [10] vs 188 [8] beats·min−1; P =.16). Agreement between the 2 tests was moderate for HRmax and good for heart rates >180 beats·min−1. Mean average VO2peak was 51.7 (3.9) and 50.9 (2.8) mL·min–1·kg–1 for the Yo-Yo SC IR test and the Yo-Yo IR test (P =.693), respectively. Conclusions: A Yo-Yo test with multidirectional changes of direction in response to visual stimuli yielded good agreement with the frequently used linear running tests and can be used to assess players' VO2peak. The HRmax achieved during this test should be used with caution. [ABSTRACT FROM AUTHOR]

Purpose: To assess the survival of double-crown-retained implant-and-tooth-supported removable partial dentures (DCR-ITSRPDs), evaluate abutment survival, and identify first aftercare measures. Materials and Methods: The influence of various factors on the survival of the DCR-ITSRPDs and the abutments were observed in this retrospective and clinical follow-up study using the Kaplan-Meier estimate. In addition, the first-required aftercare measure for each prosthesis was evaluated. Results: In total, 47 DCR-ITSRPDs were investigated (mean observation: 4.3 ± 3.8 years; max: 14.3 years), 3 of which (6.4%) had to be replaced. The survival probability for DCR-ITSRPDs was 100% at 5 years and 75% at 10 years. A total of 297 abutments (120 natural teeth and 177 dental implants) were observed, 22 of which (7.4%; 6 teeth and 16 implants) failed. The survival probability for teeth was 90.2% at the 5- and 10-year mark; for dental implants, it was 90.4% at 5 years and 76.3% at 10 years. Conclusions: DCR-ITSRPDs are a successful and durable treatment option for patients with substantially reduced residual dentitions. Both prostheses and abutments show good survival times after 5 and 10 years in function. The patient-associated factors tested showed no influence on the survival of DCR-ITSRPDs and abutments. Peri-implant infection was the decisive factor for abutment loss; therefore, regular dental prophylaxis and examinations are of major importance. [ABSTRACT FROM AUTHOR]

This retrospective study reports on the survival of two-piece angulated prosthetic platform (APP) implants consecutively placed at a specialist periodontics clinic with a mean follow-up of 28.2 ± 15.6 months (range: 4.0 to 71.0). For 183 returning patients who received 239 implants, the survival rates at follow-up (up to 71 months) were 99.2% and 91.1% at the patient and implant levels, respectively. A majority of patients were nonsmokers and did not have diabetes, with a quarter having a history of treated periodontitis. Eighty percent of patients received a single APP implant. Of the implants, 63% supported a single crown, 28% a fixed partial denture, and 9% a fixed complete denture. Nearly all implants were placed either at tooth extraction or after complete bone healing, in approximately equal numbers. Of the implant sites, approximately 75% received bone grafting, with approximately 25% receiving adjunct soft tissue grafting. For 210 surviving and restored implants with satisfactory intraoral radiographs taken at the last recall (mean follow-up: 28.4 ± 15.5 months; range: 4.0 to 71.0 months), the mean radiographic bone levels were -0.70 ± 0.87 mm (range: -3.60 to 2.15 mm). The results demonstrated clinically successful use of this unique geometry implant for multiple applications with acceptable short- to medium-term clinical outcomes. [ABSTRACT FROM AUTHOR]

As medical schools move to integrate the Core Entrustable Professional Activities for Entering Residency (EPAs) into curricula and address the transition from student to resident, residency preparatory courses have become more prevalent. The authors developed an experiential learning EPA-based capstone course for assessment to determine impact on learner self-assessed ratings of readiness for residency and acquisition of medical knowledge. All fourth-year students from the classes of 2018-2020 completed a required course in the spring for assessment of multiple EPAs, including managing core complaints, performing basic procedures, obtaining informed consent, and providing patient handoffs. Learners selected between three specialty-based parallel tracks - adult medicine, surgery, or pediatrics. Students completed a retrospective pre-post questionnaire to provide self-assessed ratings of residency preparedness and comfort in performing EPAs. Finally, the authors studied the impact of the course on knowledge acquisition by comparing student performance in the adult medicine track on multiple choice pre- and post-tests. Four hundred and eighty-one students were eligible for the study and 452 (94%) completed the questionnaire. For all three tracks, there was a statistically significant change in learner self-assessed ratings of preparedness for residency from pre- to post-course (moderately or very prepared: adult medicine 61.4% to 88.6% [p-value < 0.001]; surgery 56.8% to 81.1% [p-value < 0.001]; pediatrics 32.6% to 83.7% [p-value 0.02]). A similar change was noted in all tracks in learner self-assessed ratings of comfort from pre- to post-course for all studied EPAs. Of the 203 students who participated in the adult medicine track from 2019-2020, 200 (99%) completed both the pre- and post-test knowledge assessments. The mean performance improved from 65.0% to 77.5% (p-value < 0.001). An experiential capstone course for the assessment of EPAs can be effective to improve learner self-assessed ratings of readiness for residency training and acquisition of medical knowledge.

INTRODUCTION: Student-run free clinics (SRFCs) offer medical students a unique opportunity to develop their clinical, diagnostic, and social skills while providing care to medically underserved communities. This study aims to evaluate the value of SRFC involvement on students self-reported confidence in various clinical domains and satisfaction with their medical education. METHODS: We conducted a single-center retrospective pre-post assessment at an urban academic institution among second- to fourth-year medical students. We administered a 25-item questionnaire capturing the scope of clinic involvement and assessing self-reported confidence in multiple clinical domains following a one-year-long participation in student-run free clinics. RESULTS: Fifty-six students completed the survey. Participation in SRFCs significantly increased self-reported confidence in patient history-taking (p

OBJECTIVE: To examine linguistic disparities between English- and Spanish-speaking patients in access to care, satisfaction, and telehealth appointment attendance. DESIGN: Retrospective study recording demographics for non-attendance analysis and conducting phone surveys assessing satisfaction with telehealth. SETTING: Data was collected between March and December 2020 at the UCSF Craniofacial Center (CFC), a multidisciplinary pediatric clinic. Patients: English- and Spanish-speaking patients with a telehealth appointment. Interventions: The CFC offered language-concordant outreach, assistance with the telehealth platform, and interpreters at all telehealth appointments. MAIN OUTCOME MEASURES: Demographics and patient-reported satisfaction with telehealth, barriers, and instruction clarity. RESULTS: Medicaid insurance was the only predictor of non-attendance. Surveys revealed that Spanish-speakers had 12.4 times the odds of lacking access to telehealth technology and 10.7 times the odds of needing help with logging on compared to English-speakers. There were no significant differences in satisfaction outcomes. CONCLUSIONS: We attribute this equity in satisfaction to our language-concordant outreach efforts.

BACKGROUND: Stroke remains a major health concern globally, with oral anticoagulants widely prescribed for stroke prevention. The efficacy and safety of mechanical thrombectomy (MT) in anticoagulated patients with distal medium vessel occlusions (DMVO) are not well understood. METHODS: This retrospective analysis involved 1282 acute ischemic stroke (AIS) patients who underwent MT in 37 centers across North America, Asia, and Europe from September 2017 to July 2023. Data on demographics, clinical presentation, treatment specifics, and outcomes were collected. The primary outcomes were functional outcomes at 90 days post-MT, measured by modified Rankin Scale (mRS) scores. Secondary outcomes included reperfusion rates, mortality, and hemorrhagic complications. RESULTS: Of the patients, 223 (34%) were on anticoagulation therapy. Anticoagulated patients were older (median age 78 vs 74 years; p

PURPOSE: Patients with invasive lobular carcinoma (ILC) face high rates of positive margins and completion mastectomy, which can be improved with the use of specific techniques, such as oncoplastic surgery. However, prior studies have shown that type of breast cancer surgery performed is also associated with patient factors such as elevated body mass index (BMI). Thus, this study investigates whether BMI impacts the type of surgical interventions in patients with ILC. METHODS: A retrospective analysis of 705 patients with stage I-III ILC from an institutional database was conducted. Patients were stratified by BMI (underweight, normal weight, overweight, obese). Pearsons Chi-square, ANOVA, and multivariable logistic regression were used to evaluate the relationship between BMI and surgical procedures. RESULTS: Breast-conserving surgery (BCS) was the initial operation in 60% of patients, with no significant difference by BMI. Among those undergoing BCS, patients with obese BMI were significantly more likely to undergo oncoplastic surgery (46.9% vs. 7.7%, 37.3%, and 33.6% for underweight, normal, and overweight, respectively, p = 0.032). Obese BMI patients undergoing mastectomy were less likely to have reconstruction compared to those with underweight, normal weight, and overweight BMI (44.2% vs. 50%, 71.1%, and 64.1%, p = 0.002). CONCLUSION: Overweight/obese BMI patients with ILC underwent different surgical interventions compared to those with lower BMI. While initial BCS rates were similar, overweight/obese patients had higher oncoplastic surgery rates in BCS and lower reconstruction rates in mastectomy. Further research is needed to understand BMIs impact on surgical decisions and outcomes in ILC.

BACKGROUND: Time and money are limited resources to pursue quality improvement (QI) goals. Computer simulation using Monte Carlo methods may help focus resources towards the most efficacious interventions to pursue. METHODS: This observational, cross-sectional study analysed the length of stay (LOS) for adult American Society of Anesthesiologists (ASA) 1-3 patients in the postanaesthesia care unit (PACU) at a major academic medical centre. Data were collected retrospectively from 1 April 2023 to 31 March 2024. Statistical analysis with Monte Carlo methods simulated the per cent reduction in PACU LOS following the elimination of postoperative nausea and vomiting (PONV), hypothermia (initial temperature

BACKGROUND: We previously showed worse outcomes among lower socioeconomic status (SES) groups following metabolic/bariatric surgery (MBS). In light of healthcare changes in response to COVID-19, this study aims to evaluate post-pandemic MBS outcomes and determine if prior socioeconomic disparities persisted in the post-COVID era. METHODS: A retrospective chart review of patients undergoing primary Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) between 2015 and 2022 was performed. Patients were stratified into pre- and post-COVID groups. Post-COVID cohort was further stratified into high (HT) and low (LT) tier status based on Distressed Communities Index, a geocoded composite measure of SES. Preoperative characteristics and postoperative outcomes were compared between pre- and post-COVID cohorts, as well as between post-COVID HT and LT groups. RESULTS: Of 709 patients, 82.9% were pre-COVID and 17.1% were post-COVID. Post-COVID cohort had greater rate of public insurance (46% vs. 37%, p

OBJECTIVE: The aim of this study was to analyze the origins of prostatic arteries (PAs) in the Korean population and compare them with those reported in the literature. MATERIALS AND METHODS: From April 2018 to February 2024, 108 male (mean age ± standard deviation: 71.6 ± 9.7 years) with lower urinary tract symptoms (n = 102) or refractory hematuria (n = 6) underwent prostatic artery embolization (PAE). Computed tomography and angiography images were retrospectively reviewed. The branching pattern of the internal iliac artery (IIA) was classified according to the Yamaki system. The origin of the PA was categorized using the de Assis definition, and the incidence of each type was recorded. A systematic literature review was conducted and the most common types of PA were investigated. RESULTS: PAE was successfully implemented on 211 of the 216 pelvic sidewalls. PA cannulation failed in five sidewalls due to a steno-occlusive state. The most common IIA type was type A, in which the IIA was divided into the superior gluteal artery and gluteal-pudendal trunk (77%). Of 226 PAs analyzed, including 15 in 211 sidewalls exhibiting dual PAs, the most common PA origin was the internal pudendal artery (type IV, 35%), followed by the superior vesical (type I, 25%) and obturator (type III, 21%) arteries. Anterior division of IIA (type II) was less common (10%). Type V (uncommon origins) occurred in 8% of cases, including five distal internal pudendal arteries, four quadfurcations, three inferior gluteal arteries, three trifurcations, two medial femoral circumflex arteries, and two rectal arteries. Two of the five patients with surgically or endovascularly altered anatomy were successfully treated via PAs originating from the medial femoral circumflex arteries. Globally, type I is the most common PA type. CONCLUSION: In the Korean population, the most common IIA pattern and PA origin were types A and IV, respectively.

BACKGROUND: The pandemic rapidly expanded telemedicine, which has persisted as a widely available primary care modality. The uptake of telemedicine among people with dementia specifically in the primary care setting, who have more complex care needs but also benefit from more accessible primary care, is unknown. OBJECTIVE: Among people with dementia, assess uptake of telemedicine-based primary care in the post-pandemic period and determine associations with key socio-demographic characteristics. DESIGN: Retrospective observational study. SUBJECTS: People with dementia at UCSF and Kaiser Permanente Northern CA (KPNC) with at least one primary care encounter in pre- (3/1/2019-2/29/2020) or post-COVID (3/1/2021-2/28/2022) periods, post-COVID sample: N= 419 individuals (UCSF), N=18,037 (KPNC). MAIN MEASURES: Encounter modality: in-person, video telemedicine, or telephone telemedicine. Focal socio-demographic characteristics: age, limited English proficiency, socioeconomic status, driving distance to clinic, and caregiver at encounter. KEY RESULTS: There was a large increase in telemedicine among people with dementia in the post-pandemic period at both sites. At KPNC, those with only in-person primary care visits shrunk from 60.47% (pre) to 26.95% (post). At UCSF, the change was even greater: 98.99% to 35.08%. Across both sites, the only measure significantly associated with use of telemedicine was greater driving distance from home to clinic. At KPNC, those over age 90 were most likely to use telemedicine while patients with limited English proficiency and those with a caregiver at the encounter used telemedicine at lower levels. The relationships were similar at UCSF but not statistically significant. CONCLUSIONS: Telemedicine use is high for people with dementia in the primary care setting in the post-pandemic period. Those with longer drives to clinic and the oldest patients were most likely to use telemedicine, likely due to challenges traveling to appointments. Still, not all people with dementia used telemedicine equally-particularly those with limited English proficiency.

This study investigates the efficacy of predicting age-related macular degeneration (AMD) activity through deep neural networks (DNN) using a cross-instrument training dataset composed of Optical coherence tomography-angiography (OCTA) images from two different manufacturers. A retrospective cross-sectional study analyzed 2D vascular en-face OCTA images from Heidelberg Spectralis (1478 samples: 1102 training, 276 validation, 100 testing) and Optovue Solix (1003 samples: 754 training, 189 validation, 60 testing). OCTA scans were labeled based on clinical diagnoses and adjacent B-scan OCT fluid information, categorizing activity into normal, dry AMD, active wet AMD, and wet AMD in remission. Experiments explored cross-instrument disease classification using separate and combined datasets for training the DNN. Testing involved 100 Heidelberg and 60 Optovue samples. Training on Heidelberg data alone yielded 73% accuracy on Heidelberg images and 60% on Optovue images. Training on Optovue data alone resulted in 34% accuracy on Heidelberg and 85% on Optovue images. Combined training data from both instruments achieved 78% accuracy on Heidelberg and 76% on Optovue test sets. Results indicate that cross-instrument classifier training demonstrates high classification prediction accuracy, making cross-instrument training viable for future clinical applications. This implies that vascular morphology in OCTA can predict disease progression.

BACKGROUND: Surgical and adjuvant management of mucinous cystic neoplasms (MCNs) lacks formal guidelines and data is limited to institutional studies. Factors associated with receipt of adjuvant therapy and any associated impact on survival remain to be clarified. In the absence of other data, guidelines that recommend adjuvant chemotherapy for invasive pancreatic adenocarcinoma have been extrapolated to MCN. PATIENTS AND METHODS: The National Cancer Database (2004-2019) was utilized to identify all patients that underwent pancreatic resection for invasive MCNs. Patients that received neoadjuvant therapy or did not undergo lymphadenectomy were excluded. Patient, tumor, and treatment factors associated with survival were assessed. RESULTS: For 161 patients with invasive MCN, median overall survival (OS) was 133 months and 45% of patients received adjuvant therapy. Multivariable analysis demonstrated that poorly differentiated tumors [odds ratio (OR) 4.19, 95% confidence interval (CI) 1.47-11.98; p = 0.008] and positive lymph node status (OR 2.67, 95% CI 1.02-6.98; p = 0.042) were independent predictors of receiving adjuvant therapy. Lymph node positivity [hazard ratio (HR) 2.90, 95% CI 1.47-5.73; p = 0.002], positive margins (HR 5.28, 95% CI 2.28-12.27; p

OBJECTIVES: Up to a quarter of pregnant individuals with SLE have small for gestational age (SGA) infants. We aimed to characterize placental pathology associated with SGA infants in SLE. METHODS: We retrospectively analysed SLE deliveries with placental analysis at UCSD from November 2018 to October 2023, comparing SLE pregnancies resulting in SGA to those that did not, and additionally, to matched pregnancies with SGA but without SLE. RESULTS: Placental analysis was available only for 28/70 (40%) SLE deliveries, which had high rates of adverse outcomes (75%). All exhibited at least one histopathologic abnormality. Key findings distinguishing 12 SLE placentas resulting in SGA infants (vs.16 without) included small placental disc for gestational age (100% vs 56%, P = 0.01), placental disc infarct (50% vs 6%, P = 0.02) and increased perivillous fibrin deposition (PVFD, 58% vs 0%, P = 0.001). All seven SLE placentas with increased PVFD resulted in SGA infants. Compared with matched non-SLE pregnancies with SGA (n = 36), the only distinguishing placental lesion was a higher prevalence of increased PVFD in SLE-associated SGA (58% vs 22%, P = 0.03). CONCLUSION: The higher prevalence of increased PVFD in placentas of SLE-associated SGA may indicate a specific mechanism of placental injury leading to SGA in this context. Thus, its presence, particularly in context of SGA, should prompt providers to screen for an underlying autoimmune disease, including SLE. Systematic placental examination in context of SLE and associated autoimmune diseases could help evaluate responses to existing therapies, comparative studies of novel therapies and correlation to adverse outcomes.

C1q deficiency is a rare inborn error of immunity characterized by increased susceptibility to infections and autoimmune manifestations mimicking SLE, with an associated morbidity and mortality. Because C1q is synthesized by monocytes, to date, four patients treated with allogeneic HSCT have been reported, with a positive outcome in three. We conducted an international retrospective study to assess the outcome of HSCT in C1q deficiency. Eighteen patients, fourteen previously unreported, from eleven referral centres, were included. Two patients had two HSCTs, thus 20 HSCTs were performed in total, at a median age of 10 years (range 0.9-19). Indications for HSCT were autoimmune manifestations not controlled by ongoing treatment in seventeen, and early development of MALT lymphoma in one patient. Overall survival (OS) was 71% and event-free survival was 59% at two years (considering an event as acute GvHD ≥ grade III, disease recurrence and death). In eleven patients HSCT led to resolution of autoimmune features and discontinuation of immunosuppressive treatments (follow-up time range 3-84 months). Five patients died due to transplant-related complications. Patients with a severe autoimmune phenotype, defined as neurological and/or renal involvement, had the worst OS (40% vs 84%; p = 0.034). Reviewing data of 69 genetically confirmed C1q deficient patients, we found that anti-Ro antibodies are associated with neurologic involvement, and anti-RNP and anti-DNA antibodies with renal involvement. In conclusion, HSCT may be a valid curative option for C1q deficiency, but careful selection of patients, with an accurate assessment of risk and benefit, is mandatory.

BACKGROUND: The COVID-19 pandemic led to dramatic changes in the lives of children that impact cardiometabolic health. Cities and counties had varying policies with respect to school closure, recreational programs, and efforts to mitigate food insecurity and economic distress. Our objective was to evaluate changes in BMI-z score and prevalence of overweight/obesity prior to and during the pandemic among children in San Francisco, CA, where public schools were closed for 18-months. METHODS: This was an electronic medical record-based retrospective cohort study. We included 15,401 children, 4-17 years of age at study onset. Our exposure was time into each of three time periods: (1) March 2018-February 2019; (2) March 2019-February 2020; (3) March 2020-August 2021 (the pandemic period of school closure). Generalized estimating equations (GEE) were used to assess changes in BMI-z score and overweight/obesity across the three time periods. We assessed for effect modification by age-category, insurance status, and race/ethnicity. RESULTS: Mean BMI-z score increased by 0.06 per year in time period 2, the year prior to the pandemic (p

BACKGROUND: The mechanism for recording International Classification of Diseases (ICD) and diagnosis related groups (DRG) codes in a patients chart is through a certified medical coder who manually reviews the medical record at the completion of an admission. High-acuity ICD codes justify DRG modifiers, indicating the need for escalated hospital resources. In this manuscript, we demonstrate that value of rules-based computer algorithms that audit for omission of administrative codes and quantifying the downstream effects with regard to financial impacts and demographic findings did not indicate significant disparities. METHODS: All study data were acquired via the UCLA Department of Anesthesiology and Perioperative Medicines Perioperative Data Warehouse. The DataMart is a structured reporting schema that contains all the relevant clinical data entered into the EPIC (EPIC Systems, Verona, WI) electronic health record. Computer algorithms were created for eighteen disease states that met criteria for DRG modifiers. Each algorithm was run against all hospital admissions with completed billing from 2019. The algorithms scanned for the existence of disease, appropriate ICD coding, and DRG modifier appropriateness. Secondarily, the potential financial impact of ICD omissions was estimated by payor class and an analysis of ICD miscoding was done by ethnicity, sex, age, and financial class. RESULTS: Data from 34,104 hospital admissions were analyzed from January 1, 2019, to December 31, 2019. 11,520 (32.9%) hospital admissions were algorithm positive for a disease state with no corresponding ICD code. 1,990 (5.8%) admissions were potentially eligible for DRG modification/upgrade with an estimated lost revenue of $22,680,584.50. ICD code omission rates compared against reference groups (private payors, Caucasians, middle-aged patients) demonstrated significant p-values

In this study, associations between prenatal exposure to fine particulate matter (PM2.5) from 9 sources and development of autism spectrum disorder (ASD) were assessed in a population-based retrospective pregnancy cohort in southern California. The cohort included 318,750 mother-child singleton pairs. ASD cases (N = 4559) were identified by ICD codes. Source-specific PM2.5 concentrations were estimated from a chemical transport model with a 4 × 4 km2 resolution and assigned to maternal pregnancy residential addresses. Cox proportional hazard models were used to estimate the hazard ratios (HR) of ASD development for each individual source. We also adjusted for total PM2.5 mass and in a separate model for all other sources simultaneously. Increased ASD risk was observed with on-road gasoline (HR [CI]: 1.18 [1.13, 1.24]), off-road gasoline (1.15 [1.12, 1.19]), off-road diesel (1.08 [1.05, 1.10]), food cooking (1.05 [1.02, 1.08]), aircraft (1.04 [1.01, 1.06]), and natural gas combustion (1.09 [1.06, 1.11]), each scaled to standard deviation increases in concentration. On-road gasoline and off-road gasoline were robust for other pollutant groups. PM2.5 emitted from different sources may have different impacts on ASD. The results also identify PM source mixtures for toxicological investigations that may provide evidence for future public health policies.

Study designRetrospective cohort study of prospectively accrued data.ObjectiveTo evaluate a large, prospective, multicentre dataset of surgically treated degenerative cervical myelopathy (DCM) cases on the contemporary risk of C5 palsy with surgical approach.Summary of background dataThe influence of surgical technique on postoperative C5 palsy after decompression for DCM is intensely debated. Comprehensive, covariate-adjusted analyses are needed using contemporary data.MethodsPatients with moderate to severe DCM were prospectively enrolled in the multicenter, randomized, Phase III CSM-Protect clinical trial and underwent either anterior or posterior decompression between Jan 31, 2012 and May 16, 2017. The primary outcome was the incidence of postoperative C5 palsy, defined as the onset of muscle weakness by at least one grade in manual muscle test at the C5 myotome with slight or absent sensory disruption after cervical surgery. Two comparative cohorts were made based on the anterior or posterior surgical approach. Multivariate hierarchical mixed-effects logistic regression was used to estimate odds ratios (OR) with 95% confidence intervals (CI) for C5 palsy.ResultsA total of 283 patients were included, and 53.4% underwent posterior decompression. The total incidence of postoperative C5 palsy was 7.4% and was significantly higher in patients who underwent posterior decompression compared with anterior decompression (11.26% vs. 3.03%, P =0.008). After multivariable regression, the posterior approach was independently associated with greater than four times the likelihood of postoperative C5 palsy ( P =0.017). Rates of C5 palsy recovery were comparable between the two surgical approaches.ConclusionThe odds of postoperative C5 palsy are significantly higher after posterior decompression compared to anterior decompression for DCM. This may influence surgical decision-making when there is equipoise in deciding between anterior and posterior treatment options for DCM.Level of evidenceTherapeutic Level-II.

Enhancing the efficacy of immunotherapy in brain metastases (BrM) requires an improved understanding of the immune composition of BrM and how this is affected by radiation and dexamethasone. Our two-arm pilot study (NCT04895592) allocated 26 patients with BrM to either low (Arm A) or high (Arm B) dose peri-operative dexamethasone followed by pre-operative stereotactic radiosurgery (pSRS) and resection (n= 13 per arm). The primary endpoint, a safety analysis at 4 months, was met. The secondary clinical endpoints of overall survival, distant brain failure, leptomeningeal disease and local recurrence at 12-months were 66%, 37.3%, 6%, and 0% respectively and were not significantly different between arms (p= 0.7739, p= 0.3884, p= 0.3469). Immunological data from two large retrospective BrM datasets and confirmed by correlates from both arms of this pSRS prospective trial revealed that BrM CD8 T cells were composed of predominantly PD1+ TCF1+ stem-like and PD1+ TCF1-TIM3+ effector-like cells. Clustering of TCF1+ CD8 T cells with antigen presenting cells in immune niches was prognostic for local control, even without pSRS. Following pSRS, CD8 T cell and immune niche density were transiently reduced compared to untreated BrM, followed by a rebound 6+ days post pSRS with an increased frequency of TCF1- effector-like cells. In sum, pSRS is safe and therapeutically beneficial, and these data provide a framework for how pSRS may be leveraged to maximize intracranial CD8 T cell responses.

OBJECTIVE: This study aimed to validate claims-based algorithms for identifying SLE and lupus nephritis (LN) in Medicare data, enhancing the use of the Lupus Index for geospatial research on SLE prevalence and outcomes. METHODS: We retrospectively evaluated the performance of rule-based algorithms using the International Classification of Diseases, 10th Revision (ICD-10) codes to identify SLE and LN in a well-defined prospective longitudinal cohort of patients with and without SLE from a South Carolina registry and rheumatology outpatient clinics. The analysis included comparison of algorithms based on Medicare fee-for-service claims data to these rigorously phenotyped populations. The primary classification for SLE cases was based on the American College of Rheumatology and Systemic Lupus Erythematosus International Collaborating Clinics criteria for SLE and LN. Algorithms were based on the number of ICD-10 codes with and without a 30-day separation in the observation period, including all of 2016-2018. RESULTS: The algorithm using two ICD-10 codes for SLE, with or without a 30-day separation, showed the best overall performance. For LN, specific ICD-10 codes outperformed combinations of SLE and renal/proteinuria codes that were found in ICD-9. CONCLUSIONS: The findings of this study highlight the performance of specific ICD-10 code algorithms in identifying SLE and LN cases within Medicare data, providing a valuable tool for informing use of the Lupus Index. This index allows for improved geographical targeting of clinical resources, health disparity studies and clinical trial site selection. The study underscores the importance of algorithm selection based on research objectives, recommending more specific algorithms for precise tasks like clinical trial site identification and less specific ones for broader applications such as health disparities research.

INTRODUCTION: Personalized and tumor-informed circulating tumor DNA (ctDNA) testing is feasible and allows for molecular residual disease (MRD) identification in patients with pancreatic ductal adenocarcinoma (PDAC). METHODS: In this retrospective analysis of commercial cases from multiple US institutions, personalized, tumor-informed, whole-exome sequenced, and germline-controlled ctDNA levels were quantified and analyzed in patients with PDAC. Plasma samples (n = 1329) from 298 clinically validated patients were collected at diagnosis, perioperatively (MRD-window; within 2-12 weeks after surgery, before therapy), and during surveillance (>12 weeks post-surgery if no ACT or starting 4 weeks post-ACT) from November 2019 to March 2023. RESULTS: Of the initially diagnosed patients with stages I-III PDAC who went for resection, the median follow-up time from surgery was 13 months (range 0.1-214). Positive ctDNA detection rates were 29% (29/100) and 29.6% (45/152) during the MRD and surveillance windows, respectively. Positive ctDNA detection was significantly associated with shorter DFS within the MRD window (median DFS of 6.37 months for ctDNA-positive vs 33.31 months for ctDNA-negative patients; HR: 5.45, P

BACKGROUND: Women who reach menarche and menopause at earlier ages have been shown to be at increased risk for numerous conditions including cardiovascular disease, cancer, depression, and obesity; however, risk factors for earlier ages of menarche and menopause are not fully understood. Therefore, we aimed to perform a retrospective investigation of the associations between a personal birthweight and/or being born preterm and the age of and menarche and menopause and related events in the Womens Health Initiative, a large, racially and ethnically diverse cohort of postmenopausal women. METHODS: At study entry, women reported their birthweight by category (

BACKGROUND: Video games have rapidly become mainstream in recent decades, with over half of the US population involved in some form of digital gaming. However, concerns regarding the potential harms of excessive, disordered gaming have also risen. Internet gaming disorder (IGD) has been proposed as a tentative psychiatric disorder that requires further study by the American Psychological Association (APA) and is recognized as a behavioral addiction by the World Health Organization. Substance use among gamers has also become a concern, with caffeinated or energy drinks and prescription stimulants commonly used for performance enhancement. OBJECTIVE: This study aimed to identify substance use patterns and health-related concerns among gamers among a population of Reddit users. METHODS: We used the public streaming Reddit application programming interface to collect and analyze all posts from the popular subreddit, r/StopGaming. From this corpus of posts, we filtered the dataset for keywords associated with common substances that may be used to enhance gaming performance. We then applied an inductive coding approach to characterize substance use behaviors, gaming genres, and physical and mental health concerns. Potential disordered gaming behavior was also identified using the tentative IGD guidelines proposed by the APA. A chi-square test of independence was used to assess the association between gaming disorder and substance use characteristics, and multivariable logistic regression was used to analyze whether mental health discussion or the mention of any substance with sufficient sample size was significantly associated with IGD. RESULTS: In total, 10,551 posts were collected from Reddit from June 2017 to December 2022. After filtering the dataset for substance-related keywords, 1057 were included for further analysis, of which 286 mentioned both gaming and the use of ≥1 substances. Among the 286 posts that discussed both gaming and substance use, the most mentioned substances were alcohol (n=132), cannabis (n=104), and nicotine (n=48), while the most mentioned genres were role-playing games (n=120), shooters (n=90), and multiplayer online battle arenas (n=43). Self-reported behavior that aligned with the tentative guidelines for IGD was identified in 66.8% (191/286) posts. More than half, 62.9% (180/286) of the posts, discussed a health issue, with the majority (n=144) cited mental health concerns. Common mental health concerns discussed were depression and anxiety. There was a significant association between IGD and substance use (P

BACKGROUND AND OBJECTIVE: Upadacitinib is indicated for diseases affecting persons of childbearing potential including rheumatoid arthritis, psoriatic arthritis, axial spondyloarthritis, atopic dermatitis, Crohns disease, and ulcerative colitis; however, teratogenicity was observed in animal studies. Given the potential for human fetal risk, pregnancy avoidance measures were required during clinical trials. This analysis describes pregnancy outcomes in patients exposed to upadacitinib during pregnancy. METHODS: Clinical trial and postmarketing cases of in utero exposure to upadacitinib were identified in AbbVies safety database through 25 April, 2023. Analysis of clinical trial cases and postmarketing reports are presented separately; prospective and retrospectively reported pregnancy outcomes are integrated for each. Descriptive rates are presented to summarize outcomes. RESULTS: There were 128 maternal upadacitinib-exposed pregnancies with known outcomes identified; 80 and 48 pregnancies were reported in clinical trials and the postmarketing setting, respectively. In clinical trials (mean in utero exposure of 5 weeks, 3 days), live births (54%), spontaneous abortions (24%), elective terminations (21%), and ectopic pregnancy (1%) were reported. There was one report of a congenital malformation: a 35-week infant with an atrial septal defect. In postmarketing cases, live births (46%), spontaneous abortions (38%), elective terminations (15%), and ectopic pregnancy (2%) were reported. CONCLUSIONS: As the data are limited for in utero exposure to upadacitinib, definitive conclusions cannot be drawn regarding the effect of upadacitinib on pregnancy outcomes. Rates of adverse pregnancy outcomes with upadacitinib exposure were comparable to rates observed in the general population or patients with autoimmune inflammatory diseases. To date, no apparent evidence of teratogenicity exists in the analyses of human pregnancies exposed to upadacitinib during the first trimester.

Clinical trials in metabolic dysfunction-associated steatohepatitis (MASH, formerly known as nonalcoholic steatohepatitis) require histologic scoring for assessment of inclusion criteria and endpoints. However, variability in interpretation has impacted clinical trial outcomes. We developed an artificial intelligence-based measurement (AIM) tool for scoring MASH histology (AIM-MASH). AIM-MASH predictions for MASH Clinical Research Network necroinflammation grades and fibrosis stages were reproducible (κ = 1) and aligned with expert pathologist consensus scores (κ = 0.62-0.74). The AIM-MASH versus consensus agreements were comparable to average pathologists for MASH Clinical Research Network scores (82% versus 81%) and fibrosis (97% versus 96%). Continuous scores produced by AIM-MASH for key histological features of MASH correlated with mean pathologist scores and noninvasive biomarkers and strongly predicted progression-free survival in patients with stage 3 (P

INTRODUCTION: Staged treatment of high-energy periarticular tibia fractures involves temporization with closed reduction and external fixation, aiming to provide early reduction and stabilization while mitigating soft-tissue complications. Various external fixator configurations exist, including those that use a multipin clamp capable of holding multiple pins but limiting pin placement to a single plane. The purpose of this study was to compare clinical and radiographic outcomes and associated costs of standard and multipin outrigger clamp constructs in tibial plateau and pilon fractures treated with temporary external fixation. We hypothesized that use of the multipin clamp may be associated with poorly aligned reductions and increased complication rates. METHODS: A retrospective review of 100 patients with periarticular tibial plateau (AO/OTA: 41B/C) or pilon (43B/C) fracture at a Level 1 trauma center from 2014 to 2023 was conducted. Patient, injury, and complication characteristics were collected. Patients were categorized based on the external fixator clamp used: multipin (MP) or standard (S). Clinical outcomes and complication rates were assessed. Radiographic alignment was evaluated by the change in anterior and lateral distal tibial angles, and sagittal plane translation for pilon fractures, and medial and posterior proximal tibial angles for plateau fractures. RESULTS: 70 patients underwent standard (25 pilon, 45 plateau) and 30 multipin (10 pilon, 20 plateau) external fixation. MP and S groups showed no notable differences in demographics or injury characteristics. Both groups demonstrated comparable complication rates and radiological alignment outcomes, with no notable differences observed. MP constructs were more costly than standard systems. CONCLUSION: In this retrospective study of 100 patients, there was no difference in radiographic or clinical outcomes between the standard frame and multipin frame groups. Typical costs for the multipin frame constructs were $635 to $1249 more than the standard frame constructs.

BACKGROUND: Invasive lobular carcinoma (ILC) of the breast grows in a diffuse pattern, resulting in a high risk of positive margins at surgical resection. Oncoplastic approaches have been shown to reduce this risk, but concerns persist around the safety of immediate oncoplastic surgery for those with ILC. This study evaluated the short- and long-term oncologic outcomes of immediate oncoplastic surgery for patients with ILC. METHODS: This study retrospectively analyzed an institutional database of stages I to III ILC patients who underwent breast-conserving surgery (BCS) with or without immediate oncoplastic surgery (oncoplastic closure or oncoplastic reduction mammoplasty [ORM]). The study compared positive margin rates, rates of successful BCS, and recurrence-free survival (RFS) by type of surgery. RESULTS: For 494 patients the findings showed that the use of immediate ORM was associated with significantly lower odds of positive margins (odds ratio [OR], 0.34; 95 % confidence interval [CI], 0.17-0.66; p = 0.002). Both lumpectomy with oncoplastic closure and ORM were significantly associated with higher rates of successful BCS than standard lumpectomy (94.2 %, 87.8 %, and 73.9 %, respectively; p < 0.001). No difference in RFS was observed between those undergoing immediate oncoplastic surgery and those undergoing standard lumpectomy alone. CONCLUSIONS: The patients with stages I to III ILC who underwent immediate oncoplastic surgery had significant benefits including lower odds of positive margins and higher rates of successful BCS, with both types of immediate oncoplastic surgery showing similar RFS compared with lumpectomy alone. This supports the oncologic safety of immediate oncoplastic surgery for diffusely growing tumors such as ILC, providing it an ideal option for patients desiring BCS.

BACKGROUND: Invasive lobular carcinoma (ILC) is the second most common subtype of breast cancer. Although mammography is known to have low sensitivity for ILC, there are no data to guide the optimal surveillance after treatment. We explored surveillance strategies after breast-conserving surgery (BCS) for ILC and determined the proportion of imaging-detected recurrences versus interval cancers. METHODS: From an institutional database of 813 women, we retrospectively identified patients who underwent BCS for stage I-III ILC and subsequently had a recurrence. We categorized patients by surveillance strategy and determined the modality of recurrence detection. Interval cancer rates for local recurrences were compared across surveillance strategies using the Chi-square test. We evaluated overall survival with the log-rank test and a Cox proportional hazards model. RESULTS: We included 58 patients with ILC who had a recurrence after BCS. Of these, 22 (37.9%) had local recurrence, 27 (46.6%) had distant recurrence, and 9 (15.5%) had both local and distant recurrence. Most patients underwent routine mammographic surveillance (65.2%), with 19.6% having supplemental breast magnetic resonance imaging (MRI) and 15.2% having no surveillance. The interval cancer rate was significantly higher in the mammographic surveillance group compared with the MRI surveillance group (61.9% vs. 16.7%; p

BACKGROUND: For patients with clinically node-positive (cN+) breast cancer undergoing neoadjuvant chemotherapy (NAC), retrieving previously clipped, biopsy-proven positive lymph nodes during sentinel lymph node biopsy [i.e., targeted axillary dissection (TAD)] may reduce false negative rates. However, the overall utilization and impact of clipping positive nodes remains uncertain. PATIENTS AND METHODS: We retrospectively analyzed cN+ ISPY-2 patients (2011-2022) undergoing axillary surgery after NAC. We evaluated trends in node clipping and associations with type of axillary surgery [sentinel lymph node (SLN) only, SLN and axillary lymph node dissection (ALND), or ALND only] and event-free survival (EFS) in patients that were cN+ on a NAC trial. RESULTS: Among 801 cN+ patients, 161 (20.1%) had pre-NAC clip placement in the positive node. The proportion of patients that were cN+ undergoing clip placement increased from 2.4 to 36.2% between 2011 and 2021. Multivariable logistic regression showed nodal clipping was independently associated with higher odds of SLN-only surgery [odds ratio (OR) 4.3, 95% confidence interval (CI) 2.8-6.8, p < 0.001]. This was also true among patients with residual pathologically node-positive (pN+) disease. Completion ALND rate did not differ based on clip retrieval success. No significant differences in EFS were observed in those with or without clip placement, both with or without successful clip retrieval [hazard ratio (HR) 0.85, 95% CI 0.4-1.7, p = 0.7; HR 1.8, 95% CI 0.5-6.0, p = 0.3, respectively]. CONCLUSION: Clip placement in the positive lymph node before NAC is increasingly common. The significant association between clip placement and omission of axillary dissection, even among patients with pN+ disease, suggests a paradigm shift toward TAD as a definitive surgical management strategy in patients with pN+ disease after NAC.

Nearly 10% of pregnant women suffer traumatic injury. Clinical outcomes for pregnant trauma patients (PTPs) with severe injuries have not been well studied. We sought to describe outcomes for PTPs presenting with severe injuries, hypothesizing that PTPs with severe injuries will have higher rates of complications and mortality compared to less injured PTPs. A post-hoc analysis of a multi-institutional retrospective study at 12 Level-I/II trauma centers was performed. Patients were stratified into severely injured (injury severity score [ISS] > 15) and not severely injured (ISS

PURPOSE: To describe U-type sacral fracture characteristics amenable to percutaneous sacral screw fixation. METHODS: U-type sacral fractures were identified from a trauma registry at a level 1 trauma center from 2014 to 2020. Patient demographics, injury mechanism, fracture characteristics, and fixation construct were retrospectively retrieved. Associations between fracture pattern and surgical fixation were identified. RESULTS: 82 U-type sacral fractures were reviewed. Six treated with lumbopelvic fixation (LPF) and 76 were treated with percutaneous sacral screws (PSS) alone. Patients receiving LBF had greater sacral fracture displacement in coronal, sagittal, and axial planes compared to patients receiving PSS alone (P

UNLABELLED: A common complication of chimeric antigen receptor (CAR) T-cell therapy is immune effector cell-associated neurotoxicity syndrome (ICANS), which presents with encephalopathy, aphasia, inattention, somnolence, seizures, weakness, or cerebral edema. Despite its significant morbidity, there are currently no effective targeted treatments. Given the clinical similarities between ICANS and the neurological manifestations of acute hypophosphatemia, we retrospectively reviewed 499 patients treated with CD19-targeted CAR T-cell therapy across multiple clinical trials between 2015 and 2020. In addition to clinical toxicities experienced by the patients, we also interrogated the impact of serum electrolyte data and repletion of corresponding electrolyte deficiencies with ICANS incidence, severity, and duration. Hypophosphatemia was a common occurrence in CAR T-cell recipients and the only electrolyte derangement associated with a significantly higher cumulative incidence of ICANS. Moreover, phosphorus repletion in patients with hypophosphatemia was associated with significantly decreased ICANS incidence and duration. Hypophosphatemia was uniquely associated with encephalopathy neurological adverse events, which also showed the strongest positive correlation with both ICANS and cytokine release syndrome severity. These findings suggest that serum phosphorus could be a reliable biomarker for ICANS, and expeditious, goal-directed phosphorus repletion in response to serum hypophosphatemia could be a safe, inexpensive, and widely available intervention for such patients. SIGNIFICANCE: Herein we show that phosphorus repletion in patients with hypophosphatemia receiving anti-CD19 chimeric antigen receptor T-cell therapeutics was associated with significantly decreased immune effector cell-associated neurotoxicity syndrome (ICANS) incidence and symptom duration. Given the significant morbidity associated with ICANS and lack of targeted interventions, hypophosphatemia may serve as both a useful biomarker and an inexpensive intervention for ICANS.

Ataxia with anti-regulator of G-protein signaling 8 autoantibodies (RGS8-Abs) is an autoimmune disease recently described in four patients. The present study aimed to identify other patients with RGS8-Abs, describe their clinical features, including the link between RGS8-related autoimmune cerebellar ataxia (ACA) and cancer. Patients with RGS8-Abs were identified retrospectively in the biological collections of the French Reference Center for Paraneoplastic Neurological Syndrome and the University of California San Francisco Center for Encephalitis and Meningitis. Clinical data were collected, and cerebrospinal fluid, serum, and tumor pathological samples were retrieved to characterize the autoantibodies and the associated malignancies. Only three patients with RGS8-Abs were identified. All of them presented with a pure cerebellar ataxia of mild to severe course, unresponsive to current immunotherapy regimens for ACA. Two patients presented with a Hodgkin lymphoma of the rare specific subtype called nodular lymphocyte-predominant Hodgkin lymphoma, with very mild extension. Autoantibodies detected in all patients enriched the same epitope on the RGS8 protein, which is an intracellular protein physiologically expressed in Purkinje cells but also ectopically expressed specifically in lymphoma cells of patients with RGS8-related ACA. The present results and those of the four cases previously described suggest that RGS8-Abs define a new paraneoplastic neurological syndrome of extreme rarity found mostly in middle-aged males that associates pure cerebellar ataxia and a particular lymphoma specifically expressing the RGS8 antigen. As in other paraneoplastic ACA with intracellular antigen, the disease course is severe, and patients tend to exhibit a poor response to immune therapy.

PURPOSE: To report patient outcomes and local tumor control rates in a cohort of patients with biopsy-proven HER-2 positive breast cancer treated with stereotactic radiosurgery (SRS) for brain metastases (BM). METHODS: This international, retrospective, multicenter study, included 195 female patients with 1706 SRS-treated BM. Radiologic and clinical outcomes after SRS were determined and prognostic factors identified. RESULTS: At SRS, median patient age was 55 years [interquartile range (IQR) 47.6-62.0], and 156 (80%) patients had KPS ≥ 80. The median tumor volume was 0.1 cm3 (IQR 0.1-0.5) and the median prescription dose was 16 Gy (IQR 16-18). Local tumor control (LTC) rate was 98%, 94%, 93%, 90%, and 88% at six-, 12-, 24-, 36- and 60-months post-SRS, respectively. On multivariate analysis, tumor volume (p =

Existing risk prediction models for hospitalized heart failure patients are limited. We identified patients hospitalized with a diagnosis of heart failure between 7 May 2013 and 26 April 2022 from a large academic, quaternary care medical centre (training cohort). Demographics, medical comorbidities, vitals, and labs were collected and were used to construct random forest machine learning models to predict in-hospital mortality. Models were compared with logistic regression, and to commonly used heart failure risk scores. The models were subsequently validated in patients hospitalized with a diagnosis of heart failure from a second academic, community medical centre (validation cohort). The entire cohort comprised 21 802 patients, of which 14 539 were in the training cohort and 7263 were in the validation cohort. The median age (25th-75th percentile) was 70 (58-82) for the entire cohort, 43.2% were female, and 6.7% experienced inpatient mortality. In the overall cohort, 7621 (35.0%) patients had heart failure with reduced ejection fraction (EF ≤ 40%), 1271 (5.8%) had heart failure with mildly reduced EF (EF 41-49%), and 12 910 (59.2%) had heart failure with preserved EF (EF ≥ 50%). Random forest models in the validation cohort demonstrated a c-statistic (95% confidence interval) of 0.96 (0.95-0.97), sensitivity (SN) of 87.3%, and specificity (SP) of 90.6% for the prediction of in-hospital mortality. Models for those with HFrEF demonstrated a c-statistic of 0.96 (0.94-0.98), SN 88.2%, and SP 91.0%, and those for patients with HFpEF showed a c-statistic of 0.95 (0.93-0.97), SN 87.4%, and SP 89.5% for predicting in-hospital mortality. The random forest model significantly outperformed logistic regression (c-statistic 0.87, SN 75.9%, and SP 86.9%), and current existing risk scores including the Acute Decompensated Heart Failure National Registry risk score (c-statistic of 0.70, SN 69%, and SP 62%), and the Get With the Guidelines-Heart Failure risk score (c-statistic 0.69, SN 67%, and SP 63%); P

BACKGROUND: After treatment of pregnancy-associated breast cancer (PABC), some women desire future pregnancy. While safety of pregnancy after breast cancer has been demonstrated, the same cannot be said about women with PABC. OBJECTIVE: The aim of this study was to describe the incidence and outcomes of patients with PABC with subsequent pregnancies compared with those without another pregnancy. METHODS: A retrospective chart review identified patients diagnosed with breast cancer during pregnancy or within 5 years postpartum between 2011 and 2023. Patients were then screened for further pregnancy. Clinicopathologic variables, oncologic outcomes, and pregnancy outcomes were recorded. The Chi-square test and t-test were used to compare patients with subsequent pregnancy with those without. Kaplan-Meier method and log-rank test were used to estimate 5-year disease-free survival (DFS). RESULTS: Overall, 75 patients with PABC were identified, 58 of whom had PABC and no further pregnancies (NSP-PABC) and 17 with subsequent pregnancy (SP-PABC). Compared with patients with NSP-PABC, patients with SP-PABC were significantly younger (p = 0.015) and less likely to have prior pregnancies (p

INTRODUCTION: Blastoid variant-mantle cell lymphoma (BV-MCL) represents an aggressive subset of patients with no established standard of care treatment approach. METHODS: We performed a retrospective analysis of the clinical characteristics and outcomes of 17 de novo BV-MCL patients treated at our institution between May 2009 and September 2023. In addition, we reviewed the literature supporting 2nd/3rd generation Brutons Tyrosine-kinase (BTKi)-based therapies for upfront management. RESULTS: The complete response rate to frontline and salvage therapy was 66.7% and 25%, respectively. Two-year overall survival (OS) was low at 62.5% (95% CI, 34.7%-81.1%). Variables associated with higher OS included receipt of consolidative HSCT (p = 0.017), TP53-wild type (p = 0.031), intermediate- versus high-risk Mantle Cell Lymphoma Prognostic Index score (p = 0.026), and achieving complete response with induction therapy (p = 0.027). DISCUSSION: Treatment outcomes with chemo-immunotherapy in BV-MCL patients are poor, especially among TP53-mutated patients. Recent findings describing positive outcomes with novel BTKi-based therapies are encouraging and should be considered in this high-risk population.

BackgroundPain is ubiquitous, yet understudied. The objective of this study was to analyze inequities in pain assessment and management for hospitalized older adults focusing on demographic and geriatric-related variables.MethodsThis was a retrospective cohort study from January 2013 through September 2021 of all adults 65 years or older on the general medicine service at UCSF Medical Center. Primary exposures included (1) demographic variables including race/ethnicity and limited English proficiency (LEP) status and (2) geriatric-related variables including age, dementia or mild cognitive impairment diagnosis, hearing or visual impairment, end-of-life care, and geriatrics consult involvement. Primary outcomes included (1) adjusted odds of numeric pain assessment versus other assessments and (2) adjusted opioids administered, measured by morphine milligram equivalents (MME).ResultsA total of 15,809 patients were included across 27,857 hospitalizations with 1,378,215 pain assessments, with a mean age of 77.8 years old. Patients were 47.4% White, 26.3% with LEP, 49.6% male, and 50.4% female. Asian (OR 0.75, 95% CI 0.70-0.80), Latinx (OR 0.90, 95% CI 0.83-0.99), and Native Hawaiian or Pacific Islander (OR 0.77, 95% CI 0.64-0.93) patients had lower odds of a numeric assessment, compared with White patients. Patients with LEP (OR 0.70, 95% CI 0.66-0.74) had lower odds of a numeric assessment, compared with English-speaking patients. Patients with dementia, hearing impairment, patients 75+, and at end-of-life were all less likely to receive a numeric assessment. Compared with White patients (86 MME, 95% CI 77-96), Asian patients (55 MME, 95% CI 46-65) received fewer opioids. Patients with LEP, dementia, hearing impairment and those 75+ years old also received significantly fewer opioids.ConclusionOlder, hospitalized, general medicine patients from minoritized groups and with geriatric-related conditions are uniquely vulnerable to inequitable pain assessment and management. These findings raise concerns for pain underassessment and undertreatment.