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To assess the effectiveness of a peritoneal flap on the formation of lymphoceles after robotic assisted radical prostatectomy with bilateral extended pelvic lymph node dissection.We conducted a single surgeon, assessor blinded prospective randomized controlled trial (the Prospective Lymphocele Ultrasound Study) in men undergoing robotic assisted radical prostatectomy with bilateral extended pelvic lymph node dissection. At the conclusion of the node dissection, patients were block randomized 1:1 to either standard of care (no bladder peritoneal flap) or to the creation of a bladder peritoneal flap. Lymphocele formation was assessed by pelvic ultrasound postoperatively. The primary outcome was lymphocele formation. Rates of lymphocele formation and complications were analyzed using chi-square. Other outcomes, including length of stay, number of lymph nodes removed, lymphocele volume, and quality of life measures, were analyzed by t-tests or Wilcoxon Ranked Sum Tests, as appropriate. An a priori power calculation was performed using O'Brien-Fleming alpha sharing for the interim analyses. Two preplanned interim analyses were performed when 45 and 90 patients per group had follow-up ultrasounds.A statistically significant difference in lymphocele formation was seen on the second interim analysis for 183 patients (4.3% vs. 15.6%, p = .011) stopping enrollment; this remained significant in the final analysis of 216 patients (3.6% vs 14.2%, p = .006). No other significant differences were observed.This prospective randomized trial supports the implementation of this simple modification for robotic assisted radical prostatectomy with bilateral extended pelvic lymph node dissection.

Our trauma performance improvement initiative recognized missed treatment opportunities for patients undergoing massive transfusion. To improve patient care, we developed a novel cognitive aid in the form of a poster entitled "TACTICS for Hemorrhagic Shock." We hypothesized that this reference and corresponding course would improve the performance of trauma leaders caring for simulated patients requiring massive transfusion.First, residents and physician assistants participated in a one-on-one, socially distanced, screen-based virtual patient simulation. Next, they watched a short presentation introducing the TACTICS visual aid. They then underwent a similar second virtual simulation during which they had access to the reference. In both simulations, the participants were assessed using a scoring system developed to measure their ability to provide appropriate predetermined interventions while leading a trauma resuscitation (score range, 0-100%). Preintervention and postintervention scores were compared using a one-group pre-post within-subject design. Participants' feedback was obtained anonymously.Thirty-two participants (21 residents and 11 physician assistants) completed the course. The median score for the first simulation without the use of the visual aid was 43.8% (interquartile range, 33.3.8-61.5%). Commonly missed treatments included giving tranexamic acid (success rate, 37.5%), treating hypothermia (31.3%), and reversing known anticoagulation (28.1%). All participants' performance improved using the visual aid, and the median score of the second simulation was 89.6% (interquartile range, 79.2-94.8%; p0.001). Ninety-two percent of survey respondents "strongly agreed" that the TACTICS visual aid would be a helpful reference during real-life trauma resuscitations.The TACTICS visual aid is a useful tool for improving the performance of the trauma leader and is now displayed in our emergency department resuscitation rooms. This performance improvement course, the associated simulations, and visual aid are easily and virtually accessible to interested trauma programs.Therapeutic/Care Management; Level IV.

The adequate duration of urinary drainage following colorectal surgery remains debated. The purpose of this study was to compare acute urinary retention (AUR) rates among various durations of urinary catheterization following colon and rectal surgery. We conducted a retrospective analysis of patients undergoing elective colorectal resection enrolled in the Enhanced Recovery After Surgery (ERAS) protocol from 2018 to 2019. Patients were placed into four groups: no catheter placement (NC), catheter removed immediately after surgery (CRAS), removal less than 24 h (CR 24). Our primary endpoint was the rate of AUR in each group. Secondary endpoints included hospital length of stay and urinary tract infections (UTI). A multivariate logistic regression analysis was done to predict AUR. A total 641 patients were included in this study. 27 patients (4.2%) had NC with an AUR rate of 3.7%. 249 patients (38.8%) had CRAS with an AUR rate of 6.8%. 214 patients (33.4%) had CR 24 with an AUR rate of 2.6%. There was no significant difference in AUR among the groups (p = 0.264). In our multivariant logistic regression, pelvic surgery was an independent risk factor for AUR (p = 0.008). There was a statistically significant higher hospital length of stay (p = 0.001) and rate of UTIs (p = 0.017) in patients with prolonged catheterization. Deferral or early removal of urinary catheters is safe and feasible following colorectal surgery without a significant increase in AUR. Avoiding prolonged indwelling urinary catheterization may decrease associated complications such as UTI and hospital length of stay.

Background Identification of novel biomarkers associated with high-risk prostate cancer or biochemical recurrence can drive improvement in detection, prognosis, and treatment. However, studies can be limited by small sample sizes and sparse clinical follow-up data. We utilized a large sample of prostate specimens to identify a predictive model of biochemical recurrence following radical prostatectomy and we validated this model in two external data sets. Methods We analyzed prostate specimens from patients undergoing radical prostatectomy at Hartford Hospital between 2008 and 2011. RNA isolated from formalin-fixed paraffin-embedded prostates was hybridized to a custom Affymetrix microarray. Regularized (least absolute shrinkage and selection operator [Lasso]) Cox regression was performed with cross-validation to identify a model that incorporated gene expression and clinical factors to predict biochemical recurrence, defined as postoperative prostate-specific antigen (PSA) > 0.2 ng/ml or receipt of triggered salvage treatment. Model performance was assessed using time-dependent receiver operating curve (ROC) curves and survival plots. Results A total of 606 prostate specimens with gene expression and both pre- and postoperative PSA data were available for analysis. We identified a model that included Gleason grade and stage as well as five genes (CNRIP1, endoplasmic reticulum protein 44 [ERP44], metaxin-2 [MTX2], Ras homolog family member U [RHOU], and OXR1). Using the Lasso method, we determined that the five gene model independently predicted biochemical recurrence better than a model that included Gleason grade and tumor stage alone. The time-dependent ROCAUC for the five gene signature including Gleason grade and tumor stage was 0.868 compared to an AUC of 0.767 when Gleason grade and tumor stage were included alone. Low and high-risk groups displayed significant differences in their recurrence-free survival curves. The predictive model was subsequently validated on two independent data sets identified through the Gene Expression Omnibus. The model included genes (RHOU, MTX2, and ERP44) that have previously been implicated in prostate cancer biology. Conclusions Expression of a small number of genes is associated with an increased risk of biochemical recurrence independent of classical pathological hallmarks.

To examine the ability of the Decipher test to predict early biochemical recurrence after radical prostatectomy and to impact clinical decisions in advance of metastasis and death.We identified Decipher tests ordered after radical prostatectomy for adverse pathology in men treated for prostate cancer between 1/1/14 and 8/31/18. Biochemical recurrence was defined as prostate-specific antigen 0.02 ng/mL. Decipher score is reported as lower risk ( 0.6) and higher risk ≥ 0.60). Kaplan-Meier analysis was used to examine the relationship between Decipher score and time to biochemical recurrence (months). Cox regression was used to analyze the relationship between Decipher score and time to biochemical recurrence while controlling for a number of clinical characteristics. Secondary analyses focused on a subset of men with prostate-specific antigen 0.02 and 0.20 ng/mL to determine if high-risk Decipher scores were associated with receipt of salvage treatment.A total of 203 cases were analyzed: 37.9% and 62.1% had lower and higher risk Decipher scores respectively, and 56.2% had a biochemical recurrence. Median (inter-quartile range) follow-up was 20 (13.5, 25.3) months. Decipher score was significantly associated with time to biochemical recurrence (p = 0.027) while in the secondary analyses, high-risk Decipher scores (≥ 0.60) were associated with salvage treatment (p = 0.018). Stage category and Decipher score were significant predictors of time from elevated PSA to salvage treatment in the secondary analyses.While it might not contribute statistically, Decipher score can be clinically useful in helping patients reach treatment decisions.

To examine outcomes of surgical procedures for urinary incontinence after radical prostatectomy (post-RP UI) and to identify patients who may benefit from a surgical intervention to treat post-RP UI. A retrospective chart review identified men who underwent radical prostatectomy (RP) from July 2004 through July 2016 at our institution. Cases underwent surgical interventions for UI following RP. Controls had RP during the study period but did not have an intervention for UI following RP. We used the UI scale of the Expanded Prostate Index Composite (EPIC) 26 to: (1) quantify post-RP UI before and after UI intervention overall and for specific surgical procedures; (2) evaluate the significance of improvement in post-RP UI before and after UI intervention and (3) identify controls with levels of post-RP UI that were comparable to the cases. Two thousand nine hundred and sixty-eight RPs were performed; 48 patients underwent further surgical intervention (39 slings, 9 artificial urinary sphincter, AUS). For 20 cases with complete EPIC UI data (15 slings, 5 AUS), the median (IQR) pre-UI intervention score was 27.00 (IQR 22.75–42.75). Improvement was significant overall (p

Background Climacturia affects up to 45% of men after radical prostatectomy (RP). Although urethral slings decrease the severity and frequency of stress incontinence after RP, their efficacy as a treatment for climacturia after RP has not been well studied. Aim The aim of this study was to assess patient-reported changes in climacturia symptoms after implantation of a urethral sling as a treatment for stress incontinence after RP. Methods After Institutional Review Board approval, a retrospective chart review identified males aged 18–80 years who received urethral slings for stress incontinence after RP at our institution from 2012 to 2017. These patients were mailed an 11-item questionnaire asking them about climacturia symptoms before and after implantation of a urethral sling. Written informed consent was obtained from patients participating in the mailed questionnaire. Outcomes Respondents were asked to report on climacturia frequency and severity, bother, partner bother, and incontinence before and after implantation of urethral slings. Results A total of 42 questionnaires were mailed; 17 were available for analysis. The median age (and interquartile range, IQR) of the sample at RP was 64 (59.5, 68.0). Almost all (94.1%) of the men were sexually active at the time of the study and 64.7% reported experiencing urinary leakage during sexual arousal. Most (58.8%) underwent the urethral sling procedure to treat general incontinence; 35.3% underwent the procedure to treat both general incontinence and incontinence during sexual activity and 1 (5.9%) underwent it for other reasons. A median of 28.1 months elapsed between RP and sling procedure (IQR: 18.36, 53.88; minimum: 8.00; maximum: 108.36). Statistically significant shifts toward improvement from presling to postsling were noted for frequency of leakage during sexual arousal or orgasm (P = .041) and for the degree to which leakage of urine during sexual arousal or orgasm was a “bother” (P = .027). While almost all (94%) of the men were incontinent before sling, this percentage dropped to 53% after sling (P = .031). Clinical Implications Urethral slings should be discussed as a treatment strategy for climacturia during clinical consultations with patients. Strengths & Limitations Strengths include consistent surgical technique. Limitations include retrospective design, lack of a nonsling comparison group, subjective nature of outcome measures, possible response bias, and variability in time interval between RP and sling procedure. Conclusion Use of urethral slings after RP is associated with improvements in climacturia symptoms, bother, and incontinence.

Background: Ischemic stroke is a devastating disease, often resulting in death or permanent neurological deficits. EMMPRIN/CD147 is a plasma membrane protein that induces the production of matrix metalloproteinases (MMPs), which contribute to secondary damage after stroke by disrupting the blood brain barrier (BBB) and facilitating peripheral leukocyte infiltration into the brain. Results: CD147 surface expression increased significantly after stroke on infiltrating leukocytes, astrocytes and endothelial cells, but not on resident microglia. Inhibition of CD147 reduced MMP levels, decreased ischemic damage, and improved functional, cognitive and histological outcomes after experimental ischemic stroke in both young and aged mice. In stroke patients, high levels of serum CD147 24 hours after stroke predicted poor functional outcome at 12 months. Brain CD147 levels were correlated with MMP-9 and secondary hemorrhage in post-mortem samples from stroke patients. Conclusions: Acute inhibition of CD147 decreases levels of MMP-9, limits tissue loss, and improves long-term cognitive outcomes following experimental stroke in aged mice. High serum CD147 correlates with poor outcomes in stroke patients. This study identifies CD147 as a novel, clinically relevant target in ischemic stroke.

We sought to identify the most effective way to refer patients with prostate cancer to germline testing.After IRB approval, we queried the electronic medical records (EMR) to identify patients (ages 18-89) with prostate cancer who were referred for or offered germline testing for prostate cancer from May 1, 2019 to February 24, 2021 through either telephone referral, EMR referral or in-office testing. The 3 cohorts were compared on receipt of testing and time to testing. Multivariate logistic regression and Cox regression evaluated the influence of referral cohort and reason for testing on receipt of testing and time to testing, respectively.A total of 184 patients met study inclusion criteria; 47 were referred for germline testing via telephone, 70 were referred through the EMR and 67 were offered testing in the office. No significant demographic or clinical differences were observed. Telephone referral yielded the lowest response (17%; P0.001) with the longest time interval between referral and testing (103 days; P0.001); in-office testing yielded the highest response (66%). More patients were referred because of both family history and high risk characteristics in the EMR and in-office testing cohorts (21.4% and 25.4% respectively). Referral method was significantly (P0.001) associated with receipt of test, while reason for testing was not. Referral method was also independently related to time to testing (P0.001) while reason for referral was not.Urologists should offer germline testing in the office for the most effective and expedient results.

The current utility of MRI-fusion targeted biopsy as either an adjunct to or replacement for systematic template biopsy for the detection of clinically significant prostate cancer is disputed. The purpose of this study is to assess the current effectiveness of MRI-targeted versus systematic template prostate biopsies at two institutions and to consider possible underlying factors that could impact variability between detection rates in our patient population compared to others.A retrospective review from our prospectively maintained prostate cancer databases was conducted. Patients with prostate MRI lesions (PI-RADSv2) receiving concurrent systematic 12-core and MRI-fusion targeted biopsies were reviewed. Clinically significant cancer was considered to be Grade Group ≥ 2.A total of 457 patients were included in the analysis; 255 patients received their biopsy at Institution A and 202 at Institution B. Overall cancer detection rate was 68%; the clinically significant cancer detection rate was 34%. Both MRI-targeted and systematic biopsies identified unique cases of clinically significant prostate cancer that the other modality missed. Out of 157 cases of clinically significant prostate cancer, MRI-targeted biopsy identified 29/157 cases (18%) missed by systematic biopsy, while systematic biopsy identified 37/157 cases (24%) missed by MRI-targeted biopsy (p = .39). Individual biopsy performance was similar when stratified by active surveillance or prior biopsy status, PI-RADSv2 score, and institution.MRI-fusion targeted and systematic biopsy each identified unique cases of clinically significant prostate cancer. Both biopsy modalities should be utilized in order to provide the greatest sensitivity for the detection of clinically significant prostate cancer.

Introduction: Understanding the potential embolic source (PES) in ESUS patients may improve the diagnosis and treatment of such patients. Hypothesis: PES differ in young vs old patients with ESUS. Methods: Young patients (age 18-49) with ESUS who were admitted to our stroke center from 2006 to 2019 were identified retrospectively and matched with next consecutive older patients (age 50-99) with ESUS by admission date. PES were categorized as atrial cardiopathy, AFib diagnosed during follow up, left ventricular disease (LVD), cardiac valvular disease (CVD), PFO or Atrial septal aneurysm (ASA) and arterial disease. Patients who had cancer or a coagulopathy were excluded. Rate of types and number of PES and stroke recurrence were determined and compared between young and older patients. Results: In young patients (55.3% women, median age 39 years), the most common PES was PFO/ASA and rate of other PES was low. Most of young patients had a single PES (54.1%), only 9 of the young patients had multiple PES. In older patients (41.7% women, median age 74 years), the 3 most common PES were atrial cardiopathy, LVD, and arterial disease. More older patients had multiple PES than single PES. More young patients as compared to older patients didn’t have any PES identified. The rate of stroke recurrence was lower in young patients as compared to older patients, the difference approached but did not reach statistical significance. During a median follow up of 3 years, only 3 young patients had recurrent stroke, two of them had unclosed PFO. There were no recurrent strokes among young patients with no PES identified. Among 9 older patients who had recurrent stroke, 6 had atrial cardiopathy, and AFib was detected in 4 patients during follow up. Conclusions: PFO is the only common PES in young patients with ESUS, atrial cardiopathy is the most common PES in old patients with ESUS. Rate of other types of PES and stroke recurrence is low in young patients.

The safe release of a patient from hospital care after bariatric surgery depends upon the achievement of satisfactory health status. Here, we describe a new objective scale (the Readiness for Discharge, RFD Scale) to measure the patient’s suitability for hospital discharge after bariatric surgery. We conducted a retrospective, observational analysis of data collected in a randomized clinical trial of an enhanced recovery after surgery protocol for laparoscopic sleeve gastrectomy from 3/15/2018 to 1/12/2019. Nursing staff assessed 122 patients every 4–8 h after surgery using a checklist to document 5 components: ambulation, vital signs, pain, nausea, and oral intake of clear fluid. Satisfaction of each component was scored as “1” (satisfactory) or “0” (not satisfactory). Scores were summed and analyzed for patterns. RFD = 5 marked the patient as ready for discharge. Sufficient intake of clear liquid was the last RFD component satisfied in 87% of patients. Two overall response patterns emerged: “Steady Progressors” (n = 51) whose RFD score rose steadily from 0 to 5 without reversion to a lower score; and “Oscillators” (n = 71) who had at least one temporary decrease in RFD score on the way to attaining 5, or showed a simultaneous oscillation of components without change in RFD. The RFD checklist allows objective scoring of medical readiness for discharge after LSG and has the potential to improve clinical communication.

INTRODUCTION AND OBJECTIVE:Emerging evidence supports the importance of germline genetic counseling and testing as a key component of prostate cancer (PCa) management. However, there is little guid...

BACKGROUND AND PURPOSE: While there exists a substantial literature on the risk factors and clinical manifestations of cervical artery dissection (CeAD) including carotid and vertebral artery, little is known about postdissection recanalization. The goal of our study was to provide a descriptive analysis of CeAD and recanalization after dissection with neuroimaging follow up. METHODS: We retrospectively analyzed 51 consecutive patients with confirmed diagnoses of CeAD based on neuroimaging. Demographic data, risk factors, and dissection characteristics were recorded. Neuroimaging studies were performed at 0, 3, 6, and >6 months. RESULTS: Among 51 cases, the mean age of dissection (mean ± standard error) was 49.4 ± 1.92 years, and female comprised 58.8% of the patients. Extent of stenosis was 100% dissection in 37.3%, 51%–99% in 41.2%, and

Background Hip fractures typically occur in frail elderly patients. Preoperative specialty consults, in addition to hospitalist comanagement, are often requested for preoperative risk assessment. Objective Determine if preoperative specialty consults meaningfully influence management and outcomes in hip fracture patients, while being comanaged by hospitalists DESIGN: Retrospective cohort study SETTING: Tertiary care hospital in Connecticut PATIENTS: 491 patients aged 50 years and older who underwent surgery for an isolated fragility hip fracture, defined as one occurring from a fall of a height of standing or less. Intervention Presence or absence of a preoperative specialty consult MEASUREMENTS: Time to surgery (TTS), length of hospital stay (LOS), and postoperative complications RESULTS: 177 patients had a preoperative specialty consult. Patients with consults were older and had more comorbidities. Most consult recommendations were minor (72.8%); there was a major recommendation only for eight patients (4.5%). Multivariate analysis demonstrates that consults are more likely to be associated with a TTS beyond 24 hours (Odds Ratio [OR] 4.28 [2.79-6.56]) and 48 hours (OR 2.59 [1.52-4.43]), an extended LOS (OR 2.67 [1.78-4.03]), and a higher 30-day readmission rate (OR 2.11 [1.09-4.08]). A similar 30-day mortality rate was noted in both consult and no-consult groups. Conclusions The majority of preoperative specialty consults did not meaningfully influence management and may have potentially increased morbidity by delaying surgery. Our data suggest that unless a hip fracture patient is unstable and likely to require active management by a consultant, such consults offer limited benefit when weighed against the negative impact of surgical delay.

Patients undergoing Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) have different healthcare needs after surgery. Our aim was to quantify non-routine healthcare utilization after RYGB vs. SG. We compared non-routine (NR) visits made and associated services provided up to 2 years post-surgery for patients undergoing RYGB or SG at a Bariatric Surgery Comprehensive Center between March 2013 and April 2015. A total of 258 and 461 patients had primary RYGB and SG, respectively. Successful follow-up rates at one (76.2%) and 2 years post-surgery (52.6%) did not differ between groups. Rates for all NR visits, expressed as the number per 100 patients, were 68.6 in RYGB vs. 35.4 in SG patients (p

BackgroundMultiple acute cerebral territory infarcts of undetermined origin are typically attributed to cardioembolism, most frequently atrial fibrillation. However, the importance of 3-territory involvement in association with malignancy is under-recognized. We sought to highlight the “Three Territory Sign” (TTS) (bilateral anterior and posterior circulation acute ischemic diffusion-weighted imaging [DWI] lesions), as a radiographic marker of stroke due to malignancy.MethodsWe conducted a single-center retrospective analysis of patients from January 2014 to January 2016, who suffered an acute ischemic stroke with MRI-DWI at our institution, yielding 64 patients with a known malignancy and 167 patients with atrial fibrillation, excluding patients with both to eliminate bias. All DWI images were reviewed for 3-, 2-, and 1-territory lesions. Chi-square test of proportion was used to test significance between the 2 groups.ResultsWe found an association between the groups (malignancy vs atrial fibrillation) and the number of territory infarcts (p < 0.0001). Pairwise comparisons using the Holm p value adjustment showed no difference between 1- and 2-territory patterns (p = 0.465). However, the TTS was 6 times more likely observed within the malignancy cohort as compared to patients with atrial fibrillation (23.4% [n = 15] vs 3.5% [n = 6]) and was different from both 1-territory (p < 0.0001) and 2-territory patterns (p = 0.0032).ConclusionThe TTS is a highly specific marker and 6 times more frequently observed in malignancy-related ischemic stroke than atrial fibrillation-related ischemic stroke. Evaluation for underlying malignancy in patients with the TTS is reasonable in patients with undetermined etiology.

The adequate duration of urinary drainage following colorectal surgery remains debated. The purpose of this study was to compare acute urinary retention (AUR) rates among various durations of urinary catheterization following colon and rectal surgery.We conducted a retrospective analysis of patients undergoing elective colorectal resection enrolled in the Enhanced Recovery After Surgery (ERAS) protocol from 2018 to 2019. Patients were placed into four groups: no catheter placement (NC), catheter removed immediately after surgery (CRAS), removal less than 24 h (CR 24), and removal greater than 24 h (CR 24). Our primary endpoint was the rate of AUR in each group. Secondary endpoints included hospital length of stay and urinary tract infections (UTI). A multivariate logistic regression analysis was done to predict AUR.A total 641 patients were included in this study. 27 patients (4.2%) had NC with an AUR rate of 3.7%. 249 patients (38.8%) had CRAS with an AUR rate of 6.8%. 214 patients (33.4%) had CR 24 with an AUR rate of 4.2%. 151 patients (23.6%) had CR 24 with an AUR rate of 2.6%. There was no significant difference in AUR among the groups (p = 0.264). In our multivariant logistic regression, pelvic surgery was an independent risk factor for AUR (p = 0.008). There was a statistically significant higher hospital length of stay (p = 0.001) and rate of UTIs (p = 0.017) in patients with prolonged catheterization.Deferral or early removal of urinary catheters is safe and feasible following colorectal surgery without a significant increase in AUR. Avoiding prolonged indwelling urinary catheterization may decrease associated complications such as UTI and hospital length of stay.

Trigger finger (TF) and carpal tunnel syndrome (CTS) are common conditions often occurring together with an unclear relationship. While some studies conclude that TFs occur as a result of carpal tunnel release (CTR), others have not established a causal relationship. Our purpose was to evaluate the prevalence and timing of TF development in the same hand after open CTR in our population. This was a retrospective review of 497 patients undergoing open CTR by a single surgeon. Two hundred twenty-nine charts were analysed for age, gender, handedness, BMI, workers' compensation status, and background disease. We analysed the specific digit involved and timing to development of triggering after CTR. Thirty-one patients developed triggering after CTR (13.5%). Mean age was 52.5 (14.0) years. Follow-up ranged from 1 to 53 months with a median follow-up of 6 months (interquartile range = 2-13). The thumb was the most common to trigger (42.22%), followed by the ring 24.44%, middle 22.22%, little 8.89%, and index fingers 2.22%. Trigger thumb occurred at 3.5 months (3.6) post-operatively, while other digits triggered at 7.5 months (4-10.25) after surgery (Le doigt à ressort et le syndrome du canal carpien sont des affections courantes et souvent conjuguées, sans qu’on en comprenne exactement le lien. Selon certaines études, le doigt à ressort se produit après une libération du canal carpien (LCC), mais selon d’autres, ce lien n’existe pas. Les chercheurs ont voulu évaluer la prévalence et le moment d’apparition des doigts à ressort après une LCC de la même main au sein de leur population. Les chercheurs ont réalisé la présente étude rétrospective auprès de 497 patients chez qui le même chirurgien avait effectué une LCC ouverte. Ils ont examiné 229 dossiers pour tenir compte de l’âge, du genre, de la manualité, de l’indice de masse corporelle, du droit ou non à l’indemnisation des travailleurs et des maladies sous-jacentes. Ils ont analysé le doigt touché et le moment de l’apparition du problème après la LCC. Trente et un patients, d’un âge moyen de 52,5 ans (14,0), ont présenté un doigt à ressort après une LCC (13,5 %). Les suivis ont duré de un à 53 mois, pour une médiane de six mois (intervalle interquartile = 2 et 13). Le pouce était le plus touché (42,22 %), succédé par l’annulaire, à 24,44 %, le majeur, à 22,22 %, l’auriculaire, à 8,89 %, et l’index, à 2,22 %. Le pouce à ressort se déclarait 3.5 mois (3 et 6) après l’opération, mais les autres doigts étaient touchés 7,5 mois (4 et 10,25) après l’opération (

Objective Up to 14% of patients undergoing carotid endarterectomy with continuous electroencephalographic (EEG) neuromonitoring will require shunt placement because of EEG changes. However, the initial studies of transcarotid artery revascularization (TCAR) found only one patient with temporary EEG changes. We report our experience with intraoperative EEG monitoring during TCAR. Methods We conducted a retrospective review of patients who underwent TCAR at two urban hospitals within an integrated healthcare network from May 2017 to January 2020. The data included demographic information, patient comorbidities, symptom status, previous carotid interventions, anatomic details, contralateral disease, intraoperative vital signs and EEG changes, and postoperative major adverse events (transient ischemic attack, stroke, myocardial infarction [MI], and death) both initially and at 30 days postoperatively. The Fisher exact test was used for categorical data and the Wilcoxon rank sum test for continuous data. Results A total of 89 patients underwent TCAR during the study period, of whom 71 (79.8%) received intraoperative EEG neuromonitoring. Of the 89 patients, 70.8% were men and 29.2% were women. The median age was 75 years (IQR, 68-82.5 years). Symptomatic patients accounted for 41.6% of the cohort. Of the 71 patients who received continuous neuromonitoring, 9 experienced EEG changes during TCAR (12.7%). The changes resolved in seven patients with pressure augmentation in three and switching to a low flow toggle in three. One patient who had sustained EEG changes had a new postoperative neurologic deficit. The median carotid stenosis percentage on preoperative computed tomography angiography was lower for patients with EEG changes than for those without (67% vs 80%; P = .01). No correlation was found between symptom status or 30-day stroke in patients with and without EEG changes (P = .49 and P = .24, respectively). Overall, three postoperative strokes, two postoperative deaths, and one MI occurred, for a composite 30-day stroke, death, and MI rate of 6.7%. Conclusions Changes in continuous EEG monitoring were more frequent in our study than previously reported. Less severe carotid stenosis might be associated with a greater incidence of EEG changes. Limited data are available on the prognostic ability of EEG to detect clinically relevant changes during TCAR, and further studies are warranted.

We evaluated the utility of C peptide as an addition to the DiaRem score for predicting type 2 diabetes (T2D) remission 1 year after bariatric surgery in 175 patients. DiaRem score was significantly correlated with C peptide (r = − .43; p < .001). Both DiaRem and C peptide were significant predictors of remission of T2D (OR (95% CI) = .81 (.75–.86); p < 0001 and OR (95% CI) = 1.35 (1.15–1.60); p < .001, respectively). ROC analysis indicated that DiaRem was a significantly stronger predictor than C peptide (p < .001). Hierarchical regression indicated that C peptide failed to significantly improve the prediction of diabetes remission after accounting for DiaRem (OR (95% CI) = 1.079 (.87–1.26); p = .406). This study does not support the inclusion of C peptide in the DiaRem algorithm.

Background Sex differences in stroke have been attributed to the neuroprotective effects of estrogen, yet most clinical trials of estrogen supplementation for stroke prevention have failed. The contribution of sex hormones to stroke outcome remains a subject of debate. Aromatization of testosterone to estradiol in neural tissue leads to sexual differentiation. Emerging data suggests aromatase activity increases in response to brain injury, and increased aromatase expression is seen in the ischemic penumbra in animal models. The objective of this study was to examine the levels of endogenous sex steroids after acute ischemic stroke and determine if levels of sex steroids were associated with acute stroke outcomes. Methods Peripheral blood from ischemic stroke patients and controls was collected under an approved IRB within 24 h of symptom onset. 17β-estradiol, testosterone, and aromatase levels were measured in the serum of both men and women using ELISA. Hormone levels were compared in men vs. women in stroke and control groups and correlated with outcomes (NIHSS and change in the modified Rankin Scale (mRS), defined as the difference of premorbid and discharge mRS) using multivariate regression. Results We found no significant difference in estradiol levels 24 h after stroke in men (p = 0.86) or women (p = 0.10). In men, testosterone significantly decreased after stroke as compared with controls (1.83 ± 0.12 vs. 2.86 ± 0.65, p = 0.01). Aromatase levels were significantly increased in women after stroke as compared with controls (2.27 ± 0.22 vs. 0.97 ± 0.22, p = 0.002), but not in men (p = 0.84). Estradiol levels positively correlated with change in mRS in both women (r = 0.38, p = 0.02) and men (r = 0.3, p = 0.04). Conclusions Estradiol levels correlated with functional outcomes (change in mRS) in both men and women, at least in the acute phase (24 h) of stroke. However, no significant difference in estradiol levels is seen 24 h post-stroke in men or women. Testosterone levels decrease at 24 h after stroke in men. As seen in animal models, aromatase levels increase after acute ischemic stroke, but this was only true for women. These indicate an active aromatization process in post-menopausal women after acute ischemic stroke.

Background: Post stroke care is multifaceted and should not end at hospital discharge. Patients often lack understanding of the importance of outpatient care to prevent secondary stroke. Objective: To demonstrate the positive impact of a stroke nurse navigator in improving the post-acute transition of care by promoting outpatient follow up after hospitalization. Methods: We retrospectively reviewed all patients discharged from our comprehensive stroke center (excluding hospice) with a primary diagnosis of ischemic or hemorrhagic stroke from January -December 2018, yielding 685 patients. We evaluated whether or not our nurse navigator influenced three aspects of follow up: if stroke clinic appointment was made before discharge, if patient attended the appointment and if patient called the clinic after discharge. Four categories were used based on level of navigator contact with the patient: (SC) Seen in-house and called within 30 days after discharge, (S) Seen only, (C) Called only or (N) No navigator contact. Chi-square test of proportions was used to evaluate the statistical significance among all four groups. Results: Out of the 685 patients, 77.5% (n=531) were scheduled for clinic follow-up before discharge, 60.7% (n=416) attended the appointment and 20% called after discharge (n=137). The distribution of navigator contact level was (SC) 26.7%, (S) 17.5%, (C) 19.3% and (N) 36.5%. Both seeing and calling the patient was proven to be the most effective in all three areas: appointment made prior to discharge (SC) 89.6%, (S) 82.5%, (C) 74.2%, (N) 68% ( p= ); patient attended the appointment (SC) 68.9%, (S) 60%, (C ) 65.9%, (N) 52.4% ( p=0.001 ) and patient called the clinic after discharge (SC) 26.2%, (S) 15.8%, (C ) 23.5%, (N) 15.6% ( p=0.02 ). Of interest, patients who were only called but not seen were more likely to attend the appointment or call the clinic as compared to being seen alone. Conclusion: Contact with our nurse navigator increased post-acute follow up in our stroke clinic. An increased number of patient calls associated with navigator interaction showed these patients had a better understanding of the need for continued care. The nurse navigator improves continuity of post-acute care.

Background: A significant proportion of patients are unable to return to work (RTW) post stroke. While post-stroke depression and fatigue have been linked to patients’ RTW status, the role of discharge NIHSS has not been studied. Objective: To evaluate role of stroke severity, depression, fatigue, and cognitive impairment on patients’ ability to RTW. Methods: A retrospective study was conducted using a survey completed by a convenience sample of patients during follow-up in stroke clinic. The survey included PHQ-9, Fatigue Assessment Scale (FAS), and the Montreal Cognitive Assessment (MoCA). Demographic, work status, and clinical data (discharge NIHSS, mRS, medical history) were also collected. NIHSS was evaluated both continuously and dichotomized ( < 1, > 1). Patients who did and did not RTW were compared using chi square tests of proportions and Wilcox Ranked Sum tests; independence of factors was explored using logistic regression predicting RTW. Results: Out of 135 patients surveyed, 41% (N=56) reported employment at the time of their stroke. Of those, a significant percentage of patients were unable to RTW post stroke (57.1%); 39.3% (N=22) were unable to RTW due to physical limitations. Further analysis revealed patients who did not RTW were more likely to suffer from fatigue (p=0.026), have higher rates of cognitive impairment (p=0.027) and a higher NIHSS at discharge (p Conclusions: For patients with mild stroke, NIHSS at discharge indicating minimal to no disability is a strong independent predictor for RTW status. For patients with greater deficit, depression, fatigue and cognitive impairment could play a greater role; additional studies of patients with greater variety of stroke severity would be needed.

Introduction: Treating patients suspect of acute stroke requires efficient multidisciplinary teamwork in order to provide appropriate care. Several “Lean Management” methods have been applied in a variety of healthcare settings. Kaizen, meaning “improvement” in Japanese is a tool which emphasizes empowerment of employees on creating value streams to identify and reduce wastes, synchronize work flow processes, manage variability, and devise communication and sustainability plans. We report on the use of this methodology to improve our acute stroke care metrics. Objective: To optimize the management of the acute stroke patient flow process from the emergency department ED to destination therapy by applying the Kaizen methods. Methodes: This is a quality improvement project designed to evaluate the efficiency of the new workflow model for acute stroke that was put into place June 2018 at Hartford Hospital. A 5 day event spent involving all stakeholders from patient registration to destination treatment (IV or mechanical thrombolytic therapy) were conducted. During this event, a time work flow process for the management of suspected stroke patients was identified and an appropriate plan was formulated to reduce times. The following parameters were utilized: Door to CT scanner time (DTCT), Door to drug (IV-tPA) (DTD), and Door to mechanical thrombectomy puncture time (DTP). We included all stroke patients presenting to the ED and treated at our institution 6 months prior and post implementation. A non-parametric analysis was utilized. Results: A total of 135 patients were included in this analysis, 60 prior and 75 post Kaizen. Improvement across all parameters was observed post Kaizen with an average reduction time of DTCT 5 min, DTD 5min, and DTP 22min. The median times pre-Kaizen were; DCT 14min IQR 6-27, DTD 55min IQR 43.5-77.5, and DTP 128min IQR 88-151. The median times post-Kaizen were; DTCT 9min IQR 6-23, DTD 50.5min IQR 37-64, and DTP 106 min IQR 83.5-141.5. Conclusion: By utilizing the Kaizen, we identified numerous opportunities to reduce variability, standardize workflow processes, and ultimately reduce all parameter times. As time is brain, reducing pretreatment times favorably impacts patients’ outcomes and reduces morbidity in stroke.

Introduction: Acute ischemic stroke treatment has undergone a paradigm shift, with patients being treated in the extended time window (6-24 hours post symptom onset). The purpose of this study is to assess outcomes in stroke patients above 80 years of age undergoing endovascular treatment (EVT) in the extended time window. Methods: Acute ischemic stroke patients presenting to Hartford Hospital between January 2017 to June 2019 were considered for the study. Stroke outcomes in patients above 80 years of age with anterior circulation ischemic strokes presenting in the extended time window (Group A, n=30) were compared to a younger cohort of patients below 80 years (Group B, n=31). Patients over 80 years treated in the traditional time window (within 6 hours of symptom onset) served as a second set of controls (Group C, n=40). Statistical analysis was performed with a significance level of 0.05 Results: For angiographic results, there were no statistically significant differences in terms of good outcomes (TICI 2b-3) among patients of Group A, when compared to Groups B or C (p>0.05). For the endovascular procedures, no significant differences were noted in the total fluoroscopy time (Median Group A 44.05, Group B 38.1, Group C 35.25 min), total intra-procedure time (Median Group A 144, Group B 143, Group C 126 min) or total radiation exposure (Median Group A 8308, Group B 8960, Group C 8318 uGy-m 2 ). For stroke outcomes, a good clinical outcome was defined as modified Rankin score of 0-2 at discharge. Significantly better outcomes were noted in the younger patients in Group B - 35.4%, when compared to 13.3% in Group A (p=0.03). Comparative outcomes differed in the elderly patients above 80 years, Group A -13.3% vs Group C - 25%, although not statistically significant (p=0.23). There was a significant difference in mortality in patients of Group A - 40% as compared to 12% in the younger cohort, Group B (p= 0.01). Conclusions: In the extended time window, patients above 80 years of age were noted to have a higher mortality, morbidity compared to the younger cohort of patients. No significant differences were noted in the stroke outcomes in patients above 80 years of age when comparing the traditional and the extended time window for stroke treatment.

Background: Stroke impacts several aspects of patients’ lives and sexual dysfunction post stroke has been reported in 40%-50% of patients. Current investigations have revealed links to depression, however this has not been examined specifically in mild stroke. Objective: To determine prevalence and factors associated with sexual dysfunction after mild stroke Design/methods: A retrospective study was conducted on a self-report questionnaire completed by a convenience sample of patients during a hospital follow-up appointment in the stroke clinic. Patients were asked about sexual dysfunction after stroke and if yes, to specify the cause: safety concern, physical limitation, consequence or change in libido. In addition, patients completed a PHQ-9 to measure depression, Fatigue Assessment Scale (FAS), and the Montreal Cognitive Assessment (MoCA). A thorough review of clinical history including NIHSS, mRS and demographics was completed by researchers. Descriptive statistics were used to identify and understand the patient population. Mild stroke was defined as NIHSS ≤ 5. Results: In our study of 135 patients, 21 (16%) did not respond to the sexual dysfunction question. Of the 114 who responded, only 11 (9.6%) reported sexual dysfunction and 9 (81%) attributed their sexual dysfunction to physical limitations. Descriptive statistics of the respondent subgroup indicate that the cohort was 59% male with a median (IQR) age of 64 (57,75) and that 52% were living with someone at the time. The mean NIHSS on discharge was 1 (IQR 0-3) and 77% were ischemic strokes. Few patients experienced post stroke depression (21.9%, N=25), and the cohort reported low levels of fatigue (median FAS=19). Low incidence and response rates precluded an analysis of specific predictors in this cohort. Conclusion: Physical limitations are reported to be the main cause of post stroke sexual dysfunction. Roughly 1 in 10 patients with mild stroke reported experiencing sexual dysfunction, however twice as many did not respond to the question. Therefore, the true incidence is unclear, prompting the need for further investigation on post stroke sexual dysfunction in mild stroke.

Background: Intracerebral hemorrhage (ICH) is a devastating condition with high 30- day mortality. Up to a third of patients experience hematoma expansion within the first 24 hours; anticoagulation with factor Xa inhibitors may increase the risk of expansion and poor outcomes. Objective: We assessed our experience using Andexanet alfa (Aα) by evaluating stabilization of the hematoma and ischemic complications. Methods: We conducted a single center prospective observational study on all patients receiving Aα for reversal of anticoagulation in the setting of an ICH and use of Factor Xa inhibitors. The degree of hematoma expansion within 12 hours of drug administration on non-contrast head CT was categorized as 'excellent' (> 20-> 35%). Secondary outcomes included dosage, median length of stay, mortality, modified Rankin score (mRS), discharge disposition, and ischemic complications. Results: Fifteen patients received Aα (5=lobar, 5=deep, 5= multicompartment). One patient with a presumed deep hemorrhage was excluded because subsequent imaging showed chronic mineralization. The predominant etiologies were hypertension (40%), amyloid angiopathy (26.6%) and trauma (13.3%). The median age was 86 years (IQR 19) and median ICH score on arrival was 2 (IQR 2), and median hematoma size was 14.3 mL (IQR 34.5). Most patients (71.4%) received the low dose formulation. Based on hematoma expansion, 64.3%, 14.3% and 21.4% of patients achieved excellent, good and poor hemostasis, respectively. Reduction in hematoma size was seen in 20% (n=3) while 13.3% (n=2) patients had no expansion. Median ICU and hospital length of stays were 2.0 days (IQR 2.2) and 6.6 days (IQR 9.78) respectively. Mortality was 28.6% and median mRS upon discharge was 4 (IQR 2), with most patients discharged to rehabilitation facilities (60%). There were no ischemic complications. Conclusion: Our experience is consistent with the results of the ANNEXA 4 study with 78.6% of patients showing excellent or good hemostasis. These results led to improved clinical outcomes, with 60% of patients being discharged to rehabilitation. These data support the efficacy of this treatment paradigm in a real-world setting.

STK-OP-1 examines transfer times for patients going to a higher level of care. Known as door in, door out or DIDO, certified stroke centers are required to report times for both ischemic and hemorrhagic stroke patients transferred to a Primary or Comprehensive Stroke Center (CSC). Purpose: Barriers to time-sensitive transfer and complex decision making are common. As a result, Hartford Healthcare (HHC) began a QI initiative to measure DIDO times while introducing advanced CTP imaging and treatment in the extended window, April 2018. This project evaluates the impact on DIDO. Methods: This multi-center QI project evaluated data pre and post implementation for stroke transfers to the CSC. Pre-implementation was May 2017 to April 2018, post-implementation May 2018 to March 2019. Patient and process of care data abstracted from Epic was entered into Excel. The main analysis compared median DIDO times using Wilcoxon Ranked Sum. Results: Data were collected on hospital, stroke type/severity and treatments administered; patient demographics, and key timing variables of door in/door out, EMS and CT. While there is no universal criterion for DIDO, 60 minutes is often the ultimate goal with 90 or 120 minutes as intermediate goals. Pre and post implementation median DIDO times for all hospitals were 117 and 139 minutes (p = 0.02), for HHC hospitals 115 and 137 minutes (p = 0.027) and for non-HHC hospitals 118 and 140.5 minutes (p = 0.423). Of the pre-implementation group, 7.8% had CTP imaging prior to transfer compared with 9.3% post. Extended times post-implementation include factors such as complex decision making, patient eligibility or hospital capacity issues. A new transfer algorithm was implemented April 2019. Future analyses will correlate DIDO with patient, stroke and treatment categories to better define delays and barriers. Relevance: A JC directive to CSCs are to develop supportive relationships with referring hospitals to facilitate efficient care. As decision making becomes more complex, the process for transfer needs to improve. DIDO goals need to be realistic to prevent secondary imaging at the CSC, i.e. the tradeoff for an extra 15 or 20 minutes should translate into shorter door to puncture times. Reducing the time to treatment may help improve patient outcomes.

We compared pathological and biochemical outcomes after radical prostatectomy in patients at favorable intermediate risk who fulfilled current NCCNWe queried our institutional review board approved prostate cancer database for patients who met NCCN criteria for very low risk (T1c, Grade Group 1, 3 or fewer of 12 cores, 50% or less core volume and prostate specific antigen density less than 0.15 ng/ml), low risk (T1-T2a, Grade Group 1 and prostate specific antigen less than 10 ng/ml) or favorable intermediate risk (major pattern grade 3 and less than 50% positive biopsy cores) and who had 1 intermediate risk factor, including T2b/c, Grade Group 2 or prostate specific antigen 10 to 20 ng/ml. Men at intermediate risk who did not meet favorable criteria were labeled as being at unfavorable intermediate risk. Patients at favorable intermediate risk were compared to those at very low and low risk, and those at unfavorable intermediate risk to identify differences in rates of adverse pathological findings at radical prostatectomy, including Gleason score Grade Group 3-5, nonorgan confined disease or nodal involvement. Time to biochemical recurrence was compared among the groups using Cox regression.A total of 3,686 patients underwent radical prostatectomy between January 1, 2014 and December 31, 2015. Of these men 1,454, 250 and 1,362 fulfilled the criteria for low, favorable intermediate and unfavorable intermediate risk, respectively. The rate of adverse pathological findings in favorable intermediate risk cases was significantly higher than in low risk cases and significantly lower than in unfavorable intermediate risk cases (27.4% vs 14.8% and 48.5%, respectively, each p0.001). Time to biochemical recurrence differed significantly among the risk groups (p0.001).Relative to men at low risk those at favorable intermediate risk represent a distinct group. Care should be taken when selecting these patients for active surveillance and monitoring them once they are in an active surveillance program.