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Heart failure with improved ejection fraction (HFimpEF) has better outcomes than HF with reduced EF (HFrEF). However, factors contributing to HFimpEF remain unclear. This study aimed to evaluate clinical and longitudinal characteristics associated with subsequent HFimpEF. This was a single-center retrospective HFrEF cohort study. Data were collected from 2014 to 2022. Patients with HFrEF were identified using International Classification of Diseases codes, echocardiographic data, and natriuretic peptide levels. The main end points were HFimpEF (defined as EF >40% at ≥3 months with ≥10% increase) and mortality. Cox proportional hazards and mixed effects models were used for analyses. The study included 1,307 patients with HFrEF with a median follow-up of 16.3 months (interquartile range 8.0 to 30.6). The median age was 65 years; 68% were male whereas 57% were White. On follow-up, 38.7% (n = 506) developed HFimpEF, whereas 61.3% (n = 801) had persistent HFrEF. A multivariate Cox regression model identified gender, race, co-morbidities, echocardiographic, and natriuretic peptide as significant covariates of HFimpEF (p

Objective: In 2018, the United States Preventive Services Task Force promoted shared decision making between healthcare provider and patient for men aged 55 to 69. This study aimed to analyze rates of prostate-specific antigen (PSA) testing across racial and ethnic groups following this new recommendation. Methods: A secondary analysis was conducted of the 2020–2021 Behavioral Risk Factor Surveillance System database to assess men aged 55 or older without a history of prostate cancer. We defined four race-ethnicity groups: non-Hispanic Whites (NHWs), non-Hispanic Blacks (NHBs), Hispanics, and Other. The primary outcome was the most recent PSA test (MRT), defined as the respondent's most recent PSA test occurring pre-2018 or post-2018 guidelines. Logistic regression adjusted for covariates including age, socioeconomic status factors, marital status, smoking history, and healthcare access factors. Results: In the age 55 to 69 study sample, NHW men had the greatest proportion of MRT post-2018 guidelines (n = 15,864, 72.5%). NHB men had the lowest percentage of MRT post-2018 guidelines (n = 965, 66.6%). With NHW as referent, the crude odds of the MRT post-2018 guidelines was 0.68 (95% confidence interval (CI) = 0.53–0.90) for NHB. The maximally adjusted odds ratio was 0.78 (0.59–1.02). Conclusions: We found that NHB aged 55 to 69 reported decreased rates of PSA testing after 2018 when compared to NHW. This was demonstrated on crude analysis but not after adjustment. Such findings suggest the influence of social determinants of health on preventative screening for at-risk populations. [ABSTRACT FROM AUTHOR]

Lyme disease is the most common vector-borne disease in the United States. It is caused by bacteria Borrelia burgdorferi and transmitted to humans by blacklegged ticks. The transmission is a complex process that involves several different non-human host species, including small mammals such as mice and large mammals such as deer. Due to this complexity, mathematical modeling has proved invaluable to understanding the spread of Lyme disease. There are about 100 models focused specifically on Lyme disease and many more applicable to generic tick-born diseases. We provide an overview of the existing literature. We discuss different models addressing major topics such as tick population growth, host biodiversity and Lyme disease risk dilution, spatial invasion of ticks, and models for Lyme disease in humans. One interesting feature of many models not typically found in other epidemiological models is the existence of two reproduction numbers--one for the ticks and one for the Lyme disease. We believe that there is a need for more models addressing co-infection with other tick-born diseases, as well as models explaining the discrepancy between tick and disease prevalence. [ABSTRACT FROM AUTHOR]

A 54-year-old male patient presented for a periodic check-up at the dental clinic. A panoramic radiograph showed bilateral ossification of the stylohyoid ligament with an oval radiopacity on the right side. Cone-beam computed tomography revealed a well-defined, homogenous hyperdense entity from the lower third of the ossified stylohyoid ligament on the right side. The differential diagnosis of osteoma on the stylohyoid chain includes Eagle syndrome and benign tumors of the stylohyoid chain and adjacent structures. Osteoma rarely manifests in the neck. Even more infrequent are tumors originating from the stylohyoid chain, with only a single documented case of osteoma reported in the literature in 1993. Due to the asymptomatic status, no surgical intervention was advised, and the case would be monitored periodically. This case report describes the details of an osteoma that emerged from the stylohyoid chain, marking it as the second recorded occurrence of this highly rare condition. [ABSTRACT FROM AUTHOR]

Introduction/Background Dupilumab is a human monoclonal antibody of the IgG4 subclass and binds to the IL-4R alpha subunit, causing downstream inhibition of IL-4 and IL-13 signaling and thus downregulating the T-helper-2 (Th2) cytokine response.1,2,3 Approved by the Food and Drug Administration in 2017, dupilumab is FDA-approved to treat atopic dermatitis (moderate-to-severe), asthma (moderate-to-severe), chronic rhinosinusitis with nasal polyposis, and eosinophilic -esophagitis. Vitiligo is a common autoimmune depigmenting skin disorder that is prevalent in 1.38% of US adults, and 2.16% in adolescents in the US, with a range of 0.4-2% in most populations.4,5,6 It occurs when the immune system of the body attacks melanocytes, skin cells, that produce melanin, and has been linked to the Koebner phenomenon which occurs when trauma induces lesions, with events including scratching as would be noted in AD.7 AD has also been linked to Vitiligo, especially in children under the age of 12 years.8,9,10 There are many available therapies for vitiligo, topical, systemic, phototherapy, and surgical types being most commonly used.11,12,13 Objectives To address specific features of AA/ Vitiligo/ AD overlap that would support benefit of dupilumab prescribing. Methods An IRB-exempt review was conducted of patient charts for individuals who received dupilumab who had alopecia areata or vitiligo associated with AD. Results Six patients with AD and alopecia universalis (AU), and one patient with AD, vitiligo, and alopecia areata (AA) were identified for review. The patients treated for AU included a 5 year-old Asian female, a 12 year-old white female, a 14 year-old African American male, A 15 year-old Hispanic female, a 26 year-old African American female, and a 78 year-old Hispanic female. The five year-old regrew hair for 4 months but had rapid loss when forced to discontinue due to insurance reasons. The 12 year-old female who had AU for 8 years and had no regrowth. The 15 year-old, 26 year-old, and 78 year-old had rapid regrowth of hair in addition to AD improvement, however, the 15 year-old required addition of an oral JAK inhibitor to retain hair growth. The vitiligo/AA patient is a 61 year-old female patient who had 50% BSA confetti lesion vitiligo affecting the chest, back, abdomen, arms, and legs. She had rapid disease stabilization (2 months) and at 1 year had 90% facial and 70% extremity repigmentation with dupilumab and topical 1.5% ruxolitinib. The same patient had 40% scalp hair loss which fully resolved upon repigmentation of the scalp. Response was noted rapidly but plateaued at 12 months. Conclusions The overlap of AD with AA and Vitiligo points to a shared pathogenesis of the conditions. One of the likely reasons for this is the Koebner phenomenon, which has been poorly characterized. We hypothesize that the Koebner phenomenon is triggered through an IL-4/ IL-13 mechanism, i.e. for specific individuals IL-4 and IL-13 hyper-reactivity can be a Koebner-based trigger. Additionally, AA overlaps with AD is poorly characterized. However, the linkage has been recognized in recent AAD guidelines addressing AD comorbidities.14 We hypothesize that IL-4/ IL-13 hyper-reactivity in the skin can act similarly in AU. There is in AA an overlap of TH1-CXCL9/10 expression and interferon gamma overexpression in addition to TH2- including IL-13 overexpression.15 Therefore, the blockade of IL-4/ IL-13 may be effective through multiple mechanisms of activity. There is already notable Phase 2a data supporting dupilumab usage in AA.16 Our experience demonstrates sustained hair growth in half of patients treated. AA/ Vitiligo overlap appears to respond well to dupilumab. This is supported by a recent case report demonstrating benefit of dupilumab in programmed cell death inhibitor-1 induced vitiligo with associated refractory pruritus.17 Liu et al have observed in vitro that rising IL-4 levels were linked to increased vitiligo risk.18 On the other hand, some reports of vitiligo after initiating dupilumab therapy do exist, with some new-onset and worsening described. These cases are limited but bear consideration. In our patient, disease stabilization was noted in a generalized confetti-vitiligo patient, but a topical JAK inhibitor was used adjunctively.19,20,21,22,23 Given the need for long-term maintenance, the safety of dupilumab is an attractive feature. Therefore, further exploration of dupilumab therapy for vitiligo/AA/AD, vitiligo/AD/Koebner+, and AU/ AD is needed. This is particularly important to address in patients under the age of 12 years who currently have no approved systemic medications for vitiligo and AU.24 When AU, vitiligo, and combinations of the two are comorbid with AD, there is an expectation of circulating IL-4/13 elevations and localized IL-4/13 elevation that support a potential role for dupilumab therapy in these conditions. Given that AD is associated with vitiligo of childhood, and severe alopecia areata is linked to AD, systemic therapy would be necessary in these individuals. [ABSTRACT FROM AUTHOR]

Background: Bunionette deformity (BD) is a painful condition of the fifth metatarsal characterized by an osseous prominence and fifth toe varus deformity. The purpose of this study is to assess the clinical, functional, and radiographic outcomes of percutaneous distal metatarsal metaphyseal osteotomy (DMMO) without fixation or postoperative strapping of the foot. Methods: A retrospective case series was performed on 111 patients (132 feet) with symptomatic BD who underwent percutaneous DMMO of the fifth metatarsal from September 2020 to January 2022 by an experienced minimally invasive surgeon. According to the Shimobayashi classification, we treated 1 type I deformity, 37 type II deformities, 52 type III deformities, 42 feet with type IV deformity, and no patient with a type V deformity. Ninety patients (81%) underwent unilateral osteotomy, and 21 (19%) had bilateral osteotomies. Most cases included other procedures including treatment of 114 associated deformities of the same feet: 68 bunions, 12 lesser metatarsal osteotomies (2-3-4 metatarsals), and 34 hammertoes (20 second hammertoes, 10 third hammertoes, 1 fourth hammertoes, 2 fifth hammertoes). Patient-reported clinical outcome measures, including the Foot Function Index (FFI) questionnaire, the visual analog score (VAS), and overall satisfaction were collected. Fourth-to-fifth intermetatarsal angle (IMA) correction, time to bone union, and complication rates were assessed in all patients. Results: Mean follow-up was 24.1 months (range, 14-39 months). Both radiographic parameters and patient-reported outcome measures significantly improved after DMMO procedure. The average fourth-to-fifth IMA improved from 12.2 degrees, preoperatively, to 4.4 degrees, postoperatively (P <.001). Patient outcomes reflect the overall outcomes of the combined surgeries on a per-patient basis. Preoperatively, patients had a mean VAS score of 7.6, which improved to 0.6 at the last follow-up (P <.001). Furthermore, the average FFI significantly decreased from pre- to postoperation from 19.2 to 4.4, respectively (P <.001). Overall, 108 of 111 patients reported being satisfied with the outcomes of the procedure. Average bone union was achieved at 12.6 weeks postoperation, with a minimum of 12 and a maximum of 25 weeks. The complication rate was 1.5%, including 1 case of an asymptomatic cock-up deformity and 1 case of lateral fifth metatarsal shaft bone overhang pain, which resolved with an exostectomy. Conclusion: The results of this study of patients who had minimally invasive surgery from an experienced surgeon suggest that percutaneous DMMO of the fifth metatarsal without internal fixation or postoperative immobilization or strapping can be effective at improving radiographic alignment, pain, function, and overall satisfaction with minimal rates of complication. Level of Evidence: Level IV, case series. [ABSTRACT FROM AUTHOR]

Background: Extracorporeal membrane oxygenation (ECMO) has extended the survivability of critically ill patients beyond their unsupported prognosis and has widened the timeframe for making an informed decision about the goal of care. However, an extended time window for survival does not necessarily translate into a better outcome and the sustaining treatment is ultimately withdrawn in many patients. Emerging evidence has implicated the determining role of palliative care consult (PCC) in direction of the care that critically ill patients receive. Objective: To evaluate the impact of PCC in withdrawal of life-sustaining treatment (WOLST) among critically ill patients, who were placed on venovenous ECMO (VV-ECMO) at the intensive care unit (ICU) of a tertiary care hospital. Methods: In a retrospective observational study, electronic medical records of 750 patients admitted to the ICU of our hospital between January 1, 2015, and October 31, 2021, were reviewed. Data was collected for patients on VV-ECMO, for whom WOLST was withdrawn during the ICU stay. Clinical characteristics and the underlying reasons for WOLST were compared between those who received PCC (PCC group) and those who did not (non-PCC group). Results: A total of 95 patients were included in our analysis, 63 in the PCC group and 32 in the non-PCC group. The average age of the study population was 48.8 ± 12.6 years, and 64.2% were male. There was no statistically significant difference between the two groups in terms of demographics or clinical characteristics at the time of ICU admission. The average duration of ICU stay and VV-ECMO were 14.1 ± 19.9 days and 9.4 ± 16.6 days, respectively. The number of PCC visits was correlated with the length of ICU stay. The average duration of ICU stay (40.3 ± 33.2 days vs 27.8 ± 19.3 days, P =.05) and ECMO treatment (31.9 ± 27 days vs 18.6 ± 16.1 days, P =.01) were significantly longer in patients receiving PCC than those not receiving PCC. However, the frequency of life sustaining measures or the underlying reasons for WOLST did not significantly differ between the two groups (P >.05). Conclusion: Among ICU patients requiring ECMO support, longer duration of ICU stay and treatment with a higher number of life-sustaining measures seemed to be correlated with the number of PCC visits. The underlying reasons for WOLST seem not to be affected by PCC. [ABSTRACT FROM AUTHOR]

We report a case of a 46‑year‑old female – a postrenal transplant patient, having developed rhabdomyolysis and neuroleptic malignant syndrome (NMS), after 2.5 months of desidustat initiation – for anemia. Post renal transplant anemia (PTA) is common among renal transplant recipients. Apart from treating it with iron supplements, folic acid, andrecombinant human erythropoietin (EPO), novel agents like hypoxia‑inducible factor–prolyl hydroxylase domain (HIF–PHI) are also used, with a very few studies available on its efficacy and safety in PTA patients. Anemia occurring in the first 6 months is called early PTA – occurring most commonly due to iron deficiency, while anemia occurring after 6 months is called late PTA– associated with impaired graft function. The optimal target of hemoglobin in transplant recipients is 12.5–13 gm/dl, which is higher than targets in chronic kidney disease patients. NMS is a life‑threatening emergency – mainly seen in patients on antipsychotic medications. It needs to be differentiated from other closely related conditions such as central nervous system infections(meningitis and encephalitis), tetanus, heatstroke, serotonin syndrome, and thyrotoxicosis. Desidustat is an oral HIF–PHI that stimulates erythropoiesis by preventing EPO degradation. Its adverse effects include high blood pressure, myocardial infarction, heart failure, high potassium, and dizziness; however, there is only one case report of rhabdomyolysis associated with desidustat, and none of NMS. It is, therefore, important to be aware of this potential severe side effect of the drug that was not known earlier so that practicing physicians can be vigilant of the same. [ABSTRACT FROM AUTHOR]

Background: Marginal mandibulectomy defects in patients with oral malignancy pose a challenge to reconstructive surgeons. With the availability of varied microvascular flap options, free flap reconstruction has become a gold standard for the same. However, the PMMC flap can be reliably used for marginal mandibulectomy defects with its advantages being robust flap, ease of harvest, and economical. We wish to present our experience with the use of PMMC flaps for the reconstruction of marginal mandibulectomy defects. Material and Methods: A retrospective study was conducted on patients operated for PMMC flap reconstruction for marginal mandibulectomy defects from January 2018 to January 2023 at a tertiary hospital in India. Patients were evaluated based on functional satisfaction, cosmetic outcome, and complications using patient data from case sheets, pre-operative, postoperative, and follow-up clinical photos. Results: A total of 9 patients underwent PMMC flap reconstruction for marginal mandibulectomy defects. 7 patients had reconstruction of buccal mucosa defect while folded PMMC flap was done in 2 patients with associated cheek skin defect. Early complications were noted in 3 patients viz. chyle leak (1), partial necrosis of flap with wound dehiscence (1), and parotid fistula (1) which were managed conservatively. Late complications included recurrence in 2 patients who needed additional procedures. 3 patients needed adjuvant radiotherapy, none developed osteoradionecrosis. Conclusion: PMMC flap can thus be concluded to be a robust, simple to harvest, and reliable flap for reconstruction of marginal mandibulectomy defects with satisfactory functional and cosmetic outcomes. It can also be used as a salvage flap after failed microvascular reconstruction. [ABSTRACT FROM AUTHOR]