Carotid Artery Stenosis and Ischemic Stroke in Patients with Head and Neck Cancer Treated with Radiotherapy: A Critical Review

PURPOSE

The purpose of this review is to summarize the literature on carotid artery stenosis (CAS) and ischemic stroke (IS) in head and neck cancer (HNC) patients treated with radiotherapy (RT) to guide assessment, screening, and management strategies.

RESULTS

Patients treated with RT for HNC are at an elevated risk of developing CAS with published meta-analyses demonstrating that CAS >50% occurs in approximately 25% of patients. Previous research suggests a 10-year cumulative incidence of stroke between 5.7% and 12.5%. Cardiovascular (CVD) risk prediction tools such as QSTROKE, QRISK-2 and Framingham risk score perform poorly for predicting IS for HNC patients who received RT. Duplex US is the most common imaging modality to assess CAS, but controversy remains as to the utility of screening asymptomatic individuals. Only three of the five major HNC survivorship guidelines acknowledge RT as a risk factor for CAS or IS, whilst only one makes a specific recommendation on screening for CAS (American Head and Neck Society). Within the general population only one CVD guideline discusses RT as a risk factor for CAS (Society for Vascular Surgery).

CONCLUSIONS

Clinicians involved in the care of HNC patients treated with RT should be aware of the increased risk of CAS and IS and the challenges in risk prediction. While there is a lack of evidence to make firm recommendations, HNC survivorship recommendations should ensure HNC survivors and primary care providers are informed of these risks and the importance of assessment and management of CVD risk factors. Future studies are required to refine risk prediction models in HNC patients, and to determine those most likely to benefit from targeted screening and initiation of early preventative strategies.

Nurse Practitioner Certification Examination Development: From Reflecting Clinical Practice to Ensuring Lifelong Learning

OBJECTIVE

Certifications in psychiatric-mental health nursing promote safe practice by psychiatric-mental health nurse practitioners (PMHNPs) and nurses (PMHNs) and help protect the public from harm. This protection begins with the development of an examination that meets rigorous national education, practice, and accreditation standards and reflects PMHNPs' or PMHNs' clinical practice. Achievement and maintenance of a certification is a journey that involves a commitment to lifelong learning and the improvement of the field of psychiatric-mental health nursing through involvement in the examination process.

METHODS

This discussion paper outlines the role nurses can play in the development of certification examinations. It describes the process of developing an effective certification examination, including the role of standards, accrediting bodies, and content experts; determining necessary tasks, knowledge, and skills; surveying practitioners to validate information; writing test questions; and ongoing analysis of examination content. The Psychiatric-Mental Health Nurse Practitioner (across the lifespan) Certification (PMHNP-BC) is presented as an example of the process.

RESULTS

This discussion paper raises awareness of how certification exams are developed, PMHNPs participate in certification development, and volunteering promotes career development.

CONCLUSION

The PMHNP-BC examination is based on education, practice, and certification accreditation standards and reflects current clinical practice. PMHNPs can (a) point to the rigor of certification as an indication of the quality of care they deliver, (b) volunteer to participate in the examination process to ensure examination rigor, and (c) advance their careers through the development and application of a valuable skill set.

Systemic lupus erythematosus presenting with atypical hemolytic uremic syndrome: a case report and review of the literature

Systemic lupus erythematosus (SLE) can present with a diverse array of hematologic manifestations, among which atypical hemolytic uremic syndrome (aHUS) is a rare entity. SLE-triggered aHUS has significant morbidity and mortality without timely intervention, yet its frequency remains uncertain and optimal strategies for complement-directed therapies are largely expert-driven. We performed a comprehensive literature review and present a case of a 23-year-old female newly diagnosed with SLE/class IV lupus nephritis who developed aHUS that rapidly responded to the C5 antagonist, eculizumab. Review of the current literature identified forty-nine published cases of SLE with concurrent aHUS and revealed a predilection for aHUS in younger SLE patients, concurrent presentation with lupus nephritis, anti-dsDNA positivity, and complement system abnormalities. Over seventy percent of cases used eculizumab as complement-directed therapy with a trend towards faster time to improvement in laboratory parameters, though reported outcomes were highly variable. Early recognition of aHUS in SLE is pivotal in guiding appropriate therapeutic interventions, and prompt initiation of eculizumab may reduce the potential morbidity associated with plasmapheresis and additional immunosuppression. While eculizumab showcases promising results, its optimal timing and duration remain elusive. An understanding of a patients' complement genetics could aid management strategies, and ongoing research into complement-targeted therapies offers promising avenues for both SLE and aHUS treatment.

Adapting to change: exploring perceptions and demands of the coronavirus (COVID-19) workforce changes - an Australian multi-institutional radiation oncology survey

ObjectiveTo evaluate the perceptions of the coronavirus disease 2019 (COVID-19) initiated workplace strategies implemented in radiation oncology departments across Australia.MethodsA multidisciplinary team from Princess Alexandra Hospital developed a survey to address the impact of the pandemic strategies on areas such as patient care, staff education, well-being, flexible working arrangements, and research. The survey was conducted from November 2020 to April 2021.ResultsOut of 210 respondents from seven institutions, 45% reported burnout and 57% experienced work work-related stress. A significant majority of respondents were in favour of continued remote work (86%, 131/153). Radiation oncologists identified administrative or non-clinical work (92%, 34/37), telehealth clinics (32%, 12/37), or radiation therapy planning (22%, 8/37) as suitable for remote work. Additionally, 54% (21/39) of the radiation oncologists plan to use telehealth more frequently, with 67% (26/39) feeling more confident with the technology. The majority (81%, 171/210) of participants favoured continuation of hybrid in-person and virtual meetings. Virtual solutions were adopted for quality assurance activities (72%, 118/165) and 52% (60/116) indicated preference for ongoing utility of virtual platforms. However, 38% (79/210) of the respondents expressed concerns about the negative impact on junior staff training.ConclusionThese findings reveal a strong inclination towards technological advancements and remote work arrangements to enable flexible working conditions. Our study suggests the need for ongoing reforms, focusing on improving clinical service delivery efficiencies and enhancing job satisfaction among clinicians.

Doctor Versus Artificial Intelligence: Patient and Physician Evaluation of Large Language Model Responses to Rheumatology Patient Questions in a Cross-Sectional Study

OBJECTIVE

The objective of the current study was to assess the quality of large language model (LLM) chatbot versus physician-generated responses to patient-generated rheumatology questions.

METHODS

We conducted a single-center cross-sectional survey of rheumatology patients (n = 17) in Edmonton, Alberta, Canada. Patients evaluated LLM chatbot versus physician-generated responses for comprehensiveness and readability, with four rheumatologists also evaluating accuracy by using a Likert scale from 1 to 10 (1 being poor, 10 being excellent).

RESULTS

Patients rated no significant difference between artificial intelligence (AI) and physician-generated responses in comprehensiveness (mean 7.12 ± SD 0.99 vs 7.52 ± 1.16; P = 0.1962) or readability (7.90 ± 0.90 vs 7.80 ± 0.75; P = 0.5905). Rheumatologists rated AI responses significantly poorer than physician responses on comprehensiveness (AI 5.52 ± 2.13 vs physician 8.76 ± 1.07; P < 0.0001), readability (AI 7.85 ± 0.92 vs physician 8.75 ± 0.57; P = 0.0003), and accuracy (AI 6.48 ± 2.07 vs physician 9.08 ± 0.64; P < 0.0001). The proportion of preference to AI- versus physician-generated responses by patients and physicians was 0.45 ± 0.18 and 0.15 ± 0.08, respectively (P = 0.0106). After learning that one answer for each question was AI generated, patients were able to correctly identify AI-generated answers at a lower proportion compared to physicians (0.49 ± 0.26 vs 0.97 ± 0.04; P = 0.0183). The average word count of AI answers was 69.10 ± 25.35 words, as compared to 98.83 ± 34.58 words for physician-generated responses (P = 0.0008).

CONCLUSION

Rheumatology patients rated AI-generated responses to patient questions similarly to physician-generated responses in terms of comprehensiveness, readability, and overall preference. However, rheumatologists rated AI responses significantly poorer than physician-generated responses, suggesting that LLM chatbot responses are inferior to physician responses, a difference that patients may not be aware of.

Assessing Surgical Outcomes for Cage Plate System versus Stand-Alone Cage in Anterior Cervical Discectomy and Fusion: A Systematic Review and Meta-Analysis

BACKGROUND

Anterior cervical discectomy and fusion (ACDF) is a common surgical procedure for addressing cervical spine conditions. It involves the utilization of either cage plate system (CPS) or stand-alone cage (SC). The objective of our study is to compare perioperative complications, patient-reported clinical outcomes measures, and radiographic outcomes of SC versus CPS in ACDF.

METHODS

We carried out a literature search in PubMed, Embase, Cochrane library, Web of science, Medline, and Google Scholar. All studies comparing the outcomes between CPS versus SC in ACDF were included.

RESULTS

Forty-one studies, 33 observational and 8 randomized clinical trials met the inclusion criteria. We found that both devices demonstrated comparable effectiveness in monosegmental ACDF with respect to Japanese Orthopedic Association Score, Neck Disability Index score, visual analog score, and fusion rates. CPS demonstrated superior performance in maintaining disc height, cervical lordosis, and exhibited lower incidence rates of cage subsidence. SC showed significant advantages over CPS in terms of shorter surgical duration, less intraoperative bleeding, shorter duration of hospitalization, as well as lower incidence rates of early postoperative dysphagia and adjacent segment disease.

CONCLUSIONS

Most of the included studies had monosegmented fusion, and there wasn't enough data to set recommendations for the multisegmented fusions. Larger studies with longer follow-up are necessary to draw more definitive conclusions to provide evidence for clinicians to make clinical decisions.

Achievement of Target Gain Larger than Unity in an Inertial Fusion Experiment

On December 5, 2022, an indirect drive fusion implosion on the National Ignition Facility (NIF) achieved a target gain G_{target} of 1.5. This is the first laboratory demonstration of exceeding "scientific breakeven" (or G_{target}>1) where 2.05 MJ of 351 nm laser light produced 3.1 MJ of total fusion yield, a result which significantly exceeds the Lawson criterion for fusion ignition as reported in a previous NIF implosion [H. Abu-Shawareb et al. (Indirect Drive ICF Collaboration), Phys. Rev. Lett. 129, 075001 (2022)PRLTAO0031-900710.1103/PhysRevLett.129.075001]. This achievement is the culmination of more than five decades of research and gives proof that laboratory fusion, based on fundamental physics principles, is possible. This Letter reports on the target, laser, design, and experimental advancements that led to this result.

Recommendations for Method Development and Validation of qPCR and dPCR Assays in Support of Cell and Gene Therapy Drug Development

The emerging use of qPCR and dPCR in regulated bioanalysis and absence of regulatory guidance on assay validations for these platforms has resulted in discussions on lack of harmonization on assay design and appropriate acceptance criteria for these assays. Both qPCR and dPCR are extensively used to answer bioanalytical questions for novel modalities such as cell and gene therapies. Following cross-industry conversations on the lack of information and guidelines for these assays, an American Association of Pharmaceutical Scientists working group was formed to address these gaps by bringing together 37 industry experts from 24 organizations to discuss best practices to gain a better understanding in the industry and facilitate filings to health authorities. Herein, this team provides considerations on assay design, development, and validation testing for PCR assays that are used in cell and gene therapies including (1) biodistribution; (2) transgene expression; (3) viral shedding; (4) and persistence or cellular kinetics of cell therapies.

Machine Learning Potentials with the Iterative Boltzmann Inversion: Training to Experiment

Methodologies for training machine learning potentials (MLPs) with quantum-mechanical simulation data have recently seen tremendous progress. Experimental data have a very different character than simulated data, and most MLP training procedures cannot be easily adapted to incorporate both types of data into the training process. We investigate a training procedure based on iterative Boltzmann inversion that produces a pair potential correction to an existing MLP using equilibrium radial distribution function data. By applying these corrections to an MLP for pure aluminum based on density functional theory, we observe that the resulting model largely addresses previous overstructuring in the melt phase. Interestingly, the corrected MLP also exhibits improved performance in predicting experimental diffusion constants, which are not included in the training procedure. The presented method does not require autodifferentiating through a molecular dynamics solver and does not make assumptions about the MLP architecture. Our results suggest a practical framework for incorporating experimental data into machine learning models to improve the accuracy of molecular dynamics simulations.

Does performing manipulation of nasal bones under local anaesthetic beyond two weeks after injury affect outcomes? A prospective study during the SARS-CoV-2 pandemic

Introduction

ENTUK guidelines recommend that manipulation of nasal bones (MNB) should be performed within 14 days of injury. However, evidence suggests treatment under general anaesthetic remains effective up to 5 weeks after injury. With the SARS-CoV-2 pandemic leading to delays in referral and limited access to theatre, local practice changed to offer delayed MNB under local anaesthetic. This prospective study assesses the effectiveness of MNB delayed until 3 weeks or later from time of injury when performed mostly under local anaesthetic.

Methods

Data was prospectively collected between April and November 2020. All patients referred to ENT with a new nasal bone deformity presenting more than 21 days after injury were included. Demographic information, injury details and patient satisfaction was recorded for each patient.

Results

11 patients were included. Average age was 32.6 years (Range 8-65 years). 10 procedures (91%) were performed under local anaesthetic, with 1 (9%) performed under general anaesthetic. 9 patients (82%) gained complete reduction of the deformity, and 1 patient (9%) gaining partial reduction. 10 patients (91%) patients were satisfied with the cosmetic outcome.

Conclusion

This study supports the small volume of recent literature showing that delayed manipulation of nasal bones is effective and additionally demonstrates that efficacy is maintained when performed under local anaesthetic.

Infant and Parent Outcomes Related to NICU-Based Co-occupational Engagement

Neonatal intensive care unit (NICU) co-occupations may impact parent-infant outcomes. The main objective of this study was to explore relationships between parent and infant outcomes based on whether sensory-based interventions (co-occupations) occurred most often between parent-infant dyads or provider/volunteer-infant dyads. Thirty-five families received the Supporting and Enhancing NICU Sensory Experiences (SENSE) program, which includes education defining specific amounts of sensory exposures for infants to receive each day of NICU hospitalization (with a preference for parent delivery). Infant sensory experiences in the NICU were logged, and dyads were grouped based on who conducted most of the sensory interventions with the infant in the NICU into a Parent-Infant Co-occupation group or Other Administered group. The Parent-Infant Co-occupation group had infants with less lethargy on the NICU Network Neurobehavioral Scale (p = .04), and parents with lower scores on the Parental Stress Scale (p = .003) and State-Trait Anxiety Inventory-state (p = .047). Parent-infant engagement in co-occupations was related to parental mental health and infant neurobehavior.

Commentary on the published position statement regarding the pathogenesis of fetal basal ganglia- thalamic hypoxic-ischaemic injury

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CPD providers can positively impact practice by better understanding how APNs are educated, licenced, and certified

Advanced practice nurses (APNs) care for various patient populations in a wide variety of settings. The four types of APNs in the USA (certified nurse practitioner, clinical nurse specialist, certified nurse-midwife, and certified registered nurse anaesthetist) have differences and commonalities related to education, licensure, and certification. Care provided by APNs has been demonstrated to be of high quality, and APNs are active and engaged participants in continuing professional development (CPD) as CPD is required to maintain licensure and board certification. APNs also frequently function as clinical and academic faculty.

Assessment of dose rates to non-human biota from radioactive discharges from Sellafield Ltd. using PC-CREAM

PC-CREAM is a tool for assessing the radiological impact of routine discharges of radionuclides to the environment. It can be used for prospective assessments, to calculate doses to members of the public for authorisation of proposed discharges, or for retrospective assessments of previous discharges where doses are compared with dose limits. These types of assessment are a fundamental requirement of regulations governing the control of radioactive discharges. However, the latest publications of the basic safety standards for radiation protection, EU (Council of the European Union, 2014) and the IAEA (IAEA, 2014), now include the requirement to demonstrate protection of the environment as well as members of the public. To this end, a module has been added to PC-CREAM for calculating dose rates to non-human biota (Anderson et al., 2022). The methodology used for this calculation is based on the recommendations contained in ICRP Publication 108 (ICRP, 2008), which provides a general framework for protection of the environment. The additional module means that PC-CREAM can be used to assess doses to humans and dose rates to biota in an integrated way, for the same set of discharges and using the same dispersion models. This paper describes an assessment of dose rates to biota living in the vicinity of the Sellafield nuclear site, carried out using the new biota module of PC-CREAM. Historical discharges from Sellafield to the sea and atmosphere were considered for the period 1951 to 2017, excluding those from the Windscale fire in 1957. Dose rates calculated for marine biota (flatfish, crabs and brown seaweed) are less than 1 mGy d-1 and are below the lower derived consideration reference level (DCRL) for the ICRP marine reference animals and plants (RAPs). Dose rates for terrestrial biota (bees, deer, earthworms, frogs, wild grass, pine trees and rats) are less than the relevant lower DCRL for terrestrial RAPs, ie 0.1 mGy d-1. Dose rates were also calculated for a user defined organism 'seabird' to represent birds which inhabit both marine and terrestrial environments near Sellafield. For seabird, the lower DCRL of 0.1 mGy d-1 is exceeded throughout the 1950s, 1960s and 1970s, when the discharges were at their highest, due to exposures from the marine environment. Since the mid-1980s, no dose rates were calculated that exceeded the lower DCRLs.

Mediator Kinase Inhibition Impedes Transcriptional Plasticity and Prevents Resistance to ERK/MAPK-Targeted Therapy in KRAS-Mutant Cancers

Acquired resistance remains a major challenge for therapies targeting oncogene activated pathways. KRAS is the most frequently mutated oncogene in human cancers, yet strategies targeting its downstream signaling kinases have failed to produce durable treatment responses. Here, we developed multiple models of acquired resistance to dual-mechanism ERK/MAPK inhibitors across KRAS-mutant pancreatic, colorectal, and lung cancers, and then probed the long-term events enabling survival against this class of drugs. These studies revealed that resistance emerges secondary to large-scale transcriptional adaptations that are diverse and cell line-specific. Transcriptional reprogramming extends beyond the well-established early response, and instead represents a dynamic, evolved process that is refined to attain a stably resistant phenotype. Mechanistic and translational studies reveal that resistance to dual-mechanism ERK/MAPK inhibition is broadly susceptible to manipulation of the epigenetic machinery, and that Mediator kinase, in particular, can be co-targeted at a bottleneck point to prevent diverse, cell line-specific resistance programs.

Use of high-flow nasal oxygen for pregnant women with COVID-19 in the labour ward setting

The presentation and management of SARS-CoV-2 (COVID-19) infection in the obstetric population is affected by the hormonal and mechanical changes of pregnancy. The increased oxygen demands in pregnancy in the face of conventional oxygen therapy, risks of tracheal intubation and discomfort from non-invasive positive pressure ventilation all support the use of high-flow nasal oxygen (HFNO) as an alternative therapy. The lack of published guidance for the use of HFNO has led to the development of local-level guidance based on expert consensus. More evidence exploring the use of HFNO therapy in the pregnant population is required to assist in developing clinical guidelines.

Racial Disparities and Surgical Outcomes After Anterior Cervical Discectomy and Fusion: National Surgical Quality Improvement Program Analysis 2015-2020

BACKGROUND

Our objective was to assess the effect of race on outcomes in patients undergoing anterior cervical discectomy and fusion (ACDF).

METHODS

We identified 57,913 adult patients who underwent elective ACDF spine surgery from 2015 to 2020. Data were extracted from the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database. Demographics, comorbidities, perioperative course, and 30-day postoperative outcomes were stratified by race.

RESULTS

A total of 57,913 patients, white (n = 49,016), African American (AA; n = 7200), Native American (NA; n = 565), and Asian (n = 1132) underwent ACDF fusion surgery. AA patients had higher comorbidities, including diabetes (24.7%), dyspnea (5.9%), and hypertension (61.6%) compared with the other groups (P < 0.001). NA and AA were higher tobacco users, (33.1%) and (28.7%), respectively (P < 0.001). Most of the patients reported in this dataset had single-level surgeries. AAs had a longer average hospital stay (2.51±7.31 days) and operative time (144.13±82.26 min) (P < 0.001). Lower risk of superficial surgical site infection (adjusted odds ratio [ORadj], 0.41; 95% confidence interval [CI], 0.22-0.77; P = 0.005) and greater risk of reintubation (ORadj, 1.65; 95% CI, 1.25-2.17; P < 0.001), pulmonary embolism (ORadj, 1.88; 95% CI, 1.27-2.79; P = 0.001), renal insufficiency (ORadj, 3.15; 95% CI, 1.38-7.20; P = 0.006), and return to the operating room (ORadj, 1.41; 95% CI, 1.18-1.65; P < 0.001 were reported in AAs compared with whites. NAs showed an increased risk of superficial surgical site infection compared with whites (ORadj, 2.59; 95% CI, 1.05-6.36; P = 0.037).

CONCLUSIONS

Racial disparities were found to independently affect rates of complications after surgery for ACDF.

Hospital at Home meets need for new dialysis patients

The COVID-19 pandemic has had lingering effects in healthcare. During the pandemic, inpatient bed shortages became a major barrier to providing care, and access to outpatient dialysis was delayed due to a shortage of staff. This resulted in lengthy admissions to the hospital while awaiting outpatient dialysis placement in a time when hospital bedspace was a scarce resource. In this report we describe the use of the Hospital at Home program for inpatient dialysis care as a novel method to both provide high quality patient care at home and also open inpatient beds in the hospital. Here, we present two cases where this program served both the needs of the patient and the hospital system by providing dialysis care to patients participating in the Hospital at Home program. One was a patient with a recent kidney transplant awaiting improvement in kidney function following transplant. The other was a new mother who was diagnosed with atypical hemolytic uremic syndrome and was awaiting recovery from her acute kidney injury after receiving complement inhibitor therapy. This program has been functional for the past 13 months and has served 37 patients and saved 1,007 inpatient days during that period. Each inpatient day provided by Hospital at Home represents bed space that was made available to another patient in need.

Strong Evidence for ^{9}N and the Limits of Existence of Atomic Nuclei

The boundaries of the chart of nuclides contain exotic isotopes that possess extreme proton-to-neutron asymmetries. Here we report on strong evidence of ^{9}N, one of the most exotic proton-rich isotopes where more than one half of its constitute nucleons are unbound. With seven protons and two neutrons, this extremely proton-rich system would represent the first-known example of a ground-state five-proton emitter. The invariant-mass spectrum of its decay products can be fit with two peaks whose energies are consistent with the theoretical predictions of an open-quantum-system approach; however, we cannot rule out the possibility that only a single resonancelike peak is present in the spectrum.

Assessment of autonomic symptom scales in patients with neurodevelopmental diagnoses using electronic health record data

Background

Sleep disturbances, gastrointestinal problems, and atypical heart rate are commonly observed in patients with autism spectrum disorder (ASD) and may relate to underlying function of the autonomic nervous system (ANS). The overall objective of the current study was to quantitatively characterize features of ANS function using symptom scales and available electronic health record (EHR) data in a clinically and genetically characterized pediatric cohort.

Methods

We assessed features of ANS function via chart review of patient records adapted from items drawn from a clinical research questionnaire of autonomic symptoms. This procedure coded for the presence and/or absence of targeted symptoms and was completed in 3 groups of patients, including patients with a clinical neurodevelopmental diagnosis and identified genetic etiology (NPD, n=244), those with an ASD diagnosis with no known genetic cause (ASD, n=159), and age and sex matched controls (MC, n=213). Symptoms were assessed across four main categories: (1) Mood, Behavior, and Emotion; (2) Secretomotor, Sensory Integration; (3) Urinary, Gastrointestinal, and Digestion; and (4) Circulation, Thermoregulation, Circadian function, and Sleep/Wake cycles.

Results

Chart review scores indicate an increased rate of autonomic symptoms across all four sections in our NPD group as compared to scores with ASD and/or MC. Additionally, we note several significant relationships between individual differences in autonomic symptoms and quantitative ASD traits.

Conclusion

These results highlight EHR review as a potentially useful method for quantifying variance in symptoms adapted from a questionnaire or survey. Further, using this method indicates that autonomic features are more prevalent in children with genetic disorders conferring risk for ASD and other neurodevelopmental diagnoses.

Financial Toxicity and Out-of-Pocket Costs for Patients with Head and Neck Cancer: An Australian Perspective

PURPOSE/OBJECTIVE(S)

Financial toxicity is under-investigated for patients with head and neck cancer (HNC). The aim of this study was to quantify and describe the financial toxicity and out-of-pocket costs for patients with HNC in regional Australia and to consider its relationship with quality of life.

MATERIALS/METHODS

A cross-sectional survey was administered to patients with mucosal HNC who were disease free and 1-3 years after completion of radiotherapy at a regional tertiary hospital in Australia. The survey included questions on socio-demographics, out-of-pocket expenses, and health-related quality of life (HRQoL) measured with the FACT-H&N. Financial toxicity was evaluated using the Financial Index of Toxicity (FIT) survey, which scores financial toxicity on a scale of 0-100 (higher score indicating higher financial toxicity). The relationship between high financial toxicity scores (top quartile) and HRQoL was explored.

RESULTS

Of 57 total patients, 41 (72%) reported out-of-pocket expenses at a median of AU$1,796 (interquartile range AU$2,700) and a maximum of AU$25,050. The overall median FIT score was 13.9 (interquartile range 19.5) and patients with high financial toxicity (n = 14) reported poorer HRQoL (76.5 vs 114.5, p < 0.001). Patients who were not married had a higher financial toxicity score (23.1 vs 11.1, p = 0.01). Similarly, those participants with lower levels of education had higher financial toxicity (19.3 vs 11.1, p = 0.06). Participants with private health insurance were found to have lower rates of financial toxicity (8.3 vs 17.6, p = 0.01). Medications (41%, median AU$400), dietary supplements (41%, median AU$600), travel (36%, median AU$525) and dental (29%, AU$388) were the most common out-of-pocket expenses. Only nineteen patients (33%) reported that a member of their treating team had asked if they have any financial concerns. Participants living in rural locations (> 100km from the hospital) had higher out-of-pocket expenses (AU$2655 vs AU$730, p = 0.01).

CONCLUSION

Financial toxicity is a significant issue for a significant proportion of patients with head and neck cancer which was associated with a reduced HRQoL. All clinicians should consider asking patients with HNC about financial concerns and be aware of what financial support is available in their region. Interventions are required to reduce the burden of financial toxicity for patients with HNC.

Immunologic profiles in patients with chronic limb-threatening ischemia undergoing endovascular revascularization

BACKGROUND

Inflammation and immune dysregulation have been associated with adverse outcomes in cardiovascular disease. There is limited understanding of the association of different profiles of white blood cell (WBC) subsets and red cell distribution width (RDW) in patients with chronic limb-threatening ischemia (CLTI).

METHODS

Patients with CLTI undergoing endovascular revascularization in our single-center, tertiary care hospital from 2017 to 2019, who had a preceding complete blood count (CBC) with WBC differentials (n =213), were included in the analysis. Patient characteristics, laboratory values, and clinical outcomes were collected. Cox proportional hazards regression models were used to assess for associations between all-cause mortality and leukocyte subset; multivariate analysis was used to account for confounders. Kaplan-Meier curves were generated to depict survival censored at 1 year postrevascularization using baseline CBC indices.

RESULTS

Adjusting for confounders, elevated RDW was associated with increased mortality (continuous per % increase, adjusted hazard ratio [HR] 1.33, p < 0.001). Baseline lymphopenia was associated with mortality in univariate analysis. Other leukocyte subtypes were not associated with mortality outcomes in our population. Exploratory analysis showed negative deflections in ∆WBC from pre- to postprocedure day 1 were affiliated with increased mortality when adjusted for age, sex, race, chronic kidney disease, and baseline hemoglobin (∆WBC HR 1.16, p = 0.004). Further exploratory analysis showed an association between RDW and all-comers readmission.

CONCLUSIONS

The utilization of a periprocedural WBC subset differential can be a useful adjunct to risk-stratify patients with CLTI undergoing endovascular revascularization. Further studies are needed to understand potential ways to modulate immune dysregulation so as to improve mortality outcomes.

A Case of Cocaine Toxicity From Body Stuffing

Here, we report a case of body stuffing leading to severe cocaine toxicity. Medical management and supportive care are usually the best course of action in cases of body stuffing, as seen in our case. While surgery is rarely indicated, surgical consultation should occur early to ensure prompt intervention if obstruction or perforation occurs.

Socioeconomic and racial/ethnic spatial polarization and incarceration among people who inject drugs in 19 US metropolitan areas, 2015

The purpose of this study is to test, for the first time, the association between spatial social polarization and incarceration among people who inject drugs (PWID) in 19 large U.S. metropolitan statistical areas (MSAs) in 2015. PWID were recruited from MSAs for the Centers for Disease Control and Prevention's 2015 National HIV Behavioral Surveillance. Administrative data were used to describe the ZIP-code areas, counties, and MSAs where PWID lived. We operationalized spatial polarization using the Index of Concentration at the Extremes (ICE), a measure that reflects polarization in race and household income at the ZIP-code level. We tested the association between spatial polarization and odds of past-year arrest and detainment using multilevel multivariable models. We found 37% of the sample reported being incarcerated in the past year. Report of past-year incarceration varied by race/ethnicity: 45% of non-Hispanic white PWID reported past-year incarceration, as did 25% of non-Hispanic Black PWID, and 43% of Hispanic/Latino PWID (N = 9047). Adjusted odds ratios suggest that Black PWID living in ZIP-code areas with a higher ICE score, meaning more white and affluent, had higher odds of past-year incarceration, compared to white PWID. In previous research, incarceration has been found to be associated with HIV acquisition and can deter PWID from engaging in harm reduction activities.

Childhood-Onset Lupus Nephritis in the Childhood Arthritis and Rheumatology Research Alliance Registry: Short-Term Kidney Status and Variation in Care

OBJECTIVE

The goal was to characterize short-term kidney status and describe variation in early care utilization in a multicenter cohort of patients with childhood-onset systemic lupus erythematosus (cSLE) and nephritis.

METHODS

We analyzed previously collected prospective data from North American patients with cSLE with kidney biopsy-proven nephritis enrolled in the Childhood Arthritis and Rheumatology Research Alliance (CARRA) Registry from March 2017 through December 2019. We determined the proportion of patients with abnormal kidney status at the most recent registry visit and applied generalized linear mixed models to identify associated factors. We also calculated frequency of medication use, both during induction and ever recorded.

RESULTS

We identified 222 patients with kidney biopsy-proven nephritis, with 64% class III/IV nephritis on initial biopsy. At the most recent registry visit at median (interquartile range) of 17 (8-29) months from initial kidney biopsy, 58 of 106 patients (55%) with available data had abnormal kidney status. This finding was associated with male sex (odds ratio [OR] 3.88, 95% confidence interval [95% CI] 1.21-12.46) and age at cSLE diagnosis (OR 1.23, 95% CI 1.01-1.49). Patients with class IV nephritis were more likely than class III to receive cyclophosphamide and rituximab during induction. There was substantial variation in mycophenolate, cyclophosphamide, and rituximab ever use patterns across rheumatology centers.

CONCLUSION

In this cohort with predominately class III/IV nephritis, male sex and older age at cSLE diagnosis were associated with abnormal short-term kidney status. We also observed substantial variation in contemporary medication use for pediatric lupus nephritis between pediatric rheumatology centers. Additional studies are needed to better understand the impact of this variation on long-term kidney outcomes.

2022 White Paper on Recent Issues in Bioanalysis: FDA Draft Guidance on Immunogenicity Information in Prescription Drug Labeling, LNP & Viral Vectors Therapeutics/Vaccines Immunogenicity, Prolongation Effect, ADA Affinity, Risk-based Approaches, NGS, qPCR, ddPCR Assays (Part 3 - Recommendations on Gene Therapy, Cell Therapy, Vaccines Immunogenicity & Technologies; Immunogenicity & Risk Assessment of Biotherapeutics and Novel Modalities; NAb Assays Integrated Approach)

The 2022 16th Workshop on Recent Issues in Bioanalysis (WRIB) took place in Atlanta, GA, USA on September 26-30, 2022. Over 1000 professionals representing pharma/biotech companies, CROs, and multiple regulatory agencies convened to actively discuss the most current topics of interest in bioanalysis. The 16th WRIB included 3 Main Workshops and 7 Specialized Workshops that together spanned 1 week in order to allow exhaustive and thorough coverage of all major issues in bioanalysis, biomarkers, immunogenicity, gene therapy, cell therapy and vaccines. Moreover, in-depth workshops on ICH M10 BMV final guideline (focused on this guideline training, interpretation, adoption and transition); mass spectrometry innovation (focused on novel technologies, novel modalities, and novel challenges); and flow cytometry bioanalysis (rising of the 3rd most common/important technology in bioanalytical labs) were the special features of the 16th edition. As in previous years, WRIB continued to gather a wide diversity of international, industry opinion leaders and regulatory authority experts working on both small and large molecules as well as gene, cell therapies and vaccines to facilitate sharing and discussions focused on improving quality, increasing regulatory compliance, and achieving scientific excellence on bioanalytical issues. This 2022 White Paper encompasses recommendations emerging from the extensive discussions held during the workshop and is aimed to provide the bioanalytical community with key information and practical solutions on topics and issues addressed, in an effort to enable advances in scientific excellence, improved quality and better regulatory compliance. Due to its length, the 2022 edition of this comprehensive White Paper has been divided into three parts for editorial reasons. This publication (Part 3) covers the recommendations on Gene Therapy, Cell therapy, Vaccines and Biotherapeutics Immunogenicity. Part 1 (Mass Spectrometry and ICH M10) and Part 2 (LBA, Biomarkers/CDx and Cytometry) are published in volume 15 of Bioanalysis, issues 16 and 15 (2023), respectively.

Financial Toxicity and Out-of-Pocket Costs for Patients with Head and Neck Cancer

AIM

To quantify financial toxicity and out-of-pocket costs for patients with HNC in Australia and explore their relationship with health-related quality of life (HRQoL).

METHODS

A cross-sectional survey was administered to patients with HNC 1-3 years after radiotherapy at a regional hospital in Australia. The survey included questions on sociodemographics, out-of-pocket expenses, HRQoL, and the Financial Index of Toxicity (FIT) tool. The relationship between high financial toxicity scores (top quartile) and HRQoL was explored.

RESULTS

Of the 57 participants included in the study, 41 (72%) reported out-of-pocket expenses at a median of AUD 1796 (IQR AUD 2700) and a maximum of AUD 25,050. The median FIT score was 13.9 (IQR 19.5) and patients with high financial toxicity (n = 14) reported poorer HRQoL (76.5 vs. 114.5, p < 0.001). Patients who were not married had higher FIT scores (23.1 vs. 11.1, p = 0.01), as did those with lower education (19.3 vs. 11.1, p = 0.06). Participants with private health insurance had lower financial toxicity scores (8.3 vs. 17.6, p = 0.01). Medications (41%, median AUD 400), dietary supplements (41%, median AUD 600), travel (36%, median AUD 525), and dental (29%, AUD 388) were the most common out-of-pocket expenses. Participants living in rural locations (≥100 km from the hospital) had higher out-of-pocket expenses (AUD 2655 vs. AUD 730, p = 0.01).

CONCLUSION

Financial toxicity is associated with poorer HRQoL for many patients with HNC following treatment. Further research is needed to investigate interventions aimed at reducing financial toxicity and how these can best be incorporated into routine clinical care.

Asymmetric control of food intake by left and right vagal sensory neurons

We investigated the lateralization of gut-innervating vagal sensory neurons and their roles in feeding behavior. Using genetic, anatomical, and behavioral analyses, we discovered a subset of highly lateralized vagal sensory neurons with distinct sensory responses to intestinal stimuli. Our results demonstrated that left vagal sensory neurons (LNG) are crucial for distension-induced satiety, while right vagal sensory neurons (RNG) mediate preference for nutritive foods. Furthermore, these lateralized neurons engage different central circuits, with LNG neurons recruiting brain regions associated with energy balance and RNG neurons activating areas related to salience, memory, and reward. Altogether, our findings unveil the diverse roles of asymmetrical gut-vagal-brain circuits in feeding behavior, offering new insights for potential therapeutic interventions targeting vagal nerve stimulation in metabolic and neuropsychiatric diseases.

Physiologic risk factors increase risk of myocardial infarction with transcarotid artery revascularization in prospective trials

OBJECTIVE

Patients can be considered at high risk for carotid endarterectomy (CEA) because of either anatomic or physiologic factors and will often undergo transcarotid artery revascularization (TCAR). Patients with physiologic criteria will be considered to have a higher overall surgical risk because of more significant comorbidities. Our aim was to study the incidence of stroke, myocardial infarction (MI), death, and combined end points for patients who had undergone TCAR stratified by the risk factors (anatomic vs physiologic).

METHODS

An analysis of prospectively collected data from the ROADSTER (pivotal; safety and efficacy study for reverse flow used during carotid artery stenting procedure), ROADSTER 2 (Food and Drug Administration indicated postmarket trial; postapproval study of transcarotid artery revascularization in patients with significant carotid artery disease), and ROADSTER extended access TCAR trials was performed. All 851 patients were considered to be at high risk for CEA and were included and stratified using high-risk anatomic criteria (ie, contralateral occlusion, tandem stenosis, high cervical artery stenosis, restenosis after previous endarterectomy, bilateral carotid stenting, hostile neck anatomy with previous neck irradiation, neck dissection, cervical spine immobility) or high-risk physiologic criteria (ie, age >75 years, multivessel coronary artery disease, history of angina, congestive heart failure New York Heart Association class III/IV, left ventricular ejection fraction <30%, recent MI, severe chronic obstructive pulmonary disease, permanent contralateral cranial nerve injury, chronic renal insufficiency). For trial inclusion, asymptomatic patients were required to have had ≥80% carotid stenosis and symptomatic patients to have had ≥50% stenosis. The primary outcome measures were stroke, death, and MI at 30 days. The data were statistically analyzed using the χ² test, as appropriate.

RESULTS

A total of 851 high surgical risk patients were categorized into two groups: those with anatomic-only risk factors (n = 372) or at least one physiologic risk factor present (n = 479). Of the 851 patients, 74.5% of those in the anatomic subset were asymptomatic, and 76.6% in the physiologic subset were asymptomatic. General anesthesia was used similarly in both groups (67.7% anatomic vs 68.1% physiologic). MI had occurred in eight patients in the physiologic group (1.7%), all of whom had been asymptomatic and in none of the anatomic patients (P = .01). The combined stroke, death, and MI rate was 2.1% in the anatomic cohort and 4.2% in the physiologic cohort (P = .10). Stratification of each group into asymptomatic and symptomatic patients did not yield any further differences.

CONCLUSIONS

The patients who had undergone TCAR in the present prospective, neurologically adjudicated trial because of high-risk physiologic factors had had a higher rate of MI compared with the patients who had qualified for TCAR using anatomic criteria only. These patients had experienced comparable rates of combined stroke, death, and MI rates. The anatomic patients represented a healthier and younger subset of patients, with notably low overall event rates.

Management and Outcome of Non-Aneurysmal Primary Aortic Infection

INTRODUCTION

Aortic infection without prior intervention or aneurysm is exceedingly rare. We report the presentation, diagnosis, management, and outcome of patients with this unusual entity.

METHODS

Retrospective chart and imaging review of patients with primary aortic infection.

RESULTS

5 patients (3 male, mean age 71.2 years) presented between 2014 and 2022. All had abdominal, back, or flank pain. Four had constitutional symptoms. All were evaluated with a complete blood count; 3 had leukocytosis. Both serum C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) were elevated in the 4 patients evaluated with these tests. All were studied with peripheral blood culture on the first hospital day prior to any antibiotic administration. Blood culture was positive in only 1 patient. Computed tomography (CT) scan showed periaortic inflammation without aneurysm in all. Fluorodeoxyglucose positron emission tomography (PET) was obtained in 3 and a radiolabeled leukocyte single-photon emission CT (SPECT) scan was performed in 2. All demonstrated periaortic concentration of the radioisotope consistent with inflammation or infection. Intraoperative cultures were positive in 3. One patient who had a negative intraoperative culture was examined with broad range polymerase chain reaction (PCR) and DNA sequencing which identified a causative bacterium. The other patient with a negative intraoperative culture had periaortic abscess but was on antibiotics preoperatively, potentially confounding the culture. All patients underwent in-situ repair with rifampin impregnated polyester (N = 2), cryopreserved aortic allograft (N = 2), or autogenous femoral vein (N = 1). No patient developed recurrent infection or aortic related complications following surgery with an average follow up of 31.8 months (range 8-88 months).

CONCLUSIONS

Patients with primary aortic infection present similarly with the triad of abdominal or back pain, laboratory markers of infection, and imaging demonstrating periaortic inflammation. Patients were treated successfully with in-situ repair. Preoperative identification of a causative organism was difficult, and PCR may be useful to help identify an organism.

Electronic Patient Portal Use After Kidney Transplant: A Single-Center Retrospective Study

INTRODUCTION

Online patient portals have become a core component of patient-centered care. Limited research exists on such portal use in patients after kidney transplantation. The aim of this study was to examine preoperative, perioperative, and postoperative factors associated with post-transplantation portal use.

METHODS

This cross-sectional study included all patients who underwent kidney transplantation from April 2016 to May 2019 at the University of Toledo Medical Center. Exclusion criteria included international travel for transplantation and those without available postoperative lab or follow-up records. Data were collected for 2 y post-transplantation. Univariable and multivariable linear regression was performed to determine associations with portal use.

RESULTS

Two hundred and forty-seven kidney transplant recipients were included in the study; 35.6% (n = 88) used the portal versus 64.4% (n = 159) did not. Preoperative factors associated with increased use included income >$40,000 (odds ratio [OR], 2.95; P = 0.006) and cancer history (OR, 2.46; P = 0.007), whereas diabetes history had reduced use (OR, 0.51; P = 0.021). The Black race had the least use. Perioperatively, reduced use was associated with dialysis before transplant (OR, 0.25; P < 0.001) and hospital stay ≥4 d (OR, 0.49; P = 0.009). Postoperatively, associations with increased use included average eGFR >30 (P = 0.04) and hospital readmissions (n = 102), whereas those with ER (n = 138) visits had decreased use. Multivariable analysis revealed increased use with income >$40,000 (OR, 2.51; P = 0.033).

CONCLUSIONS

There was no observed difference in clinical outcomes for portal users and nonusers undergoing kidney transplantation, although portal use may decrease the likelihood of ER visits. Socioeconomic status and ethnicity may play a role on who utilizes the patient portals.

Ending the HIV epidemic PrEP equity recommendations from a rapid ethnographic assessment of multilevel PrEP use determinants among young Black gay and bisexual men in Atlanta, GA

BACKGROUND

Efforts to mitigate HIV transmission among gay and bisexual men have not been sufficient to level persistent racial inequities which now extend to the use of daily oral pre-exposure prophylaxis (PrEP) for HIV prevention. Community-involved ethnographic research is crucial to galvanizing collaboration between patients, researchers, and policymakers to identify the social determinants of emerging PrEP inequities. In partnership with community key informants, we conducted a Rapid Ethnographic Assessment (REA) of multilevel PrEP use determinants among young Black gay and bisexual (YBGBM) men in the metropolitan Atlanta area to inform the development and coordination of local HIV programs.

METHODS

In the assessment, we drew upon the perspectives of local clinicians, community-based organization leaders, health educators, and PrEP clients to identify barriers and facilitators to PrEP use among YBGBM through interviews (N = 23). Data were collected from September 2020 -to January 2021 and were analyzed through a staged deductive-inductive thematic analysis. The themes were later summarized and presented to community stakeholder participants to facilitate member-checking.

RESULTS

Our analyses revealed structural, cultural, relationship, and developmental factors which shaped PrEP use. The most prominent being "ease of access to PrEP" (structural level), "provider support" (interpersonal), and "life-stage traits" (individual). Our results also contribute novel information concerning the axes of intersectional stigma (spatial, racial, sexual identity, and HIV) among YBGBM in Atlanta and its divergent effects on PrEP use.

CONCLUSION

Increased PrEP use among YBGBM, particularly among those living in the south, is essential to ending the domestic HIV epidemic. Altogether, our results emphasize the need for PrEP program modifications, which increase flexibility in methods and modes of access and are culturally adapted to the needs of YBGBM. There is also a need for resources that holistically focus on mental health, trauma, and racism as critical components of support.

Management of patients with impella devices or intra-aortic balloon pumps during helicopter air ambulance transport in observational data

INTRODUCTION

Placement of percutaneous ventricular support devices such as an intraaortic balloon pump (IABP) or Abiomed Impella device can treat severe cardiogenic shock. Critical care transport medicine (CCTM) providers frequently manage patients supported by these devices during interfacility transfers, often using a helicopter air ambulance (HAA). An understanding of patient needs and management during transport is essential to informing crew configuration and training, and this study adds to the limited existing data on the HAA transport of this complex patient population.

METHODS

We performed a retrospective chart review of all HAA transports of patients with an IABP (n = 38) or Impella (n = 11) device at a single CCTM program from 2016 to 2020. We evaluated transport times and composite variables for the frequency of adverse events, condition changes requiring critical care evaluation, and critical care interventions.

RESULTS

In this observational cohort, patients with an Impella device more frequently had an advanced airway and at least 1 vasopressor or inotrope active prior to transport. While flight times were similar, CCTM teams remained at referring facilities longer for patients with an Impella device (99 vs 68 minutes; p = 0.0097). Compared to patients with an IABP, patients with an Impella device more frequently had a condition change requiring critical care evaluation (100% vs 42%; p = 0.0005) and more frequently received critical care interventions (100% vs 53%; p = 0.0037). Adverse events were uncommon and did not differ for patients with an Impella device compared to an IABP (27% vs 11%; p = 0.178).

CONCLUSION

Patients requiring mechanical circulatory support with IABP and Impella devices frequently require critical care management during transport. Clinicians should ensure the CCTM team has appropriate staffing, training, and resources to meet the critical care needs of these high acuity patients.

Self-reported beta-lactam allergy in government and private hospitals in Cape Town, South Africa

BACKGROUND

Up to a quarter of inpatients in high-income countries (HICs) self-report beta-lactam allergy (BLA), which if incorrect,increases the use of alternative antibiotics, worsening individual health outcomes and driving bacterial resistance. In HICs, up to 95% ofself-reported BLAs are incorrect. The epidemiology of BLA in low- and middle-income African countries is unknown.

OBJECTIVES

To describe the epidemiology and de-labelling outcomes of self-reported BLA in hospitalised South African (SA) patients.

METHODS

Point-prevalence surveys were conducted at seven hospitals (adult, paediatric, government and privately funded, district andtertiary level) in Cape Town, SA, between April 2019 and June 2021. Ward prescription records and in-person interviews were conductedto identify and risk-stratify BLA patients using the validated PEN-FAST tool. De-labelling was attempted at the tertiary allergy clinic atGroote Schuur Hospital.

RESULTS

A total of 1 486 hospital inpatients were surveyed (1 166 adults and 320 children). Only 48 patients (3.2%) self-reported a BLA,with a higher rate in private than in government-funded hospitals (6.3% v. 2.8%; p=0.014). Using the PEN-FAST tool, only 10.4% (n=5/48)of self-reported BLA patients were classified as high risk for true penicillin hypersensitivity. Antibiotics were prescribed to 70.8% (n=34/48)of self-reported BLA patients, with 64.7% (n=22/34) receiving a beta-lactam. Despite three attempts to contact patients for de-labelling atthe allergy clinic, only 3/36 underwent in vivo testing, with no positive results, and 1 patient proceeded to a negative oral challenge.

CONCLUSION

Unlike HICs, self-reported BLA is low among inpatients in SA. The majority of those who self-reported BLA were low risk fortype 1 hypersensitivity, but outpatient de-labelling efforts were largely unsuccessful.

Multicenter review of a tadalafil suspension formulation in infants and children with pulmonary hypertension: a north american experience

Funding Acknowledgements

Type of funding sources: None.

Background

Pulmonary arterial hypertension (PAH) is a disease characterised by an increase in pulmonary vascular resistance and pulmonary artery pressure. Phosphodiesterase type 5 (PDE5) inhibitors, with sildenafil the earliest among them, are widely used in the management of pediatric PAH. There has more recently been a transition to once-daily tadalafil suspensions. Herein, we present a multicenter experience detailing safety, tolerability and haemodynamic data utilizing tadalafil suspension alone or in combination for the management of pediatric PAH.

Methods and materials

We performed a retrospective review of all infants and children at two North American paediatric PH centres between December 2013 and April 2022. We included all patients less than 9 years of age who were treated with a tadalafil suspension after an initial treatment with sildenafil. Demographic, clinical, imaging, and laboratory data were collected.

Results

Over the study period, 158 children were treated with tadalafil therapy: 41 (25.9%) had group 1 PAH, 81 (51.3%) had group 3 PH, and 33 (20.9%) had group 5 PH. The median initial dose of tadalafil was 1.0 mg/kg once daily with a median time to maximum dose of 1 day. The majority of patients required the suspension formulation due to an inability to take oral tablets or the need for nasogastric or nasojejunal feeding. We observed improvements in median echocardiographic parameters in the six months following initiation, namely, in RVFAC from 34.7% (Q1 = 31.0%, Q3 = 42.0%) to 37.0% (Q1 = 31.0%, Q3 = 44.0%) and in TAPSE from 1.0 (Q1 = 0.8, Q3 = 1.7) cm to 1.3 (Q1 = 1.0, Q3 = 1.7) cm. We observed median decreases in RVSp from 51.0 (Q1 = 35.0, Q3 = 69.0) mmHg to 37.0 (Q1 = 30.0, Q3 = 50.0) mmHg and in NT pro BNP levels from 439.0 (Q1 = 217.0, Q3 = 2051.0) ng/L to 313.0 (Q1 = 193.0, Q3 = 1110.0) ng/L. Tadalafil therapy was well tolerated over the six-month period: at baseline, only four patients (2.5%) reported gastrointestinal side effects, two (1.3%) reported adverse skin adverse effects (i.e., rash and flushing), and one (0.6%) reported adverse neurological effects. At six months, 150 patients (94.9%) reported no adverse effects.

Conclusion

Tadalafil, a long-acting PDE5 inhibitor, when administered in a suspension formulation, has a safe and tolerable adverse effect profile once patients are established on sildenafil therapy. Following 6 months of once daily tadalafil suspension, alone or in combination, showed a trend towards improvement in clinical parameters, echocardiographic measurements, and laboratory results for pediatric PAH. All patient adverse effects were managed with non pharmacological measures and there was good patient compliance.

The Effects of Global Alignment and Proportionality Scores on Postoperative Outcomes After Adult Spinal Deformity Correction

BACKGROUND

Recent studies have suggested achieving global alignment and proportionality (GAP) alignment may influence mechanical complications after adult spinal deformity (ASD) surgery.

OBJECTIVE

To investigate the association between the GAP score and mechanical complications after ASD surgery.

METHODS

Patients with ASD with at least 5-level fusion to pelvis and minimum 2-year data were included. Multivariate analysis was used to find an association between proportioned (P), GAP-moderately disproportioned, and severely disproportioned (GAP-SD) states and mechanical complications (inclusive of proximal junctional kyphosis [PJK], proximal junctional failure [PJF], and implant-related complications [IC]). Severe sagittal deformity was defined by a "++" in the Scoliosis Research Society (SRS)-Schwab criteria for sagittal vertebral axis or pelvic incidence and lumbar lordosis.

RESULTS

Two hundred ninety patients with ASD were included. Controlling for age, Charlson comorbidity index, invasiveness and baseline deformity, and multivariate analysis showed no association of GAP-moderately disproportioned patients with proximal junctional kyphosis, PJF, or IC, while GAP-SD patients showed association with IC (odds ratio [OR]: 1.7, [1.1-3.3]; P = .043). Aligning in GAP-relative pelvic version led to lower likelihood of all 3 mechanical complications (all P < .04). In patients with severe sagittal deformity, GAP-SD was predictive of IC (OR: 2.1, [1.1-4.7]; P = .047), and in patients 70 years and older, GAP-SD was also predictive of PJF development (OR: 2.5, [1.1-14.9]; P = .045), while improving in GAP led to lower likelihood of PJF (OR: 0.2, [0.02-0.8]; P = .023).

CONCLUSION

Severely disproportioned in GAP is associated with development of any IC and junctional failure specifically in older patients and those with severe baseline deformity. Therefore, incorporation of patient-specific factors into realignment goals may better strengthen the utility of this novel tool.

Cohort profile: the ESC EURObservational Research Programme Non-ST-segment elevation myocardial infraction (NSTEMI) Registry

AIMS

The European Society of Cardiology (ESC) EURObservational Research Programme (EORP) Non-ST-segment elevation myocardial infarction (NSTEMI) Registry aims to identify international patterns in NSTEMI management in clinical practice and outcomes against the 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without ST-segment-elevation.

METHODS AND RESULTS

Consecutively hospitalised adult NSTEMI patients (n = 3620) were enrolled between 11 March 2019 and 6 March 2021, and individual patient data prospectively collected at 287 centres in 59 participating countries during a two-week enrolment period per centre. The registry collected data relating to baseline characteristics, major outcomes (in-hospital death, acute heart failure, cardiogenic shock, bleeding, stroke/transient ischaemic attack, and 30-day mortality) and guideline-recommended NSTEMI care interventions: electrocardiogram pre- or in-hospital, pre-hospitalization receipt of aspirin, echocardiography, coronary angiography, referral to cardiac rehabilitation, smoking cessation advice, dietary advice, and prescription on discharge of aspirin, P2Y12 inhibition, angiotensin converting enzyme inhibitor (ACEi)/angiotensin receptor blocker (ARB), beta-blocker, and statin.

CONCLUSION

The EORP NSTEMI Registry is an international, prospective registry of care and outcomes of patients treated for NSTEMI, which will provide unique insights into the contemporary management of hospitalised NSTEMI patients, compliance with ESC 2015 NSTEMI Guidelines, and identify potential barriers to optimal management of this common clinical presentation associated with significant morbidity and mortality.

Higher scores on autonomic symptom scales in pediatric patients with neurodevelopmental disorders of known genetic etiology

INTRODUCTION

Features of underlying autonomic dysfunction, including sleep disturbances, gastrointestinal problems, and atypical heart rate, have been reported in neurodevelopmental conditions, including autism spectrum disorder (ASD). The current cross-sectional, between-groups study aimed to quantify symptoms of autonomic dysfunction in a neurodevelopmental pediatric cohort characterized by clinical diagnoses as well as genetic etiology.

METHOD

The Pediatric Autonomic Symptom Scales (PASS) questionnaire was used to assess autonomic features across a group of patients with clinical neurodevelopmental diagnoses (NPD; N = 90) and genetic etiologies. Patients were subdivided based on either having a clinical ASD diagnosis (NPD-ASD; n = 37) or other non-ASD neurodevelopmental diagnoses, such as intellectual disability without ASD, speech and language disorders, and/or attention deficit hyperactivity disorder (NPD-OTHER; n = 53). Analyses focused on characterizing differences between the NPD group compared to previously published reference samples, as well as differences between the two NPD subgroups (NPD-ASD and NPD-OTHER).

RESULTS

Our results indicate higher PASS scores in our NPD cohort relative to children with and without ASD from a previously published cohort. However, we did not identify significant group differences between our NPD-ASD and NPD-OTHER subgroups. Furthermore, we find a significant relationship between quantitative ASD traits and symptoms of autonomic function.

CONCLUSION

This work demonstrates the utility of capturing quantitative estimates of autonomic trait dimensions that may be significantly linked with psychosocial impairments and other core clinical features of ASD.

Return to work in patients with head and neck cancer: Systematic review and meta-analysis

BACKGROUND

The aim of this review was to determine the prevalence of return to work (RTW) amongst head and neck cancer (HNC) survivors and to determine its impact on quality of life (QoL).

METHODS

A literature search was conducted in PubMed, Scopus, Embase and CINAHL in March 2021. Articles were included if they reported the number of patients with HNC receiving definitive treatment who were working at the time of diagnosis and returned to work.

RESULTS

There were 21 articles deemed eligible for inclusion. Meta-analysis suggested that 67% of patients with HNC who were employed at diagnosis RTW (95% CI 62%-73%, I²  = 97.53%). Patients who RTW were demonstrated to have lower levels of anxiety and depressive symptoms on the Hospital Anxiety and Depression Scale.

CONCLUSIONS

Return to work is an important clinical outcome which must be considered in the survivorship care of patients with HNC.

Intraarticular steroids as DMARD-sparing agents for juvenile idiopathic arthritis flares: Analysis of the Childhood Arthritis and Rheumatology Research Alliance Registry

BACKGROUND

Children with juvenile idiopathic arthritis (JIA) who achieve a drug free remission often experience a flare of their disease requiring either intraarticular steroids (IAS) or systemic treatment with disease modifying anti-rheumatic drugs (DMARDs). IAS offer an opportunity to recapture disease control and avoid exposure to side effects from systemic immunosuppression. We examined a cohort of patients treated with IAS after drug free remission and report the probability of restarting systemic treatment within 12 months.

METHODS

We analyzed a cohort of patients from the Childhood Arthritis and Rheumatology Research Alliance (CARRA) Registry who received IAS for a flare after a period of drug free remission. Historical factors and clinical characteristics and of the patients including data obtained at the time of treatment were analyzed.

RESULTS

We identified 46 patients who met the inclusion criteria. Of those with follow up data available 49% had restarted systemic treatment 6 months after IAS injection and 70% had restarted systemic treatment at 12 months. The proportion of patients with prior use of a biologic DMARD was the only factor that differed between patients who restarted systemic treatment those who did not, both at 6 months (79% vs 35%, p < 0.01) and 12 months (81% vs 33%, p < 0.05).

CONCLUSION

While IAS are an option for all patients who flare after drug free remission, it may not prevent the need to restart systemic treatment. Prior use of a biologic DMARD may predict lack of success for IAS. Those who previously received methotrexate only, on the other hand, are excellent candidates for IAS.