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Sara S McCoy,1 Zubin Mukadam,2 Keith C Meyer,2 Jeffrey P Kanne,3 Cristopher A Meyer,3 Maria D Martin,3 Emmanuel Sampene,4 Scott W Aesif,5 Laurie N Rice,6 Christie M Bartels1 1Division of Rheumatology, Department of Internal Medicine, School of Medicine and Public Health, University of Wisconsin, Madison, WI 53705, USA; 2Division of Pulmonary and Critical Care, Department of Internal Medicine, School of Medicine and Public Health, University of Wisconsin, Madison, WI 53705, USA; 3Department of Radiology, University of Wisconsin, Madison, WI 53792-3252, USA; 4Department of Biostatistics, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA; 5Department of Pathology, University of Wisconsin, Madison, WI 53792-3252, USA; 6Department of Pulmonology, SSM Health Dean Medical Group, Madison, WI 53715, USA Objectives: International experts recently characterized interstitial pneumonia with autoimmune features (IPAF) as a provisional diagnosis for patients with interstitial lung disease who have characteristics of autoimmune disease but do not meet criteria for a specific autoimmune disease. We describe clinical characteristics of IPAF patients and examine responses to mycophenolate as a therapy for IPAF.Methods: This retrospective cohort included adult patients meeting European Respiratory Society/American Thoracic Society classification criteria for IPAF. Sociodemographic, clinical, and pulmonary function test data were abstracted for patients with and without mycophenolate treatment and followed longitudinally from interstitial lung disease diagnosis for change in pulmonary function test results.Results: We identified 52 patients who met criteria for IPAF. Of 52 IPAF patients, 24 did not receive mycophenolate and 28 did, with median time to mycophenolate treatment 22 months. Changes in FVC% and percentage predicted lung diffusion capacity for carbon monoxide (DLCO%) between the mycophenolate-treated and untreated groups were not significantly different (FVC% change P=0.08, DLCO% change P=0.17). However, there was a trend toward more rapid baseline decline of both FVC% and DLCO% in the mycophenolate-treated cohort before vs after mycophenolate therapy. The slope of both FVC% and DLCO% values improved after onset of mycophenolate exposure for the treated group, although this finding was not statistically significant.Conclusion: Patients with IPAF might benefit from mycophenolate therapy. Larger prospective clinical trials are needed to evaluate the efficacy of mycophenolate for patients who meet criteria for IPAF. Keywords: interstitial lung disease, autoimmune disease, connective tissue disease, myco­phenolate

OBJECTIVES:. Continuous renal replacement therapy (CRRT) and shock are both associated with high morbidity and mortality in the ICU. Adult data suggest renoprotective effects of vasopressin vs. catecholamines (norepinephrine and epinephrine). We aimed to determine whether vasopressin use during CRRT was associated with improved kidney outcomes in children and young adults. DESIGN:. Secondary analysis of Worldwide Exploration of Renal Replacement Outcomes Collaborative in Kidney Disease (WE-ROCK), a multicenter, retrospective cohort study. SETTING:. Neonatal, cardiac, PICUs at 34 centers internationally from January 1, 2015, to December 31, 2021. PATIENTS/SUBJECTS:. Patients younger than 25 years receiving CRRT for acute kidney injury and/or fluid overload and requiring vasopressors. Patients receiving vasopressin were compared with patients receiving only norepinephrine/epinephrine. The impact of timing of vasopressin relative to CRRT start was assessed by categorizing patients as: early (on or before day 0), intermediate (days 1–2), and late (days 3–7). INTERVENTIONS:. None. MEASUREMENTS AND MAIN RESULTS:. Of 1016 patients, 665 (65%) required vasopressors in the first week of CRRT. Of 665, 248 (37%) received vasopressin, 473 (71%) experienced Major Adverse Kidney Events at 90 days (MAKE-90) (death, renal replacement therapy dependence, and/or > 125% increase in serum creatinine from baseline 90 days from CRRT initiation), and 195 (29%) liberated from CRRT on the first attempt within 28 days. Receipt of vasopressin was associated with higher odds of MAKE-90 (adjusted odds ratio [aOR], 1.80; 95% CI, 1.20–2.71; p = 0.005) but not liberation success. In the vasopressin group, intermediate/late initiation was associated with higher odds of MAKE-90 (aOR, 2.67; 95% CI, 1.17–6.11; p = 0.02) compared with early initiation. CONCLUSIONS:. Nearly two-thirds of children and young adults receiving CRRT required vasopressors, including over one-third who received vasopressin. Receipt of vasopressin was associated with more MAKE-90, although earlier initiation in those who received it appears beneficial. Prospective studies are needed to understand the appropriate timing, dose, and subpopulation for use of vasopressin.

Background: The role of neoadjuvant therapy (NAT) in gallbladder cancer (GBC) is not well established. We sought to evaluate the effect of NAT on postoperative outcomes following surgical resection of GBC. We hypothesized that patients receiving NAT would have similar rates of 30-day mortality, readmission, and postoperative complications (e.g. bile leakage and liver failure) compared to those who did not receive NAT. Methods: The 2014–2017 American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) Procedure-Targeted Hepatectomy database was queried for patients that underwent surgery for GBC. Propensity scores were calculated to match patients in a 1:2 ratio based on age, comorbidities, functional status, and tumor staging. Results: A total of 37 patients undergoing NAT were matched to 74 patients without NAT. There was no difference in any matched characteristics. Compared to the NAT group, the no NAT cohort had similar rates of postoperative bile leakage (NAT 13.5 % vs. no NAT 10.8 %, p = 0.31), postoperative liver failure (5.4 %, vs. 8.1 %, p = 0.60), 30-day readmission (10.8 % vs. 10.8 %, p = 1.00), and 30-day mortality (10.8 % vs. 2.7 %, p = 0.075). All 30-day complications were similar except for a higher rate of postoperative blood transfusion (NAT 32.4 % vs. no NAT 10.8 %, p = 0.005). Conclusion: In patients undergoing surgical resection for GBC, those with and without NAT had similar rates of readmission and 30-day mortality, however NAT was associated with an increased risk for transfusion. Despite use of a large national database, this study may be underpowered to adequately assess the effect of NAT on perioperative GBC outcomes and thus warrants further investigation.

Objectives: Patients with non–small cell lung cancer treated with immunotherapy and modern chemoradiation regimens show improved progression-free and overall survival. However, patients with limited oligo-progression represent a potential population in which local therapy such as surgery may have a potential role as salvage treatment. The objectives of our study were to evaluate the feasibility and safety of salvage lung resection after immunotherapy in patients with non–small cell lung cancer. Methods: The National Cancer Database was queried for patients diagnosed and treated for non–small cell lung cancer stage I to IV, from 2013 to 2020. Patients who underwent surgery as salvage after immunotherapy were defined as undergoing surgery >5 months from the initiation of immunotherapy. As a sensitivity analysis, patients who underwent surgery as salvage after chemoradiation were also analyzed in a similar fashion. Surgical outcomes such as type of surgery, complete resection (R0) rates, and complete pathologic response rates were determined for feasibility. Length of stay, 30-day readmission rates, and 30-day mortality rates were determined and overall survivals were estimated with Kaplan-Meier analysis to evaluate for safety. Results: Of the 934,093 patients diagnosed with non–small cell lung cancer stage I to IV from 2013 to 2020, 164 patients received immunotherapy and after 5 months underwent surgery. Lobectomy was the most commonly performed operation (74%) and pneumonectomy was required in 9% (n = 15). R0 resection was achieved in 89% (n = 146) and of these patients, 23% (n = 37) had complete pathologic response. Median length of stay was 4 days, 30-day readmission was 5%, and 30-day mortality was 0.6%. In our sensitivity analysis of chemoradiation patients (n = 445), the above data were similar to previously reported cohort studies of patients undergoing chemoradiation and subsequently salvage surgery. Conclusions: Lung resection after immunotherapy appears to be a feasible salvage treatment option, with lobectomy being most common and with high R0 resection rates. Low patient morbidity and mortality rates also suggest the safety of this approach. Salvage surgery may be considered in patients who have oligo-progression after immunotherapy within the context of a comprehensive multidisciplinary treatment plan.

Background: Patients with partial thickness rotator cuff tears (PTRCTs) often present with concurrent pathology of the long head of the biceps tendon (LHBT). To address both conditions simultaneously, long head of the biceps (LHB) tenotomy or tenodesis can be performed at the time of arthroscopic rotator cuff repair (RCR). This study aims to compare postoperative shoulder active range of motion (AROM) and complications following transtendinous RCR with concurrent LHB tenodesis or tenotomy. Methods: A total of 90 patients with PTRCTs met inclusion criteria for this study. Patients who underwent tear-completion-and-repair, revision surgery, or open repair of the LHB tendon were excluded. Patients were stratified into tenotomy, arthroscopic suprapectoral tenodesis, or no biceps operation cohorts and were propensity matched 1:1:1 on age, sex, body mass index, and smoking status. Primary outcome measures included AROM in forward flexion, abduction, external rotation, and internal rotation at 6 weeks, 3 months, and 6 months postoperatively. The development of severe stiffness and rates of rotator cuff retear at final follow-up were recorded as secondary outcomes. Results: When comparing the tenotomy and tenodesis cohorts, tenotomy patients were found to have increased AROM at 3 months in forward flexion (153.2° vs. 130.1°, P = .004), abduction (138.6° vs. 114.2°, P = .019), and external rotation (60.4° vs. 43.8°, P = .014), with differences in forward flexion remaining significant at 6 months (162.4° vs. 149.4°, P = .009). There were no significant differences in interval rates of recovery in any plane between cohorts. Additionally, there were no significant differences in rates of symptomatic retears between groups (P = .458). Rates of severe postoperative stiffness approached but did not achieve statistical significance between tenotomy (4.2%) and tenodesis (29.2%) cohorts (P = .066). Smoking status was a significant predictor of severe stiffness (odds ratio, 13.69; P = .010). Conclusion: Despite significant differences in absolute AROM between cohorts, the decision to perform tenotomy or tenodesis was not found to differentially affect rates of AROM recovery for patients undergoing arthroscopic transtendinous RCR for PTRCT. Notably, however, transient stiffness complications were more commonly observed in smokers, and data trends suggested an increased risk of stiffness for patients undergoing LHB tenodesis. Overall, postoperative stiffness is likely multifactorial and attributable to both patient- and procedure-specific factors, and LHB tenotomy may be more appropriate for patients with risk factors for developing stiffness postoperatively.

Background: The Latarjet procedure was developed for the treatment of anterior shoulder instability in young, high-demand patients with attritional glenoid bone loss, whose risk of redislocation following primary dislocation may exceed 90%. Coracoid graft osteolysis and prominent screws are commonly observed in late computed tomography (CT) scans of patients who re-present following the procedure, but the clinical relevance of osteolysis in the overall Latarjet cohort is undetermined. We aimed to evaluate clinical and radiological outcomes in patients who underwent the Latarjet procedure, and to determine if severe coracoid graft osteolysis compromised clinical outcomes. Methods: This was a retrospective analysis of patients who underwent the open Latarjet procedure. Patients were invited via an e-questionnaire that contained a Western Ontario Shoulder Instability Index (WOSI), and queried about redislocation and reoperation since index surgery. Preoperative glenoid bone loss was calculated on CT using the best-fit circle method. Osteolysis was graded (0, screw head buried in graft; 1, screw head exposed; 2, threads exposed; 3, complete resorption/severe osteolysis) at the level of the proximal and distal screws respectively, on axial CT scans performed ≥ 12 months postoperatively. Results: Between 2011 and 2022, a single surgeon performed 442 Latarjet procedures. One hundred fifty eight patients responded to the questionnaire at median (interquartile range [IQR]) 44 (27-70) months postoperatively, among whom the median (IQR) WOSI score was 352 (142-666) points (0 = best, 2100 = worst). Recurrent anterior instability occurred in 3/158 (2%) patients. One patient required reoperation for this indication. Among patients who had CT scans ≥ 12 months postoperatively (median [IQR] 40 [29-69] months), 1 patient developed severe osteolysis around both screws (WOSI = 90), 17/62 (27%) patients developed severe osteolysis around 1 screw, all of which were proximal (median [IQR] WOSI = 235 [135-644]), and 44/62 (71%) patients did not develop severe osteolysis around either screw (median [IQR] WOSI = 487 [177-815]). There were no statistically significant differences in WOSI scores between groups based on the presence of severe osteolysis. Conclusion: The Latarjet is reliable procedure that has a low rate of redislocation and reoperation. Severe coracoid graft osteolysis occurs with time, and always affects the proximal graft first. The presence of severe osteolysis did not compromise clinical outcomes.

Background: While studies have assessed comparative rates of restoration of shoulder function and alleviation of symptoms, comparative systemic postoperative complication rates between biceps tenotomy and tenodesis have yet to be assessed. The purpose of the present study was to use a national administrative database to perform a comprehensive investigation into 30-day complication rates after biceps tenotomy versus tenodesis, thus providing valuable insights for informed decision-making by clinicians and patients regarding the optimal surgical approach for pathologies of the long head of the biceps tendon. Methods: The National Surgical Quality Improvement Program database was queried to analyze postoperative complication rates and metrics associated with biceps tenotomy and tenodesis. Patient data spanning from 2012 to 2021 was extracted, with relevant variables assessed to identify and compare these two surgical approaches. Adjusted and unadjusted analyses were utilized to analyze patient demographics, comorbidities, operative times, lengths of stay, readmissions, adverse events, and yearly surgical volume, along with trends in usage, across cohorts. Results: Of 11,527 total patients, 264 (2.29%), 6826 (59.22%), and 4437 (38.49%) underwent tenotomy, tenodesis with open repair, and tenodesis with arthroscopic repair, respectively. Tenotomy operative times ([mean ± SD]: 66.25 ± 44.76 minutes) were shorter than those for open tenodesis (78.83 ± 41.82) and arthroscopic tenodesis (75.98 ± 40.16). Conversely, tenotomy patients had longer hospital days (0.88 ± 4.86 days) relative to open tenodesis (.08 ± 1.55) and arthroscopic tenodesis (.12 ± 2.70). Multivariable logistic regression controlling for demographics and comorbidities demonstrated that patients undergoing tenodesis were less likely to be readmitted (adjusted odds ratio [AOR]: 0.42, 95% confidence interval [CI]: 0.17-0.98, P = .050) or sustain serious adverse events (AOR: 0.27, 95% CI: 0.13-0.57, P

Background: Aseptic loosening is the most common aseptic failure modality following total knee arthroplasty. Recent literature suggests that the implant-cement interface is the “weak-link” in fixation and lipid contamination may drive this debonding pattern. Therefore, the purpose of this study was to determine if the “double-butter” technique would significantly decrease lipid contamination of the tibial tray. Methods: Transparent acrylic models of 7 different tibial baseplates were created to allow for direct visualization of fluid contamination of the implant-cement interface during experimental cementation. Three cementation techniques were then employed in triplicate for each implant: coating only the tibia (“single butter”) and coating of the tibia and baseplate (with and without keel included; “double-butter”). A dye was added centrally to simulate lipid contamination. After each trial, the degree of implant-cement contamination was calculated. Standard statistical analyses were conducted. Results: With the double-butter technique, there was a significant reduction in contamination for all studied implant designs (range: 0%-7%; P < .05) and contamination was eliminated when the entire implant was coated prior to implantation. The single-butter technique resulted in contamination of 16%-43% of the tibial undersurface. There were significant differences in percent contamination between component designs (P < .05). Conclusions: Cementation technique and implant design each influenced baseplate lipid contamination. While significant differences were noted between keel geometries, we found that the double-butter technique effectively eliminated baseplate contamination, even in the most susceptible designs in this study. We therefore advocate for the incorporation of the double-butter technique to limit lipid contamination and potentially reduce aseptic tibial loosening.

Introduction:. The American Board of Orthopaedic Surgery (ABOS) Knowledge, Skills, and Behavior (KSB) project sets up a framework for competency-based medical education for orthopaedic surgery residency training. The Behavior aspect of KSB includes use of the American Board of Orthopaedic Surgery Behavior Tool (ABOSBT) to assess 5 domains of professional behavior. The purpose of this study was to analyze the results of 2 years of ABOSBT assessments and to characterize the low score ratings. Methods:. All ABOSBT assessments from January 1, 2022, to December 31, 2023, were reviewed totaling 51,678 completed assessments with 48,648 (94%) assessments from a 360° process and 3,030 (6%) as end-of-rotation assessments. Results:. Distribution of 51,678 ABOSBT assessments with 258,390 scores demonstrated low scores (disagree or strongly disagree) in 0.9% of assessments. All 5 domains identified low scores in a small percentage at all years-in-training with the greatest number in second- and third-year residents. Comparison of scores from 360° vs. end-of-rotation requests demonstrated a higher percentage of low scores given during the 360° process (p < 0.0001). Three thousand seven hundred seven unique evaluators completed ABOSBT assessments, with attending physicians as the most frequent evaluator type (44%); inpatient nurses assessed residents with low ABOSBT scores more frequently (4.5%) than any other evaluator type. Residents with 2 or more low scores by 2 or more different evaluators were analyzed for each of the 5 domains; low scores were most frequently observed in the reliability domain. Discussion:. The ABOSBT was originally validated 5 years ago in 18 programs with 9,892 assessments; this article updates results using the ABOSBT across 95 programs assessing 2,397 residents with 3,707 evaluators. The ABOSBT demonstrates that most residents demonstrate professional behavior across 5 domains of assessment; the ABOSBT identifies residents with low scores. A strength of KSB is the ability to identify professionalism deficiencies while residents are in training and can focus on individualized educational improvement. Tracking residents with low scores on the ABOSBT assessment over time will help determine its effectiveness in identifying unprofessional behavior.

Background: Application time and viscosity are factors that can significantly affect the properties of bone cement and implant fixation. The aim of this study was to investigate the influence of different application times of 2 different cements on mechanical parameters, cement interdigitation, and cement distribution. Methods: P.F.C. Sigma tibial trays were cemented with high-viscous Palacos R and medium- to low-viscous Simplex P in an open-cell model. The application was performed at different times within the manufacturer’s specifications. Cement interdigitation and micromotion were measured with computed tomography scan using a novel method. Results: Significant differences of insertion forces were found at all times of cement application. Cement penetration decreased with increasing pressure and viscosity. No significant differences were shown for micromotion between Palacos R and Simplex P except for an increase for Simplex P from 3 to 7 minutes at the bone-cement interface. Simplex P appeared to trap air at the implant-cement interface at 3 minutes and increased at 7 minutes. Conclusions: Cement distribution and intrusion of Palacos R and Simplex P decreased with time. Simplex P trapped air at the implant-cement interface, decreasing the amount of contact at the implant-cement interface, which is worrisome for long-term implant fixation. Given the significant changes in cement properties after mixing, it is necessary for surgeons to understand the viscosity and timing of cement application to achieve optimal cement penetration and surface contact area to potentially decrease implant loosening. High-viscous Palacos R should be applicated immediately with doughing time and medium-viscous Simplex P for about 4 minutes considering a threshold of minimum pressure.

Background: Periprosthetic femur fractures (PPFFs) following total hip arthroplasty (THA) have increased in the past decade as the demand for primary surgery continues to grow. Although there is now more evidence to describe the treatment of Vancouver B fractures, there is still limited knowledge regarding factors that cause surgeons to perform either an open reduction and internal fixation (ORIF) or revision THA (rTHA). The purpose of this study was to determine what type of surgeons treat Vancouver B PPFFs at 11 major academic institutions and if there are trends in treatment decision-making regarding the use of ORIF or rTHA based on surgical training or patient factors. Methods: This multicenter retrospective study evaluated patients surgically treated for Vancouver B PPFF after THA between 2014 and 2019. Patients from 11 academic centers located in the United States were included in this study. Surgical outcomes and patient demographics were evaluated based on surgeon training, surgical treatment type, and institution. Results: Presence of Vancouver B2 (odds ratio [OR]: 0.02, P < .001) or B3 (OR: 0.04, P < .001) fractures were independent risk factors for treatment with rTHA. Treatment by a trauma (OR: 12.49, P < .001) or other-specified surgeon (OR: 13.63, P < .001) were independent risk factors for ORIF repair of Vancouver B fractures. There were no differences in outcomes based on surgeon subspecialty training. Conclusions: This study showed the trends in surgeons who surgically manage Vancouver B fractures at 11 major academic institutions and highlighted that regardless of surgical training or surgical treatment type, postoperative outcomes following management of PPFF were similar.

Objectives: To identify factors associated with prolonged postoperative length of stay (LOS) after VATS lobectomy (VATS-L), explore potential intersurgeon variation in LOS and ascertain whether or not early discharge influences hospital readmission rates. Methods: We conducted a retrospective analysis of patients who underwent VATS-L at a single academic center between 2018 and 2021. Each VATS lobectomy procedure was performed by 1 of 7 experienced thoracic surgeons. The primary end point of interest was prolonged LOS, defined as an index LOS >3 days. Results: Among 1006 patients who underwent VATS lobectomy, 632 (63%) had a prolonged LOS. On multivariate analysis, the factors independently associated with prolonged LOS were: surgeon (P 3, and prior ipsilateral thoracic surgery or sternotomy. There was no association between LOS ≤3 days and hospital readmission (20 [5.3%] vs 39 [5.9%]; OR, 0.88; 95% CI, 0.50-1.53). Conclusions: An intersurgeon variation in postoperative LOS after VATS-L exists and is independent of patient baseline characteristics or perioperative complications. This variation seems to be more closely related to differences in postoperative management and discharge practices rather than to surgical quality. Postoperative discharge within 3 days is safe and does not increase hospital readmissions.

Persistent hypoglossal artery (PHA) is a rare, anatomical variant in which the posterior cerebral circulation is primarily supplied by a branch of the carotid artery, rather than the vertebral arteries. This case report discusses carotid endarterectomy performed on a man, 67 years of age, with high-grade, asymptomatic carotid artery stenosis and ipsilateral PHA. Preoperative computed tomography angiography identified the PHA arising from the internal carotid artery, compensating for atretic bilateral vertebral arteries and providing primary perfusion to anterior spinal artery. A carotid endarterectomy with a bovine pericardial patch was executed under general anesthesia, incorporating preemptive shunting of the PHA and intraoperative electroencephalogram monitoring. The operation proceeded without complications, maintaining normal electroencephalogram readings, and the patient exhibited no focal neurological deficits postoperatively, although transient dysphagia was noted. Follow-up imaging at 4 months confirmed the patency of the internal carotid artery and PHA. This case underscores the necessity for meticulous surgical planning and monitoring in the presence of rare vascular anomalies to ensure successful outcomes. The key takeaway is that comprehensive, preoperative imaging, individualized surgical strategies, and vigilant postoperative monitoring are critical for managing rare vascular anomalies, such as PHA.

Background: The COVID-19 pandemic prompted rapid expansion of telemedicine to access subspecialty care. However, potential disparities in access to telemedicine in cardiology remain to be fully characterized. Objectives: The authors aimed to study whether telemedicine visit modality (video or audio only) differed by sociodemographic characteristics in the outpatient cardiology population of a large academic health center. Methods: We conducted a retrospective cross-sectional study of telemedicine encounter data from all outpatient cardiology telemedicine visits from January 1, 2020, to December 31, 2021. We examined unique patients’ first telemedicine encounter during the study period. The primary outcome was visit modality, video versus audio-only visit. Predictors of audio-only visit modality were assessed using adjusted logistic regression analyses. Results: There were 47,961 total adult cardiology telemedicine encounters among 39,381 unique patients. Of all encounters, 20.4% were audio only. Odds of audio-only visit modality increased with age, with the highest odds of audio-only visits in patients aged >75 years (OR: 3.4; 95% CI: 2.8-4.2). Non-White race (OR: 1.2; 95% CI: 1.1-1.3), lack of private insurance (Medicaid OR: 2.8; 95% CI: 2.5-3.1 and Medicare OR: 1.7; 95% CI: 1.5-1.8), and higher social deprivation index quintile (social deprivation index 5, most deprived, OR: 2.0; 95% CI: 1.9-2.2) were also associated with increased odds of audio-only modality. Conclusions: We identified sociodemographic disparities in telemedicine visit modality in a large outpatient cardiology population. These findings highlight the important role of audio-only visits in accessing telemedicine, and opportunities to narrow the digital health divide.

In 2010, the United States Human and Health Services (US HHS) and the European Union's (EU) Directorate General for Communications Networks, Content and Technology signed a memorandum of understanding to stimulate cooperation surrounding health-related information communications technology. The key project that emerged from this agreement is the International Patient Summary (IPS), intended to provide succinct clinically relevant patient summaries, which are generalizable and condition-independent, that can be readily used by all clinicians for the care of patients. Although allergies are included in the main information required by the IPS library and framework, it is misrepresented which leads to underdiagnosis or misdiagnosis of patients suffering from allergic and hypersensitivity conditions (A/H). The French and Montpellier World Health Organization (WHO) Collaborating Centres have provided arguments for supporting representation of A/H in the IPS. These are based on the relevance of the new classification of A/H in the WHO International Classification of Diseases 11th version (ICD-11), and the need for alignment of eHealth tools with harmonized health information. We first present the A/H in the IPS initiative with the mission of producing an international information system that can be used globally in electronic health records to standardize clinical diagnoses and facilitate communication between clinicians caring for patients with A/H diseases. It is believed this initiative will provide a strong voice for the allergy community and an effective process for improving the quality of health data that will optimize medical care for our patients worldwide.

Objectives: Acute kidney injury has been described after Fontan surgery, but the duration and outcomes are unknown. We sought to describe the incidence of and risk factors for acute kidney injury and the phenotype of renal recovery, and evaluate the impact of renal recovery phenotype on outcomes. Methods: All children who underwent a Fontan operation at a single center between 2009 and 2022 were included. Data collected included Fontan characteristics, vasopressor use, all measures of creatinine, and postoperative outcomes. Logistic regression models were used to assess predictors of acute kidney injury and the association between acute kidney injury and outcomes. Results: We enrolled 141 children (45% female). Acute kidney injury occurred in 100 patients (71%). Acute kidney injury duration was transient (

Background: This study showcases an analysis performed using the National Readmission Database (NRD) from 2016 to 2019 to analyze the impact of ownership, location, size, and teaching status of transplant centers on cardiac transplant outcomes. Methods: Demographic variables and hospital characteristics were identified using NRD data and International Classification of Diseases,10th revision codes. Comorbidities were assessed using the Elixhauser comorbidity index. Multivariable linear and logistic regression analyses were used to assess in-hospital mortality, 30-day and 180-day readmission rates, length of stay, days from admission to procedure, transfer to a rehab center, graft rejection, graft failure, and index admission total cost. Results: Most cardiac transplants occurred in privately owned, large metropolitan areas, large bed size, and teaching centers. No significant difference was seen in in-hospital mortality, graft rejection, or graft failure by hospital ownership, location, size, or teaching status. Patients in private hospitals were more likely to be readmitted at 180 days and less likely to be transferred to rehab center compared to government-owned hospitals. Patients in private, small bed size, and teaching centers were more likely to have shorter length of stay. Additionally, days of admission to procedure were shorter in small bed size and teaching centers. Furthermore, the cost of index-hospital stay was higher in privately owned, large metropolitan areas, large bed size, and teaching centers. Conclusions: While in-hospital mortality was not significantly different, various other outcomes related to cost and efficiency seem to be impacted by hospital characteristics.

OBJECTIVES:. We assessed the association of preexisting diabetes mellitus with all-cause mortality and organ support receipt in adult patients with sepsis. DESIGN:. Population-based cohort study. SETTING:. Ontario, Canada (2008–2019). POPULATION:. Adult patients (18 yr old or older) with a first sepsis-related hospitalization episode. INTERVENTIONS:. None. MEASUREMENTS AND MAIN RESULTS:. The main exposure of interest was preexisting diabetes (either type 1 or 2). The primary outcome was all-cause mortality by 90 days; secondary outcomes included receipt of invasive mechanical ventilation and new renal replacement therapy. We report adjusted (for baseline characteristics using standardization) risk ratios (RRs) alongside 95% CIs. A main secondary analysis evaluated the potential mediation by prior metformin use of the association between preexisting diabetes and all-cause mortality following sepsis. Overall, 503,455 adults with a first sepsis-related hospitalization episode were included; 36% had preexisting diabetes. Mean age was 73 years, and 54% of the cohort were females. Preexisting diabetes was associated with a lower adjusted risk of all-cause mortality at 90 days (RR, 0.81; 95% CI, 0.80–0.82). Preexisting diabetes was associated with an increased risk of new renal replacement therapy (RR, 1.53; 95% CI, 1.46–1.60) but not invasive mechanical ventilation (RR, 1.03; 95% CI, 1.00–1.05). Overall, 21% (95% CI, 19–28) of the association between preexisting diabetes and reduced risk of all-cause mortality was mediated by prior metformin use. CONCLUSIONS:. Preexisting diabetes is associated with a lower risk of all-cause mortality and higher risk of new renal replacement therapy among adult patients with sepsis. Future studies should evaluate the underlying mechanisms of these associations.

Background: Hereditary angioedema (HAE) is a potentially life-threatening disorder characterized by recurrent episodes of subcutaneous or submucosal swelling. HAE with normal C1 inhibitor (HAE-nC1-INH) is an underdiagnosed condition. Although the association with genetic variants has been identified for some families, the genetic causes in many patients with HAE-nC1-INH remain unknown. The role of genes associated with bradykinin catabolism is not fully understood. Objective: We sought to investigate the biological parameters and the genes related to kallikrein-kinin system in families with a clinical phenotype of HAE-nC1-INH and presenting with a carboxypeptidase N (CPN) deficiency. Methods: This study includes 4 families presenting with HAE-nC1-INH and CPN deficiency. Patients’ clinical records were examined, biological parameters of kallikrein-kinin system were measured, and genetics was analyzed by next-generation sequencing and Sanger sequencing. Predictive algorithms (Human Splicing Finder, Sorting Intolerant From Tolerant, Polymorphism Phenotyping v2, MutationTaster, and ClinPred) were used to classify variants as affecting splicing, as benign to deleterious, or as disease-causing. Results: Patients presented with angioedema and urticaria, mainly on face/lips, but also with abdominal pain or laryngeal symptoms. Affected patients displayed low CPN activity—30% to 50% of median value in plasma. We identified 3 variants of the CPN1 gene encoding the catalytic 55-kDa subunit of CPN: c.533G>A, c.582A>G, and c.734C>T. CPN deficiency associated with genetic variants segregated with HAE-nC1-INH symptoms in affected family members. Conclusions: CPN1 gene variants are associated with CPN deficiency and HAE-nC1-INH symptoms in 4 unrelated families. Genetic CPN deficiency may contribute to bradykinin and anaphylatoxin accumulation, with synergistic effects in angioedema and urticarial symptoms.

Introduction/Purpose: This study sought to establish normative values for baseline physical and mental health by foot and ankle diagnosis using validated Patient-Reported Outcomes Measurement Information System (PROMIS) scores and to compare the correlation between these two outcomes across common foot and ankle diagnoses. Additionally, it investigated the effect of specific foot and ankle diagnoses on self-reported mental health at first presentation. Methods: We retrospectively reviewed baseline PROMIS Physical Function Short Form 10a (PF10a) and PROMIS Global-Mental (PGM) scores of 14,374 patients who had one of the 10 most common foot and ankle diagnoses seen at our institution between 2016 and 2021. Pearson correlation coefficients were calculated to assess the relationship between PF10a and PGM by diagnosis. A multivariable regression model was also used to determine the effect of each diagnosis on PGM score. Results: On unadjusted analysis, patients diagnosed with an ankle fracture had the lowest mean physical function, while patients with hallux valgus had the highest (PF10a=33.9 vs 46.7). Patients with foot/ankle osteoarthritis had the worst mean self-reported mental health, while patients with hallux rigidus had the best (PGM=49.9 vs 53.4). PF10a and PGM scores were significantly positively correlated for all diagnoses; the correlation was strongest in patients diagnosed with foot/ankle osteoarthritis or hammertoes (r=0.511) and weakest in patients with ankle fractures (r=0.239) or ankle sprains (r=0.287). Chronic conditions, including hammertoes (β=-4.9, 95%CI [-5.6, -4.2], p< 0.001), foot/ankle osteoarthritis (β=-4.8, 95%CI [-5.5, -4.1], p< 0.001), and hallux valgus (β=-4.6, 95%CI [-5.3, -3.9], p< 0.001) were associated with the largest negative effects on patients’ self-reported mental health. Conclusion: Self-reported physical function and mental health varied across common foot and ankle diagnoses and were more tightly correlated in chronic than acute conditions. The effect of diagnosis on mental health scores appears to be worse for more chronic diagnoses, including those that are generally associated with relatively unimpaired physical function. Comparison of mean unadjusted PROMIS Physical Function 10a and PROMIS Global-Mental scores by diagnosis.

Introduction: RET inhibitors with impressive overall response rates are now available for patients with NSCLC, yet the identification of RET fusions remains a difficult challenge. Most guidelines encourage the upfront use of next-generation sequencing (NGS), or alternatively, fluorescence in situ hybridization (FISH) or reverse transcriptase-polymerase chain reaction (RT-PCR) when NGS is not possible or available. Taken together, the suboptimal performance of single-analyte assays to detect RET fusions, although consistent with the notion of encouraging universal NGS, is currently widening some of the clinical practice gaps in the implementation of predictive biomarkers in patients with advanced NSCLC. Methods: This situation prompted us to evaluate several RET assays in a large multicenter cohort of RET fusion–positive NSCLC (n = 38) to obtain real-world data. In addition to RNA-based NGS (the criterion standard method), all positive specimens underwent break-apart RET FISH with two different assays and were also tested by an RT-PCR assay. Results: The most common RET partners were KIF5B (78.9%), followed by CCDC6 (15.8%). The two RET NGS-positive but FISH-negative samples contained a KIF5B(15)-RET(12) fusion. The three RET fusions not identified with RT-PCR were AKAP13(35)-RET(12), KIF5B(24)-RET(9) and KIF5B(24)-RET(11). All three false-negative RT-PCR cases were FISH-positive, exhibited a typical break-apart pattern, and contained a very high number of positive tumor cells with both FISH assays. Signet ring cells, psammoma bodies, and pleomorphic features were frequently observed (in 34.2%, 39.5%, and 39.5% of tumors, respectively). Conclusions: In-depth knowledge of the advantages and disadvantages of the different RET testing methodologies could help clinical and molecular tumor boards implement and maintain sensible algorithms for the rapid and effective detection of RET fusions in patients with NSCLC. The likelihood of RET false-negative results with both FISH and RT-PCR reinforces the need for upfront NGS in patients with NSCLC.

Background: The utilization of extracorporeal life support (ECLS) for intraoperative support during lung transplantation has increased over the past decade. Although veno-arterial extracorporeal membrane oxygenation (VA-ECMO) has recently emerged as the preferred modality over cardiopulmonary bypass (CPB), many centers continue to use both forms of ECLS during lung transplantation. Our novel hybrid VA-ECMO/CPB circuit allows for seamless transition from VA-ECMO to CPB at a significant cost savings compared to a standalone VA-ECMO circuit. This study describes our initial experience and outcomes in the first 100 bilateral lung transplantations using this novel hybrid VA-ECMO/CPB circuit. Methods: Medical records from September 2017 to May 2021 of the first 100 consecutive patients undergoing bilateral lung transplantation with intraoperative hybrid VA-ECMO support were examined retrospectively. We excluded patients with single lung transplants, retransplantations, preoperative ECLS bridging, and veno-venous (VV) ECMO and those supported with CPB only. Perioperative recipient, anesthetic, perfusion variables, and outcomes were assessed. Results: Of the 100 patients supported with VA-ECMO, 19 were converted intraoperatively to CPB. Right ventricular dysfunction was seen in 37% of patients, and the median mean pulmonary artery pressure was 28 mm Hg. No oxygenator clotting was observed with a median heparin dose of 13,000 units in the VA-ECMO group. Primary graft dysfunction grade 3 at 72 hours was observed in 10.1% of all patients and observed 1-year mortality was 4%. Conclusions: The use of a hybrid VA-ECMO/CPB circuit in our institution allows for rapid conversion to CPB with acceptable outcomes across a diverse recipient group at a significantly reduced cost compared to standalone VA-ECMO circuits.

Objective: The intensivist-led cardiovascular intensive care unit model is the standard of care in cardiac surgery. This study examines whether a cardiovascular intensive care unit model that uses operating cardiac surgeons, cardiothoracic surgery residents, and advanced practice providers is associated with comparable outcomes. Methods: This is a single-institution review of the first 400 cardiac surgery patients admitted to an operating surgeon-led cardiovascular intensive care unit from 2020 to 2022. Inclusion criteria are elective status and operations managed by both cardiovascular intensive care unit models (aortic operations, valve operations, coronary operations, septal myectomy). Patients from the surgeon-led cardiovascular intensive care unit were exact matched by operation type and 1:1 propensity score matched with controls from the traditional cardiovascular intensive care unit using a logistic regression model that included age, sex, preoperative mortality risk, incision type, and use of cardiopulmonary bypass and circulatory arrest. Primary outcome was total postoperative length of stay. Secondary outcomes included postoperative intensive care unit length of stay, 30-day mortality, 30-day Society of Thoracic Surgeons–defined morbidity (permanent stroke, renal failure, cardiac reoperation, prolonged intubation, deep sternal infection), packed red cell transfusions, and vasopressor use. Outcomes between the 2 groups were compared using chi-square, Fisher exact test, or 2-sample t test as appropriate. Results: A total of 400 patients from the surgeon-led cardiovascular intensive care unit (mean age 61.2 ± 12.8 years, 131 female patients [33%], 346 patients [86.5%] with European System for Cardiac Operative Risk Evaluation II

Sternal fractures are rare and are typically caused by major trauma such as motor vehicle collisions. However, sternal insufficiency fractures can occur with minimal to no trauma in patients with exaggerated thoracic kyphosis from multiple thoracic compression fractures, especially in the setting of osteoporosis. We describe a case of a sternal insufficiency fracture that presented as chest pain resembling a myocardial infarction. As sternal insufficiency fractures may vary in clinical presentation, this case demonstrates that radiologists should carefully evaluate the sternum, especially when risk factors are present. Furthermore, awareness and identification of these fractures can prevent unnecessary cardiac workups.

Objective: This study aimed to determine whether or not transfusion of fresh red blood cells (RBCs) reduced the incidence of new or progressive multiple organ dysfunction syndrome compared with standard-issue RBCs in pediatric patients undergoing cardiac surgery. Methods: Preplanned secondary analysis of the Age of Blood in Children in Pediatric Intensive Care Unit study, an international randomized controlled trial. This study included children enrolled in the Age of Blood in Children in Pediatric Intensive Care Unit trial and admitted to a pediatric intensive care unit after cardiac surgery with cardiopulmonary bypass. Patients were randomized to receive either fresh (stored ≤7 days) or standard-issue RBCs. The primary outcome measure was new or progressive multiple organ dysfunction syndrome, measured up to 28 days postrandomization or at pediatric intensive care unit discharge, or death. Results: One hundred seventy-eight patients (median age, 0.6 years; interquartile range, 0.3-2.6 years) were included with 89 patients randomized to the fresh RBCs group (median length of storage, 5 days; interquartile range, 4-6 days) and 89 to the standard-issue RBCs group (median length of storage, 18 days; interquartile range, 13-22 days). There were no statistically significant differences in new or progressive multiple organ dysfunction syndrome between fresh (43 out of 89 [48.3%]) and standard-issue RBCs groups (38 out of 88 [43.2%]), with a relative risk of 1.12 (95% CI, 0.81 to 1.54; P = .49) and an unadjusted absolute risk difference of 5.1% (95% CI, −9.5% to 19.8%; P = .49). Conclusions: In neonates and children undergoing cardiac surgery with cardiopulmonary bypass, the use of fresh RBCs did not reduce the incidence of new or progressive multiple organ dysfunction syndrome compared with the standard-issue RBCs. A larger trial is needed to confirm these results.

Objective: To determine the safety, feasibility, and physiologic impact of a preoperative respiratory strength training (RST) program in individuals undergoing elective cardiac surgery (CS). Methods: Twenty-five adults undergoing an elective CS at an academic hospital setting enrolled and completed RST 5 days/week (50 repetitions, 50% training load, ≥3 weeks) at home via telehealth in this open-label prospective cohort study. RST adherence, telehealth attendance, and adverse events were tracked. Pre- and post-RST outcomes of maximum expiratory pressure (MEP), maximum inspiratory pressure (MIP), voluntary cough spirometry, and patient-reported dyspnea were collected. Descriptive analyses and Wilcoxon signed rank-tests were performed. Results: Two participants (9%) did not complete the prescribed RST program. No significant RST-related adverse events occurred. Treatment adherence for all enrolled participants was 90%, and telehealth attendance was 99%. Of the CS patients who completed the prescribed program (n = 23; 91%), treatment adherence and telehealth attendance were excellent (98% and 100%, respectively). Significant increases in primary outcomes were observed: MEP mean change, +15.4 (95% confidence interval [CI], +3.4 to +27.3, P .05). Conclusions: These preliminary data demonstrate that a preoperative RST program is safe and feasible and can improve short-term respiratory physiologic capacity (MEP and MIP) in CS patients. Future research is warranted to validate the current findings in a larger cohort of CS patients and to determine whether RST improves postoperative extubation outcomes, airway clearance capacity, and aspiration following cardiac surgery.

Background: Current innovation in needle arthroscopy is improving the safety of anterior portals around the elbow. This study evaluated the proximity to the radial nerve, median nerve, and brachial artery on cadaveric specimens of an anterior portal used for elbow arthroscopy. Methods: Ten fresh-frozen adult cadaveric extremities were used. After marking the cutaneous references, the NanoScope cannula was introduced just lateral to the biceps tendon, through the brachialis muscle and the anterior capsule. Elbow arthroscopy was performed. Dissection was then carefully performed on all specimens with the NanoScope cannula in place. The shortest distance from the cannula to the median nerve, radial nerve, and brachial artery was measured with a handheld sliding digital caliper. Results: The cannula was an average of 12.92 mm away from the radial nerve, 22.27 mm from the median nerve, and 16.8 mm from the brachial artery. Needle arthroscopy performed through this portal allows complete visualization of the anterior compartment of the elbow, as well as direct visualization of the posterolateral compartment. Conclusion: Needle arthroscopy of the elbow through an anterior transbrachialis portal is safe for the main neurovascular structures. In addition, this technique allows complete visualization of the anterior and posterolateral compartments of the elbow through the humerus-radius-ulna space.

OBJECTIVES:. To develop and validate machine learning (ML) models to predict high-flow nasal cannula (HFNC) failure in COVID-19, compare their performance to the respiratory rate-oxygenation (ROX) index, and evaluate model accuracy by self-reported race. DESIGN:. Retrospective cohort study. SETTING:. Four Emory University Hospitals in Atlanta, GA. PATIENTS:. Adult patients hospitalized with COVID-19 between March 2020 and April 2022 who received HFNC therapy within 24 hours of ICU admission were included. INTERVENTIONS:. None. MEASUREMENTS AND MAIN RESULTS:. Four types of supervised ML models were developed for predicting HFNC failure (defined as intubation or death within 7 d of HFNC initiation), using routine clinical variables from the first 24 hours of ICU admission. Models were trained on the first 60% (n = 594) of admissions and validated on the latter 40% (n = 390) of admissions to simulate prospective implementation. Among 984 patients included, 317 patients (32.2%) developed HFNC failure. eXtreme Gradient Boosting (XGB) model had the highest area under the receiver-operator characteristic curve (AUROC) for predicting HFNC failure (0.707), and was the only model with significantly better performance than the ROX index (AUROC 0.616). XGB model had significantly worse performance in Black patients compared with White patients (AUROC 0.663 vs. 0.808, p = 0.02). Racial differences in the XGB model were reduced and no longer statistically significant when restricted to patients with nonmissing arterial blood gas data, and when XGB model was developed to predict mortality (rather than the composite outcome of failure, which could be influenced by biased clinical decisions for intubation). CONCLUSIONS:. Our XGB model had better discrimination for predicting HFNC failure in COVID-19 than the ROX index, but had racial differences in accuracy of predictions. Further studies are needed to understand and mitigate potential sources of biases in clinical ML models and to improve their equitability.

Background: Climate change poses a substantial threat to human health, and operating rooms (ORs) have an outsized environmental impact. The Program for Research in Sustainable Medicine (PRiSM) designed a protocol for minor foot and ankle surgery intended to reduce waste, streamline instrument trays, and minimize laundry. We conducted a randomized controlled trial to compare the carbon footprint of procedures performed using the PRiSM protocol vs a traditional protocol. Methods: Forty adult patients undergoing foreign body removal, hammertoe correction, toe amputation, hardware removal, mass excision, or gastrocnemius recession were randomized to the PRiSM or our “Traditional” protocol. The PRiSM protocol used a smaller instrument tray, fewer drapes and towels, and minimal positioning blankets. No changes were made to surgical site preparation or operative techniques. Environmental impact was estimated using the carbon footprint, measured in kilograms of carbon dioxide equivalents (CO 2 e). Emissions associated with OR waste, instrument processing, and laundry were calculated. Results: On average, PRiSM cases had a smaller carbon footprint than Traditional cases (17.3 kg CO2e [SD = 3.2] vs 20.6 kg CO 2 e [SD = 2.0], P

Abstract. Introduction:. Hip fractures are a common injury associated with significant morbidity and mortality. In the United States, there has been a rapid increase in the prevalence of metabolic syndrome (MetS), a condition comprised several common comorbidities, including obesity, diabetes mellitus, and hypertension, that may worsen perioperative outcomes. This article assesses the impact of MetS and its components on outcomes after hip fracture surgery. Methods:. Patients who underwent nonelective operative treatment for traumatic hip fractures were identified in the 2015–2020 American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database. Baseline characteristics between groups were compared, and significant differences were included as covariates. Multivariate regression was performed to assess the impact of characteristics of interest on postoperative outcomes. Patients with MetS, or a single one of its constitutive components—hypertension, diabetes, and obesity—were compared with metabolically healthy cohorts. Results:. In total 95,338 patients were included. Patients with MetS had increased complications (OR 1.509; P < 0.001), but reduced mortality (OR 0.71; P < 0.001). Obesity alone was also associated with increased complications (OR 1.14; P < 0.001) and reduced mortality (OR 0.736; P < 0.001). Both hypertension and diabetes alone increased complications (P < 0.001) but had no impact on mortality. Patients with MetS did, however, have greater odds of adverse discharge (OR 1.516; P < 0.001), extended hospital stays (OR 1.18; P < 0.001), and reoperation (OR 1.297; P = 0.003), but no significant difference in readmission rate. Conclusion:. Patients with MetS had increased complications but decreased mortality. Our component-based analysis showed had obesity had a similar effect: increased complications but lower mortality. These results may help surgeons preoperatively counsel patients with hip fracture about their postoperative risks.

OBJECTIVES:. Inhaled volatile anesthetics support management of status asthmaticus (SA), status epilepticus (SE), and difficult sedation (DS). This study aimed to evaluate the effectiveness, safety, and feasibility of using inhaled anesthetics for SA, SE, and DS in adult ICU and PICU patients. DATA SOURCES:. MEDLINE, Cochrane Central Register of Controlled Trials, and Embase. STUDY SELECTION:. Primary literature search that reported the use of inhaled anesthetics in ventilated patients with SA, SE, and DS from 1970 to 2021. DATA EXTRACTION:. Study data points were extracted by two authors independently. Quality assessment was performed using the Joanna Briggs Institute appraisal tool for case studies/series, Newcastle criteria for cohort/case–control studies, and risk-of-bias framework for clinical trials. DATA SYNTHESIS:. Primary outcome was volatile efficacy in improving predefined clinical or physiologic endpoints. Secondary outcomes were adverse events and delivery logistics. From 4281 screened studies, the number of included studies/patients across diagnoses and patient groups were: SA (adult: 38/121, pediatric: 28/142), SE (adult: 18/37, pediatric: 5/10), and DS (adult: 21/355, pediatric: 10/90). Quality of evidence was low, consisting mainly of case reports and series. Clinical and physiologic improvement was seen within 1–2 hours of initiating volatiles, with variable efficacy across diagnoses and patient groups: SA (adult: 89–95%, pediatric: 80–97%), SE (adults: 54–100%, pediatric: 60–100%), and DS (adults: 60–90%, pediatric: 62–90%). Most common adverse events were cardiovascular, that is, hypotension and arrhythmias. Inhaled sedatives were commonly delivered using anesthesia machines for SA/SE and miniature vaporizers for DS. Few (10%) of studies reported required non-ICU personnel, and only 16% had ICU volatile delivery protocol. CONCLUSIONS:. Volatile anesthetics may provide effective treatment in patients with SA, SE, and DS scenarios but the quality of evidence is low. Higher-quality powered prospective studies of the efficacy and safety of using volatile anesthetics to manage SA, SE, and DS patients are required. Education regarding inhaled anesthetics and the protocolization of their use is needed.

Summary:. Local adverse reactions to breast implants and systemic reactions, mostly autoinflammatory, are numerously described in the literature. A patient presented at our institution with severe neurologic symptoms, including confusion and phasic troubles due to severe hyponatremia as part of syndrome of inappropriate antidiuretic hormone secretion (SIADH). Common etiologies for SIADH, primarily malignancy and central nervous system disturbances, have been ruled out by imaging. On the computed tomography scan of the thorax and abdomen, several masses were found in the pectoral region, inferior to the sternum and in the left axilla that were biopsied and verified as silicone. While evaluating the patient’s medical history, the patient remembered having undergone breast augmentation with silicone implants several decades ago. The only explanation left for the persisting SIADH was her ruptured silicone implants, causing an inflammatory systemic reaction. Literature was searched, and one abstract was found, in which a woman presenting with SIADH was treated successfully after removal of her silicone breast implants. We offered the same treatment to our patient, and siliconomas were removed through a bilateral inframammary approach as well as axillary on the left. There were no complications encountered. Postoperatively, the patient’s hyponatremia improved and normalized 1 month later even without hydric restriction. This potential form of etiology and treatment of SIADH is a novelty in the medical literature. Surgical removal of dispersed silicone is presumed to be the cure for this syndrome. It represents a diagnosis of exclusion after more life-threatening causes, such as central nervous system disturbances and malignancies, have been ruled out.

Buprenorphine is recommended for pregnant patients with opioid use disorder. Traditional buprenorphine initiation requires moderate withdrawal symptoms to prevent precipitating withdrawal. Low-dose buprenorphine initiation is newly emerging and does not require withdrawal prior to initiation.Case 1 is a 30-year-old pregnant patient with opioid use disorder. Inpatient rapid buprenorphine initiation precipitated withdrawal. Low-dose buprenorphine initiation was started twice, 1 outpatient and 1 inpatient with nonprescribed opioid use between. Case 2 is a 28-year-old pregnant patient with opioid use disorder. The patient started an inpatient low-dose buprenorphine initiation and planned its completion at home after discharge. Neither patient experienced precipitated withdrawal during their low-dose initiations.These buprenorphine initiations in pregnant patients guided by a low-dose initiations protocol using only split buprenorphine-naloxone films represent an alternative opioid use disorder treatment method with potentially high acceptability. Future work is warranted to advance the evidence base informing clinicians on how to optimally individualize buprenorphine initiations in pregnancy.

In the setting of structural heart disease, ventricular tachycardia (VT) is typically associated with a re-entrant mechanism. In patients with hemodynamically tolerated VTs, activation and entrainment mapping remain the gold standard for the identification of the critical parts of the circuit. However, this is rarely accomplished, as most VTs are not hemodynamically tolerated to permit mapping during tachycardia. Other limitations include noninducibility of arrhythmia or nonsustained VT. This has led to the development of substrate mapping techniques during sinus rhythm, eliminating the need for prolonged periods of mapping during tachycardia. Recurrence rates following VT ablation are high; therefore, new mapping techniques for substrate characterization are required. Advances in catheter technology and especially multielectrode mapping of abnormal electrograms has increased the ability to identify the mechanism of scar-related VT. Several substrate-guided approaches have been developed to overcome this, including scar homogenization and late potential mapping. Dynamic substrate changes are mainly identified within regions of myocardial scar and can be identified as local abnormal ventricular activities. Furthermore, mapping strategies incorporating ventricular extrastimulation, including from different directions and coupling intervals, have been shown to increase the accuracy of substrate mapping. The implementation of extrastimulus substrate mapping and automated annotation require less extensive ablation and would make VT ablation procedures less cumbersome and accessible to more patients.

Introduction: There may be an association between violence and methamphetamine use. We hypothesized that trauma patients screening positive for methamphetamines are more likely to present after penetrating trauma and have increased mortality. Methods: The 2017–2019 TQIP was used to 1:2 match methamphetamine (meth+) patients to patients testing negative for all drugs (meth-). Patients with polysubstance/alcohol use were excluded. Bivariate and logistic regression analyses were performed. Results: The rate of methamphetamine use was 3.1 %. After matching, there was no difference in vitals, injury severity score, sex, and comorbidities between cohorts (all p > 0.05). Compared to meth-, the meth+ group was more commonly sustained penetrating trauma (19.8 % vs. 9.2 %, p

Background: Intraarticular corticosteroid injections (ICIs) are widely used to treat foot and ankle conditions. Although laboratory studies indicate certain corticosteroids and local anesthetics used in ICIs are associated with chondrotoxic effects, and selected agents such as ropivacaine and triamcinolone may have less of these features, clinical evidence is lacking. We aimed to identify the patterns of drug selection, perceptions of injectate chondrotoxicity, and rationale for medication choice among surgeons in the American Orthopaedic Foot & Ankle Society (AOFAS). Methods: An e-survey including demographics, practice patterns, and rationale was disseminated to 2011 AOFAS members. Frequencies and percentages were calculated for demographic data, anesthetic and steroid choice, rationale for injectate choice, and perception of chondrotoxicity. Bivariate analysis was used to identify practice patterns significantly associated with perceptions of injectate risk and rationale. Results: In total, 387 surveys were completed. Lidocaine and triamcinolone were the most common anesthetic and corticosteroid used (51.2% and 39.3%, respectively). Less than half of respondents felt corticosteroids or local anesthetics bear risk of chondrotoxicity. Respondents agreeing that corticosteroids are chondrotoxic were more likely to use triamcinolone ( P = .037). Respondents agreeing local anesthetics risk chondrotoxicity were less likely to use lidocaine ( P = .023). Respondents choosing a local anesthetic based on literature were more likely to use ropivacaine ( P

Category: Other Introduction/Purpose: Musculoskeletal consultations constitute a growing portion of primary care physician (PCP) referrals. Optimization of communication between PCPs and orthopaedists can potentially reduce the time PCPs spend in the electronic medical record (EMR). This, in turn, may help reduce burnout. However, little is known about the preferences of PCPs regarding communication from orthopaedic specialists. The current study therefore investigated the preferences of PCPs across a large health network regarding communication from orthopaedists. Methods: One hundred and seventy-five PCPs across 15 practices within our health network were surveyed. These providers universally used the Epic Systems EMR. PCPs were asked to report their years in practice, panel size, typical number of electronic clinical messages received each day, time spent in the EMR after normal clinical hours, and burnout level. Likert scales and top-box scores were used to assess the PCPs’ perceived importance of communication from orthopedists in specific clinical scenarios. PCPs were further asked to report their preferred method of communication in each scenario and overall interest in communication from orthopaedists. Regression analyses were performed to determine if any PCP characteristics are associated with communication preferences and overall PCP interest in communication from orthopaedists. Results: A total of 107 (61%) PCPs completed the survey. PCPs most commonly rated communication from orthopaedists as highly important when the orthopaedist needed information from the PCP. In this scenario, PCPs preferred to receive an Epic Staff Message. Other scenarios rated as important included: the decision for surgery, hospitalization, and a major clinical change. In these scenarios, a CC’d Chart rather than Staff Message was preferred. Increased EMR use after-hours was associated with diminished odds of having high interest in communication from orthopaedists (odds ratio=0.65, 95% confidence interval: 0.48-0.88, P=0.005). Ninety-three PCPs (86.9%) reported spending at least 1 hour a day in Epic after normal clinical hours. Twenty-seven (25.2%) spent more than 3 hours. Forty-six PCPs (42.9%) reported experiencing at least one symptom of burnout. Conclusion: In the current study, there were distinct preferences among PCPs regarding clinical communication from orthopaedic surgeons. In addition, there was evidence of substantial burnout and after-hours work effort by PCPs. Our results may be helpful in optimizing communication between PCPs and orthopaedists, while also reducing time spent in the EMR by PCPs.

Category: Ankle Arthritis Introduction/Purpose: Despite advancements in surgical techniques, implants, and biologics, nonunion remains the most common major complication of ankle arthrodesis. While previous studies have reported delayed union or nonunion rates, few have elaborated on the clinical course of patients experiencing delayed union. We sought to better understand the trajectory of patients with delayed union by determining the rate of clinical success and failure and whether the extent of fusion on computed tomography (CT) was associated with outcomes. Methods: Delayed union was defined as incomplete ( < 75%) fusion seen on CT scan between 2 and 6 months postoperative. A total of 36 patients met inclusion criteria: isolated tibiotalar arthrodesis with delayed union. Patient-reported outcomes were obtained and patients were asked about satisfaction with their fusion. Success was defined as patients who were not revised and reported satisfaction with the procedure. Failure was defined as patients who progressed to revision or reported being not satisfied. Fusion was assessed by measuring the percent of osseous bridging across the joint on CT scan. The extent of bony bridging was categorized as absent (0%-24%), minimal (25%-49%), or moderate (50%-74%). Results: We determined the clinical outcome in 28 of the 36 eligible patients (78%) with mean follow-up of 5.6 years (range, 1.3 to 10.2 years). The majority (71%) of patients failed. A mean of 3.9 months (standard deviation, 1) elapsed between time of surgery and CT scan. Patients with minimal or moderate fusion on CT were more likely to succeed clinically than those with ‘absent’ fusion (X2 = 4.215, p = 0.040). Of those with absent ( < 25%) fusion, 11 of 12 (92%) failed. In patients with minimal or moderate fusion, 9 of 16 (56%) failed. Conclusion: We found that 71% of patients with a delayed union at roughly 4 months after ankle fusion required revision or were not satisfied. Patients with less than 25% osseous bridging on CT had an even lower rate of clinical success. These findings may help surgeons in counseling and managing patients experiencing a delayed union after ankle fusion.

OBJECTIVES:. Treatments that prevent sepsis complications are needed. Circulating lipid and protein assemblies—lipoproteins play critical roles in clearing pathogens from the bloodstream. We investigated whether early inhibition of proprotein convertase subtilisin/kexin type 9 (PCSK9) may accelerate bloodstream clearance of immunogenic bacterial lipids and improve sepsis outcomes. DESIGN:. Genetic and clinical epidemiology, and experimental models. SETTING:. Human genetics cohorts, secondary analysis of a phase 3 randomized clinical trial enrolling patients with cardiovascular disease (Evaluation of Cardiovascular Outcomes After an Acute Coronary Syndrome During Treatment With Alirocumab [ODYSSEY OUTCOMES]; NCT01663402), and experimental murine models of sepsis. PATIENTS OR SUBJECTS:. Nine human cohorts with sepsis (total n = 12,514) were assessed for an association between sepsis mortality and PCSK9 loss-of-function (LOF) variants. Incident or fatal sepsis rates were evaluated among 18,884 participants in a post hoc analysis of ODYSSEY OUTCOMES. C57BI/6J mice were used in Pseudomonas aeruginosa and Staphylococcus aureus bacteremia sepsis models, and in lipopolysaccharide-induced animal models. INTERVENTIONS:. Observational human cohort studies used genetic PCSK9 LOF variants as instrumental variables. ODYSSEY OUTCOMES participants were randomized to alirocumab or placebo. Mice were administered alirocumab, a PCSK9 inhibitor, at 5 mg/kg or 25 mg/kg subcutaneously, or isotype-matched control, 48 hours prior to the induction of bacterial sepsis. Mice did not receive other treatments for sepsis. MEASUREMENTS AND MAIN RESULTS:. Across human cohort studies, the effect estimate for 28-day mortality after sepsis diagnosis associated with genetic PCSK9 LOF was odds ratio = 0.86 (95% CI, 0.67–1.10; p = 0.24). A significant association was present in antibiotic-treated patients. In ODYSSEY OUTCOMES, sepsis frequency and mortality were infrequent and did not significantly differ by group, although both were numerically lower with alirocumab vs. placebo (relative risk of death from sepsis for alirocumab vs. placebo, 0.62; 95% CI, 0.32–1.20; p = 0.15). Mice treated with alirocumab had lower endotoxin levels and improved survival. CONCLUSIONS:. PCSK9 inhibition may improve clinical outcomes in sepsis in preventive, pretreatment settings.

OBJECTIVES:. To evaluate the study design and feasibility of drug administration and safety in a randomized clinical trial of recombinant human annexin A5 (SY-005), a constitutively expressed protein with anti-inflammatory, antiapoptotic, and anticoagulant properties, in patients with severe coronavirus disease 2019 (COVID-19). DESIGN:. Double-blind, randomized clinical trial. SETTING:. Two ICUs at an academic medical center. PATIENTS/SUBJECTS:. Adults admitted to the ICU with a confirmed diagnosis of COVID-19 and requiring ventilatory or vasopressor support. INTERVENTIONS:. SY-005, a recombinant human annexin A5, at 50 or 100 µg/kg IV every 12 hours for 7 days. MEASUREMENTS AND MAIN RESULTS:. We enrolled 18 of the 55 eligible patients (33%) between April 21, 2021, and February 3, 2022. We administered 82% (196/238) of the anticipated doses of study medication and 86% (169/196) were given within 1 hour of the scheduled time. There were no drug-related serious adverse events. We captured 100% of the data that would be required for measuring clinical outcomes in a phase 2 or 3 trial. LIMITATIONS:. The small sample size was a result of decreasing admissions of patients with COVID-19, which triggered a stopping rule for the trial. CONCLUSIONS:. Although enrollment was low, administration of SY-005 to critically ill patients with COVID-19 every 12 hours for up to 7 days was feasible and safe. Further clinical trials of annexin A5 for the treatment of COVID-19 are warranted. Given reduction of severe COVID-19 disease, future studies should explore the safety and effectiveness of SY-005 use in non-COVID-related sepsis.

Background: Anaphylaxis is the most severe clinical presentation of acute systemic allergic reactions and can cause death. Given the prevalence of anaphylaxis within healthcare systems, it is a high priority public health issue. However, management of anaphylaxis – both acute and preventative – varies by region. Methods: The World Allergy Organization (WAO) Anaphylaxis Committee and the WAO Junior Members Steering Group undertook a global online survey to evaluate local practice in the diagnosis and management of anaphylaxis across regions. Results: Responses were received from WAO members in 66 countries. While intramuscular epinephrine (adrenaline) is first-line treatment for anaphylaxis, some countries continue to recommend alternative routes in contrast to guidelines. Epinephrine auto-injector (EAI) devices, prescribed to individuals at ongoing risk of anaphylaxis in the community setting, are only available in 60% of countries surveyed, mainly in high-income countries. Many countries in South America, Africa/Middle-East and Asian-Pacific regions do not have EAI available, or depend on individual importation. In countries where EAIs are commercially available, national policies regarding the availability of EAIs in public settings are limited to few countries (16%). There is no consensus regarding the time patients should be observed following emergency treatment of anaphylaxis. Conclusion: This survey provides a global snapshot view of the current management of anaphylaxis, and highlights key unmet needs including the global availability of epinephrine for self-injection as a key component of anaphylaxis management.

Summary: Background: Diagnosis of skin cancer requires medical expertise, which is scarce. Mobile phone-powered artificial intelligence (AI) could aid diagnosis, but it is unclear how this technology performs in a clinical scenario. Our primary aim was to test in the clinic whether there was equivalence between AI algorithms and clinicians for the diagnosis and management of pigmented skin lesions. Methods: In this multicentre, prospective, diagnostic, clinical trial, we included specialist and novice clinicians and patients from two tertiary referral centres in Australia and Austria. Specialists had a specialist medical qualification related to diagnosing and managing pigmented skin lesions, whereas novices were dermatology junior doctors or registrars in trainee positions who had experience in examining and managing these lesions. Eligible patients were aged 18–99 years and had a modified Fitzpatrick I–III skin type; those in the diagnostic trial were undergoing routine excision or biopsy of one or more suspicious pigmented skin lesions bigger than 3 mm in the longest diameter, and those in the management trial had baseline total-body photographs taken within 1–4 years. We used two mobile phone-powered AI instruments incorporating a simple optical attachment: a new 7-class AI algorithm and the International Skin Imaging Collaboration (ISIC) AI algorithm, which was previously tested in a large online reader study. The reference standard for excised lesions in the diagnostic trial was histopathological examination; in the management trial, the reference standard was a descending hierarchy based on histopathological examination, comparison of baseline total-body photographs, digital monitoring, and telediagnosis. The main outcome of this study was to compare the accuracy of expert and novice diagnostic and management decisions with the two AI instruments. Possible decisions in the management trial were dismissal, biopsy, or 3-month monitoring. Decisions to monitor were considered equivalent to dismissal (scenario A) or biopsy of malignant lesions (scenario B). The trial was registered at the Australian New Zealand Clinical Trials Registry ACTRN12620000695909 (Universal trial number U1111–1251–8995). Findings: The diagnostic study included 172 suspicious pigmented lesions (84 malignant) from 124 patients and the management study included 5696 pigmented lesions (18 malignant) from the whole body of 66 high-risk patients. The diagnoses of the 7-class AI algorithm were equivalent to the specialists’ diagnoses (absolute accuracy difference 1·2% [95% CI –6·9 to 9·2]) and significantly superior to the novices’ ones (21·5% [13·1 to 30·0]). The diagnoses of the ISIC AI algorithm were significantly inferior to the specialists’ diagnoses (–11·6% [–20·3 to –3·0]) but significantly superior to the novices’ ones (8·7% [–0·5 to 18·0]). The best 7-class management AI was significantly inferior to specialists’ management (absolute accuracy difference in correct management decision –0·5% [95% CI –0·7 to –0·2] in scenario A and –0·4% [–0·8 to –0·05] in scenario B). Compared with the novices’ management, the 7-class management AI was significantly inferior (–0·4% [–0·6 to –0·2]) in scenario A but significantly superior (0·4% [0·0 to 0·9]) in scenario B. Interpretation: The mobile phone-powered AI technology is simple, practical, and accurate for the diagnosis of suspicious pigmented skin cancer in patients presenting to a specialist setting, although its usage for management decisions requires more careful execution. An AI algorithm that was superior in experimental studies was significantly inferior to specialists in a real-world scenario, suggesting that caution is needed when extrapolating results of experimental studies to clinical practice. Funding: MetaOptima Technology.

Dislocation remains the leading cause of failure following revision total hip arthroplasty. Dual mobility (DM) constructs, including monoblock cups designed for cementation, reduce but do not eliminate this risk. Cemented DM constructs offer several unique advantages in revision total hip arthroplasty, and as such, they have gained popularity. Despite their advantages, a portion of these implants will require revision for infection or recurrent dislocation. Removal of a cemented DM cup presents numerous challenges, and there is no effective published technique. Here, we present an effective technique for the safe removal of one design of cemented DM cup.

Objective: Acute lung injury is a known complication of pulmonary artery reconstruction for peripheral pulmonary artery stenosis. Severe cases may require support with extracorporeal membrane oxygenation. The purpose of this study was to evaluate the characteristics of patients requiring extracorporeal membrane oxygenation after pulmonary artery reconstruction. Methods: This was a retrospective study of 150 patients who underwent surgical repair of peripheral pulmonary artery stenosis at our institution from 2002 to 2022. Underlying diagnoses included Williams syndrome (n = 44), Alagille syndrome (n = 43), elastin arteriopathy (n = 21), tetralogy of Fallot (n = 21), and other (n = 21). Characteristics of patients who required extracorporeal membrane oxygenation were compared with those who did not require extracorporeal membrane oxygenation. Results: Eleven of the 150 patients undergoing pulmonary artery reconstruction (7.3%) required postoperative extracorporeal membrane oxygenation support (10 for acute lung injury and 1 for cardiac insufficiency). Four patients receiving extracorporeal membrane oxygenation had Williams syndrome, 3 patients had Alagille, and 4 patients had tetralogy of Fallot. Patients requiring extracorporeal membrane oxygenation had a higher preoperative right ventricle to aortic peak systolic pressure ratios (mean 1.14 vs 0.95), greater number of pulmonary artery ostial interventions (median, 23 vs 17), and longer duration of cardiopulmonary bypass (median, 597 vs 400 minutes). There were 3 in-hospital deaths (2.0%), 2 of whom required postoperative extracorporeal membrane oxygenation support. Conclusions: The data demonstrate multiple differences between patients who did and did not require extracorporeal membrane oxygenation after surgical repair of peripheral pulmonary artery stenosis. These results suggest that the preoperative extent of disease may predispose to the development of acute lung injury requiring extracorporeal membrane oxygenation support.