Factors associated with adjuvant treatment delays in patients treated surgically for head and neck cancer

OBJECTIVE

To determine the patient and treatment characteristics associated with delay in post-operative radiation therapy (PORT) for patients treated surgically for head and neck squamous cell cancer (HNSCC) at our institution.

DESIGN

Single institution retrospective review.

SETTING

Tertiary care academic medical centre.

PARTICIPANTS

Patients treated surgically for HNSCC who underwent PORT between 2013 and 2016.

MAIN OUTCOME MEASURES AND RESULTS

One hundred forty patients met inclusion criteria. A majority did not start radiotherapy within 6 weeks. Factors associated with a delayed initiation of PORT included length of stay >8 days, 30-day readmission, no adjuvant chemotherapy, post-operative complications and fragmented care.

CONCLUSIONS

A majority of patients did not initiate PORT within the guideline-recommended 6 weeks. Modifiable risks factors that delay initiation of PORT were identified.

Randomized Pilot Study of a Keratin-based Topical Cream for Radiation Dermatitis in Breast Cancer Patients

Purpose: Radiotherapy (RT) is commonly used in the treatment of breast cancer and often, despite advances in fractionated dosing schedules, produces undesirable skin toxicity. The purpose of this study was to evaluate the feasibility of using a keratin-based topical cream, KeraStat® Cream (KC; KeraNetics, Inc., Winston Salem, NC, USA) to manage the symptoms of radiation dermatitis (RD) in breast cancer patients undergoing RT. Materials and Methods: A total of 24 subjects were enrolled on this single-center, randomized, open-label study. Participants were randomly assigned to KC or standard of care (SOC, patient's choice of a variety of readily available creams or moisturizers). Patients were asked to apply the assigned treatment to the irradiated area twice daily, beginning with day 1 of RT, through 30 days post-RT. The primary outcome was compliance of use. Secondary outcomes included safety and tolerability of KC, as well as RD severity assessed using the Radiation Therapy Oncology Group (RTOG) scale and the patient-reported Dermatology Life Quality Index (DLQI). Results: All subjects in the KC group were assessed as compliant with no adverse events. The rate of RTOG Grade 2 RD was lower in the KC group (30.8%) compared to the SOC group (54.5%, P = .408). At the final RT visit, the mean RTOG RD score was lower in the KC group (1.0) versus the SOC group (1.4). Similarly, patient-reported quality of life measured by the DLQI at the end of RT was improved in the KC group (mean 4.25, small effect) versus the SOC group (mean 6.18, moderate effect, P = .412). Conclusions: KC was safe and well tolerated with no adverse events. Though efficacy measures were not powered to draw definitive conclusions, trends and clinical assessments suggest that there is a benefit of using KC compared to SOC for breast cancer patients treated with RT, and a larger powered study for efficacy is warranted. Trial Registry: This clinical trial is registered as NCT03374995 titled KeraStat(R) Cream for Radiation Dermatitis.

Central Application Service for Physician Assistants Fifteen-Year Data Report 2002-2016

PURPOSE

This study highlights trends in available physician assistant (PA) applicant and matriculant data over the first 15 years of the Central Application Service for Physician Assistants (CASPA) service (2002-2016). This study expands knowledge identified in the CASPA 10-year data report.

METHODS

This was a retrospective analysis of CASPA data from all CASPA-participating PA programs between 2002 and 2016. Central Application Service for Physician Assistants staff verified all applicant academic information. In addition, beginning in 2007, the online CASPA admissions portal linked matriculant data with applicant data.

RESULTS

During the first 15 years of the CASPA service, there was a 194% increase in the number of CASPA-participating programs (from 68 to 200) and a 409% increase in the number of total applicants. Several trends identified in the CASPA 10-year report persisted, including increasing grade point averages among applicants and matriculants and lower matriculation rates among underrepresented minority applicants and applicants who reported economic disadvantage.

CONCLUSION

This 15-year comprehensive analysis of the CASPA data will benefit the profession by providing historical information that faculty and policymakers can use as a basis for developing and evaluating future admissions policies and practices.

Remote monitoring following adult cardiac surgery: A paradigm shift?

Background

The Perfect Care (PC) initiative engages, educates, and enrolls adult cardiac surgery patients into a transformational program that includes an app for appointment scheduling, tracking biometric data and patient-reported outcomes, audiovisual visits, and messaging, paired with a digital health kit (consisting of a fitness tracker, scale, and sphygmomanometer). PC aims to reduce postoperative length of stay (LOS) as well as 30-day readmission and mortality.

Methods

This was a retrospective review of patients who underwent coronary artery bypass (CAB), valve, or combined CAB and valve procedures at either of the 2 participating hospitals between April 2018 and March 2022. Patients who participated in the PC quality improvement initiative were compared to propensity-matched controls (1:1 matching). The evaluation focused on postoperative LOS and a novel composite measure comprising 30-day readmission and mortality.

Results

Remote monitoring (PC) was associated with a shorter postoperative LOS, lower combined rate of 30-day readmission and mortality, and less variation compared to matched non-PC controls.

Conclusions

Integrated improvements in postoperative remote monitoring of adult cardiac surgery patients may reduce time in the hospital and post-acute care facilities. Future prioritized efforts include the development of additional, personalized biometric monitoring devices, use of biometric data to augment risk assessment, and investigation of the value of remote monitoring on various patient risk profiles to address potential disparities in care.

Technologic Transformation of Perioperative Cardiac Care and Outcomes

BACKGROUND

The "Perfect Care" initiative engages, educates, and enrolls adult cardiac surgery patients into a comprehensive program that incorporates remote perioperative monitoring (RPM). This study investigated the impact of RPM on postoperative length of stay, 30-day readmission and mortality, and other outcomes.

METHODS

This quality improvement project compared outcomes in 354 consecutive patients who underwent isolated coronary artery bypass and who were enrolled in RPM between July 2019 and March 2022 at 2 centers against outcomes in propensity-matched control patients from a pool of 1301 patients who underwent isolated coronary artery bypass from April 2018 to March 2022 without RPM. Data were extracted from The Society of Thoracic Surgeons Adult Cardiac Surgery Database, and outcomes were analyzed according to its definitions. RPM used perioperative standard practice routines, a digital health kit for remote monitoring, a smartphone application and platform, and nurse navigators. Propensity scores were generated with RPM as the outcome measure, and a 2:1 match was generated using a nearest-neighbor matching algorithm.

RESULTS

Patients who underwent isolated coronary artery bypass and who were participating in RPM showed a statistically significant, 15.4% (1 day) reduction in postoperative length of stay (P < .0001) and a 44% reduction in 30-day readmission and mortality (P < .039) compared with matched control patients. Significantly more RPM participants were discharged directly home instead of to a facility (99.4% vs 92.0%; P < .0001).

CONCLUSIONS

The RPM platform and associated efforts to engage and monitor adult cardiac surgery patients remotely is feasible, is embraced by patients and clinicians, and transforms perioperative cardiac care by significantly improving outcomes and reducing variation.

Reliability of Inpatient CGM: Comparison to Standard of Care

BACKGROUND

Optimal inpatient glycemic management targets a blood glucose (BG) of 140-180 mg/dL and is an important safety measure for hospitalized patients with hyperglycemia. Traditional barriers to appropriate insulin administration include incorrect timing of prandial insulin administration, failure to administer basal insulin to persons with insulin deficiency/type 1 diabetes mellitus (DM), and inaccurate insulin dosing or timing resulting in hypoglycemia. Given the ongoing rapid assimilation of technology to manage our patients with DM, we investigated the use of continuous glucose monitoring (CGM) in the inpatient setting as a potential solution to traditional barriers to optimal hyperglycemia management for inpatient care. In this study, we evaluated the efficacy of use of inpatient CGM for insulin dosing in comparison with current standard of care and whether CGM could aid in minimizing hypoglycemic events.

METHODS

This study evaluated the use of Abbott professional (blinded) Freestyle Libre CGMs in participants treated with basal bolus insulin administered with subcutaneous insulin (basal bolus therapy [BBT]: n = 20) or on intravenous insulin (IVI) infusions (n =16) compared with standard point of care (POC) BG measurements. All participants on IVI were admitted with a diagnosis of diabetic ketoacidosis (DKA). The CGM data was not available in real time. Sensors were removed at the time of discharge and data uploaded to Libre View. Continuous BG data were aggregated for each subject and matched to POC BG or lab chemistry values within five minutes. The POC BG results were assessed for comparability (CGM vs standard BG testing). Data were further analyzed for clinical decision-making for correction insulin.

RESULTS

The overall mean absolute relative difference including both IVI and BBT groups was 22.3% (SD, 9.0), with a median of 20.0%. By group, the IVI arm mean was 19.6% (SD, 9.4), with a median of 16.0%; for BBT, the arm mean was 24.6% (SD, 8.1), with a median 23.4%. Using the Wilcoxon two-sample test, the means were not different (P = .10), whereas the medians were (P = .015). The CGM consistently reported lower glucose values than POC BG in the majority of paired values (BBT arm mean difference = 44.8 mg/dL, IVI mean difference = 19.7 mg/dL). Glucose results were in agreement for the group 83% of the time with Bland-Altman Plot of Difference versus the mean of all glucometric data. Analysis of correction dose insulin using either CGM or POC BG values resulted in a negligible difference in calculated insulin dose recommended in those receiving subcutaneous insulin. Corrective doses were based on weight and insulin sensitivity (type 1 vs type 2 DM). Participants initially on IVI were included in a data set of BBT once IVI therapy ceased and basal bolus insulin regimen was started. The data of all basal bolus therapy participants with 1142 paired values of CGM versus POC glucose were used. The dosing difference was less for CGM than POC BG in the majority of paired values, and there was an absolute difference in dose of insulin of only 1.34 units. In the IVI group with 300 paired values of CGM versus POC glucose, there was an absolute difference in dose of insulin of only 0.74 units. About a third of the patients studied in the BBT arm experienced a hypoglycemic event with POC BG <70 mg/dL. If used in real time, CGM would have identified a hypoglycemic event for our patients on average 3 hours and 34 minutes before it was detected by standard POC BG. Two participants incurred severe nocturnal hypoglycemia during the study with POC BG <54 mg/dL with hypoglycemia detected on CGM up to 3 hours and 42 minutes before POC testing.

CONCLUSIONS

These results suggest that the use of inpatient CGM arrives at similar correction insulin dosing. The routine use of CGM for inpatients would consistently underestimate the BG compared with POC BG and could aid in minimizing and predicting hypoglycemia in the hospital setting. Our data support that the model of adoption of real-time inpatient CGM technology is anticipated to have significant impact in the clinical setting in efforts to maintain adequate glycemic control targeting BG 140-180 mg/dL while minimizing the frequency of hypoglycemic events.

The COST of liver disease: The Cirrhosis Outcomes Score in Trauma Study

BACKGROUND

Cirrhosis in trauma patients is an indicator of poor prognosis, but current trauma injury grading systems do not take into account liver dysfunction as a risk factor. Our objective was to construct a simple clinical mortality prediction model in cirrhotic trauma patients: Cirrhosis Outcomes Score in Trauma (COST).

METHODS

Trauma patients with pre-existing cirrhosis or liver dysfunction who were admitted to our ACS Level I trauma center between 2013 and 2021 were reviewed. Patients with significant acute liver trauma (AAST Grade ≥ 3) or those that developed acute liver dysfunction while admitted were excluded. Demographics as well as ISS, MELD, complications, and mortality were evaluated. COST was defined as the sum of age, ISS, and MELD. Univariate and multivariable analysis was used to determine independent predictors of mortality. The area under the receiver operating curve (AUROC) was calculated to assess the ability of COST to predict mortality.

RESULTS

A total of 318 patients were analyzed of which the majority were males 214 (67.3%) who suffered blunt trauma 305 (95.9%). Mortality at 30-days, 60-days, and 90-days was 20.4%, 23.6%, and 25.5%, respectively. COST was associated with inpatient, 30-day, and 90-day mortality on regression analyses and the AUROC for COST predicting mortality at these respective time points was 0.810, 0.801, and 0.813.

CONCLUSION

Current trauma injury grading systems do not take into account liver dysfunction as a risk factor. COST is highly predictive of mortality in cirrhotic trauma patients. The simplicity of the score makes it useful in guiding clinical care and in optimizing goals of care discussions. Future studies to validate this prediction model are required prior to clinical use.

The value of compassion: Healthcare savings of palliative care consults in trauma

BACKGROUND

The effects of palliative care (PC) consultation on patient costs and hospitalization metrics in the adult trauma population are unclear.

STUDY DESIGN

We interrogated our Level I trauma center databases from 1/1/19 to 3/31/21 for patients age ≥18 admitted to the trauma service. Patients undergoing PC consult were matched using propensity scoring to those without PC consultation based on age, admission Glasgow Coma Scale score, Injury Severity Score and Head Abbreviated Injury Scale. Total costs, total cost per day, hospital length of stay (LOS), ICU LOS, intubation days, discharge disposition, and rates of nephrology consultation and tracheostomy/feeding tube placements were compared.

RESULTS

140 unique patients underwent PC consultation and were matched to a group not receiving PC consult during the same period. Median total costs in the PC cohort were $39,532 compared to $70,330 in the controls (p<0.01).  Median costs per day in the PC cohort were $3,495 vs $17,970 in the controls (p<0.01).  Median costs per ICU day in the PC cohort were $3,774 vs $17,127 in the controls (p<0.01).  Mean hospital LOS (15.7 vs 7 days), ICU LOS (7.9 vs 2.9 days), and ventilator days (5.1 vs 1.5) were significantly higher in the PC cohort (all p<0.01).  Rates of nephrology consultation (8.6 vs 2.1%, p = 0.03) and tracheostomy/feeding tube placements (12.1 vs 1.4%, p<0.01) were also higher in the PC group.  Patients were more likely to discharge to hospice if they received a PC consult (33.6 vs 2.1%, p<0.01).  Mean time to PC consult was 7.2 days (range 1 hour to 45 days). LOS post-consult correlated positively with time to PC consultation (r = 0.27, p<0.01).

CONCLUSION

Expert PC services are known to alleviate suffering and avert patient goal- and value-incongruent care. While trauma patients demand significant resources, PC consultation offered in concordance with life-sustaining interventions is associated with significant savings to patients and the healthcare system. Given the correlation between LOS following PC consult and time to PC consult, savings may be amplified by earlier PC consultation in appropriate patients.

Patient-reported outcomes in a pilot clinical trial of twice-weekly hemodialysis start with adjuvant pharmacotherapy and transition to thrice-weekly hemodialysis vs conventional hemodialysis

Background

Physical and emotional symptoms are prevalent in patients with kidney-dysfunction requiring dialysis (KDRD) and the rigors of thrice-weekly hemodialysis (HD) may contribute to deteriorated health-related quality of life. Less intensive HD schedules might be associated with lower symptom and/or emotional burden.

Methods

The TWOPLUS Pilot study was an individually-randomized trial conducted at 14 dialysis units, with the primary goal to assess feasibility and safety. Patients with incident KDRD and residual kidney function were assigned to incremental HD start (twice-weekly HD for 6 weeks followed by thrice-weekly HD) vs conventional HD (thrice-weekly HD). In exploratory analyses, we compared the two treatment groups with respect to three patient-reported outcomes measures. We analyzed the change from baseline in the score on Dialysis Symptom Index (DSI, range 0–150), Generalized Anxiety Disorder-7 (GAD-7, range 0–21), and Patient Health Questionnaire-9 (PHQ-9, range 0–27) at 6 (n = 20 in each treatment group) and 12 weeks (n = 21); with lower scores denoting lower symptom burden. Analyses were adjusted for age, race, gender, baseline urine volume, diabetes mellitus, and malignancy. Participants’ views on the intervention were sought using a Patient Feedback Questionnaire (n = 14 in incremental and n = 15 in conventional group).

Results

The change from baseline to week 6 in estimated mean score (standard error; P value) in the incremental and conventional group was − 9.7 (4.8; P = 0.05) and − 13.8 (5.0; P = 0.009) for DSI; − 1.9 (1.0; P = 0.07) and − 1.5 (1.4; P = 0.31) for GAD-7; and − 2.5 (1.1; P = 0.03) and − 3.5 (1.5; P = 0.02) for PHQ-9, respectively. Corresponding changes from week 6 to week 12 were − 3.1 (3.2; P = 0.34) and − 2.4 (5.5; P = 0.67) in DSI score; 0.5 (0.6; P = 0.46) and 0.1 (0.6; P = 0.87) in GAD-7 score; and − 0.3 (0.6; P = 0.70) and − 0.5 (0.6; P = 0.47) in PHQ-9 score, respectively. Majority of respondents felt their healthcare was not jeopardized and expressed their motivation for study participation was to help advance the care of patients with KDRD.

Conclusions

This study suggests a possible mitigating effect of twice-weekly HD start on symptoms of anxiety and depression at transition from pre-dialysis to KDRD. Larger clinical trials are required to rigorously test clinically-matched incrementally-prescribed HD across diverse organizations and patient populations.

Trial registration

Registered at ClinicalTrials.gov with study identifier NCT03740048, registration date 14/11/2018.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12882-022-02946-w.

Timing of radiotherapy and chemotherapy start for patients treated with definitive concurrent chemoradiation for head and neck cancer

BACKGROUND

The ideal timing for the initiation of chemotherapy and radiation therapy (RT) in the use of definitive chemoradiation (CRT) for patients with head and neck cancer is not well established. We sought to evaluate the impact of the timing of initiating these two modalities on clinical outcomes.

MATERIALS AND METHODS

Patients with squamous cell carcinoma of the head and neck who were treated using definitive chemoradiation from 2012 to 2018 were identified. Patients undergoing re-irradiation, post-op CRT, had recurrent or second primaries, or ECOG 3-4 were excluded. Outcomes including locoregional control (LRC), distant control (DC), progression-free survival (PFS), and overall survival (OS) were estimated and compared between subgroups of the cohort based on the timing in which chemotherapy or RT were initiated: chemotherapy first, same day start, within 24 h, or start on Monday/Tuesday/Wednesday.

RESULTS

A total of 131 patients were included for analysis consisting of oropharynx (64%), larynx (22.9%), nasopharynx (6.9%), hypopharynx (3.1%), oral cavity (1.5%), and unknown primary (1.5%). Chemotherapy was administered as bolus cisplatin every 3 weeks in 40% of patients and weekly cisplatin in 60% with a median cumulative dose of 240 mg/m². In the multivariable analysis (MVA), starting chemotherapy before RT was associated with improved LRC (HR 0.33, 95% CI: 0.11-0.99). Three-year LRC for patients starting chemotherapy first was 90.9% compared to 78.2% in those starting RT first. In the MVA, cisplatin regimen and cumulative cisplatin dose were associated with improved OS, while no factors were significantly associated with DC or PFS.

CONCLUSION

Starting chemotherapy prior to radiation therapy improves LRC, but did not impact DC, PFS, or OS. Clinical outcomes were not different when stratifying by the other differences in the timing of initiating chemotherapy or RT.

Twice-Weekly Hemodialysis With Adjuvant Pharmacotherapy and Transition to Thrice-Weekly Hemodialysis: A Pilot Study

RATIONALE & OBJECTIVE

Thrice-weekly hemodialysis (HD) is the most common treatment modality for kidney failure in the United States. We conducted a pilot study to assess the feasibility and safety of incremental-start HD in patients beginning maintenance HD.

STUDY DESIGN

Pilot study.

SETTING & PARTICIPANTS

Adults with estimated glomerular filtration rate (eGFR) ≥5 mL/min/1.73 m² and urine volume ≥500 mL/d beginning maintenance HD at 14 outpatient dialysis units.

EXPOSURE

Randomized allocation (1:1 ratio) to twice-weekly HD and adjuvant pharmacologic therapy for 6 weeks followed by thrice-weekly HD (incremental HD group) or thrice-weekly HD (conventional HD group).

OUTCOME

The primary outcome was feasibility. Secondary outcomes included changes in urine volume and solute clearance.

RESULTS

Of 77 patients invited to participate, 51 consented to do so, representing 66% of eligible patients. We randomized 23 patients to the incremental HD group and 25 patients to the conventional HD group. Protocol-based loop diuretics, sodium bicarbonate, and patiromer were prescribed to 100%, 39%, and 17% of patients on twice-weekly HD, respectively. At a mean follow-up of 281.9 days, participant adherence was 96% to the HD schedule (22 of 23 and 24 of 25 in the incremental and conventional groups, respectively) and 100% in both groups to serial timed urine collection. The incidence rate ratio for all-cause hospitalization was 0.31 (95% CI, 0.08-1.17); and 7 deaths were recorded (1 in the incremental and 6 in the conventional group). At week 24, the incremental HD group had lower declines in urine volume (a difference of 51.0 [95% CI, -0.7 to 102.8] percentage points) and in the averaged urea and creatinine clearances (a difference of 57.9 [95% CI, -22.6 to 138.4] percentage points).

LIMITATIONS

Small sample size, time-limited twice-weekly HD.

CONCLUSIONS

It is feasible to enroll patients beginning maintenance HD into a randomized study of incremental-start HD with adjuvant pharmacotherapy who adhere to the study protocol during follow-up. Larger multicenter clinical trials are indicated to determine the efficacy and safety of incremental HD with longer twice-weekly HD periods.

FUNDING

Funding was provided by Vifor Inc.

TRIAL REGISTRATION

Registered at ClinicalTrials.gov, identifier NCT03740048.

Association of early sedation level with patient outcomes in moderate-to-severe acute respiratory distress syndrome: Propensity-score matched analysis

Purpose

Studies of early depth of sedation in mixed critically ill populations have suggested benefit to light sedation; however, the relationship of early depth of sedation with outcomes in patients with acute respiratory distress syndrome (ARDS) is unknown.

Materials and methods

We performed a propensity-score matched analysis of early light sedation (Richmond Agitation Sedation Scale Score, RASS 0 to −1 or equivalent) versus deep sedation (RASS −2 or lower) in patients enrolled in the non-intervention group of The Reevaluation of Systemic Early Neuromuscular Blockade trial. Primary outcome was 90 day mortality. Secondary outcomes included days free of mechanical ventilation, days not in ICU, days not in hospital at day 28.

Results

137 of 486 participants (28.2%) received early light sedation. Vasopressor usage and Apache III scores significantly differed between groups. Prior to matching, 90-day mortality was higher in the early deep sedation (45.3%) compared to light sedation (34.2%) group. In the propensity score matched cohort, there was no difference in 90-day mortality (Odds Ratio (OR) 0.72, 95% CI 0.41, 1.27, p = 0.26) or secondary outcomes between the groups.

Conclusions

We did not find an association between early depth of sedation and clinical outcomes in this cohort of patients with moderate-to-severe ARDS.

Impact of Bedside Rounding on Attending Teaching Evaluations

OBJECTIVE

To examine associations between bedside rounding (BSR) and other rounding strategies (ORS) with resident evaluations of teaching attendings and self-reported attending characteristics.

METHODS

Faculty from three academic medical centers who attended resident teaching services for ≥4 weeks during the 2018-2019 academic year were invited to complete a survey about personal and rounding characteristics. The survey instrument was iteratively developed to assess rounding strategy as well as factors that could affect choosing one rounding strategy over another. Survey results and teaching evaluation scores were linked, then deidentified and analyzed in aggregate. Included evaluation items assessed resident perceptions of autonomy, time management, professionalism, and teaching effectiveness, as well as a composite score (the numeric average of each attending's scores for all of the items at his or her institution). BSR was defined as spending >50% of rounding time in patients' rooms with the team. Hallway rounding and conference room rounding were combined into the ORS category and defined as >50% of rounding time in these settings. All of the scores were normalized to a 10-point scale to allow aggregation across sites.

RESULTS

A total of 105 attendings were invited to participate, and 65 (62%) completed the survey. None of the resident evaluation scores significantly differed based on rounding strategy. Composite scores were similar for BSR and ORS (difference of <0.1 on a 10-point scale). Spearman correlation coefficients identified no statistically significant correlation between rounding strategy and evaluation scores. An exploratory analysis of variance model identified no single factor that was significantly associated with composite teaching scores (P > 0.45 for all) or the domains of teaching efficacy, professionalism, or autonomy (P > 0.13 for all). Having a formal educational role was significantly associated with better evaluation scores for time management, and the number of lectures delivered per year approached statistical significance for the same domain.

CONCLUSIONS

Conducting BSR did not significantly affect resident evaluations of teaching attendings. Resident perception of teaching effectiveness based on rounding strategy should be neither a motivator nor a barrier to widespread institution of BSR.

927. Clinical Characteristics and Outcomes of Norovirus Infection in Patients with Hematologic Malignancies: A Retrospective, Single Center Study

Background

Norovirus (NV) gastroenteritis has been identified as a cause of significant morbidity among hematopoietic stem cell transplant (HSCT) recipients, often with associated complications. Current guidelines recommend symptomatic relief with antimotility agents, rehydration, and reduction in immune suppression. Nitazoxanide (NTZ) is an anti-parasitic agent but some literature suggests a benefit of nitazoxanide therapy for NV.

Methods

We conducted a single center, retrospective chart review study and evaluated adult patients (age >18 years) who had NV infection and either: 1) underwent stem cell transplantation; or 2) received myeloablative chemotherapy within 4 weeks of NV diagnosis by positive test on gastrointestinal pathogen panel during the time period from January 2015 through March 2020.

Results

26 patients were reviewed. 14 patients (54%) had a history of HCST prior to infection. Three patients (12%) received both myeloablative chemotherapy and HSCT within four weeks of NV infection. Six patients (46%) had autologous, six (46%) had matched unrelated donor, and one (8%) had haploidentical allogeneic transplants. Nine (69%), three (23%), and one (8%) underwent myeloablative, reduced intensity and non-myeloablative conditioning, respectively. Median duration of diarrhea was 4.5 days (IQR = 2.25-7 days). Three (12%) patients received NTZ or intravenous immune globulin. The 6 month mortality was 42% (11/26), however, none of the deaths were directly attributable to NV infection.

Conclusion

NV infection led to severe diarrheal disease in our cohort. Overall mortality was high, and a trend toward increased mortality was seen among patients receiving NV-directed therapy; these patients likely received NV-directed therapy due to the severity of their illness. Clinicians must have a high suspicion for this illness and obtain PCR testing for timely diagnosis and management.

Table 1. Characteristics of patients with hematologic malignancies and norovirus infection

Disclosures

All Authors: No reported disclosures

Optimal Adjuvant Treatment Approach After Upfront Resection of Pancreatic Cancer: Revisiting the Role of Radiation Based on Pathologic Features

OBJECTIVE

To identify the survival benefit of different adjuvant approaches and factors influencing their efficacy after upfront resection of pancreatic ductal adenocarcinoma (PDAC).

SUMMARY BACKGROUND DATA

The optimal adjuvant approach for PDAC remains controversial.

METHODS

Patients from the National Cancer Database who underwent upfront PDAC resection from 2010 to 2014 were analyzed to determine clinical outcomes of different adjuvant treatment approaches, stratified according to pathologic characteristics. Factors associated with overall survival were identified with multivariable logistic regression and Cox proportional hazards were used to compare overall survival of different treatment approaches in the whole cohort, and propensity score matched groups.

RESULTS

We included 16,709 patients who underwent upfront resection of PDAC. On multivariable analysis, tumor size, grade, positive margin, nodal involvement, lymphovascular invasion (LVI), stage, lymph node ratio, not receiving chemotherapy, and/or radiation were predictors for worse survival. In the presence of at least 1 high-risk pathologic feature (nodal or margin involvement or LVI) chemotherapy with subsequent radiation provided the most significant survival benefit (median survivals: 24.8 vs 21.0 mo for adjuvant chemotherapy; HR = 0.81; 95% CI: 0.77-0.86; P < 0.001 in propensity score matching). The addition of radiation to adjuvant chemotherapy did not significantly improve overall survival in those with no high-risk pathologic features (median survivals: 54.6 vs 42.7 mo for adjuvant chemotherapy; HR=0.90; 95% CI: 0.75-1.08; P = 0.25 in propensity score matching).

CONCLUSIONS

In the presence of any high-risk pathologic features (nodal or margin involvement or LVI), adjuvant chemotherapy followed by radiation provides a better survival advantage over chemotherapy alone after upfront resection of PDAC.

The Demographics of Patients Presenting for Laryngological Care at an Academic Medical Center

OBJECTIVES/HYPOTHESIS

Few studies address the demographics/epidemiology/socioeconomic status of patients presenting to a laryngologist at a tertiary care center for treatment. To identify any possible disparities in voice, airway, and swallowing care, we sought to analyze the aforementioned data for new patients presenting to the voice center at an academic medical center.

METHODS

This is a retrospective cohort study of prospectively collected data from an institutional database of 4,623 new adult patients presenting for laryngological care at a tertiary care, academic medical center from 2015 to 2020. Demographic data were analyzed.

RESULTS

Of 4,623 patients, 62.8% were female and 37.2% were male with ages ranging from 19 to 99 years (Avg 59.51, standard deviation 15.83). Patients were 81.8% white, 13% black, and 5.2% other, compared with 56.3% white, 34.8% black, 20% other in the local municipality from US Census Data. Payer mix included 46.98% Medicare, 42.59% commercial insurance, 3.22% Medicaid, 5.19% other, and 2.01% uninsured/self-insured. Patient demographics based on primary diagnosis codes were also examined. A majority of patients presented with voice-related complaints.

CONCLUSIONS

Understanding the demographics of those with laryngological disorders will help to develop targeted interventions and effective outreach programs for underrepresented patient populations. Future multicenter studies could provide further insight into the distribution of healthcare disparities in laryngology.

LEVEL OF EVIDENCE

3 Laryngoscope, 2021.

Who loses weight in a weight gain prevention program? A comparison of weight losers and weight maintainers at 3 years

OBJECTIVE

Despite weight loss challenges in young adulthood, 17% of participants in the Study of Novel Approaches to Weight Gain Prevention (SNAP) weight gain prevention study lost ≥ 5% of their body weight at 3 years. These "weight losers" (n = 88) were compared to "weight maintainers" (n = 143), who successfully prevented weight gains by staying within ± 2.5% of their baseline weight at 3 years.

METHOD

Weight losers and maintainers (n = 231; 18-35 years old) were drawn from the SNAP randomized controlled trial (n = 599), which compared two weight gain prevention interventions with a control group. Participants completed anthropometric and psychosocial assessments at baseline, 4 months (end of face-to-face intervention), and 1, 2, and 3 years.

RESULTS

Three-year weight losers had significantly greater weight losses than maintainers by 4 months, and weight trajectories continued to diverge. Three-year weight change group was not associated with treatment assignment. At pretreatment, weight losers were heavier, closer to their self-reported highest ever weight, and further away from their self-identified ideal weight. Across treatment, weight losers had greater dietary restraint and autonomous motivation, had lower disinhibition and self-identified ideal weight, and self-weighed more frequently than weight maintainers.

CONCLUSIONS

Weight gain prevention messaging may be sufficient to initiate weight loss in a subset of young adults who are heavier and closer to their highest weight at baseline. Psychological and behavioral characteristics more consistent with weight loss may explain differences in weight outcomes between losers and maintainers at 3 years. Future studies may consider the effects of weight gain prevention versus weight loss messaging in tailoring weight control interventions for young adults. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Normative Value for the Laryngopharyngeal Measure of Perceived Sensation

OBJECTIVES/HYPOTHESIS

The Laryngopharyngeal Measure of Perceived Sensation (LUMP) is a recently validated patient-reported outcome measure (PROM) aimed at evaluating the symptom severity of patients with globus pharyngeus (GP). The objective of this study was to define the normative values for the LUMP questionnaire.

STUDY DESIGN

Prospectively collected, descriptive research/scale development.

METHODS

The LUMP questionnaire was completed by 88 subjects. Individuals without throat-related symptoms such as dysphagia, dysphonia, or cough were provided LUMP. The results of the eight-item questionnaire were analyzed for standard error of the mean (SEM), mean, and standard deviation (SD).

RESULTS

Review of the 88 LUMP questionnaires elucidated a mean of 0.42 (SEM = 0.10, SD = 0.96) in the normative population. By gender, the female (n = 50) mean was 0.24, SD = 0.66, SEM = 0.09; for males (n = 38), the mean was 0.66, SD = 1.21, SEM = 0.20.

CONCLUSIONS

This study provides normative data for the LUMP, a recently established PROM useful in patients with GP. A LUMP score greater than or equal to 3 should be considered abnormal and warrants additional attention.

LEVEL OF EVIDENCE

3 Laryngoscope, 2021.

Persistent opioid use after curative-intent hepatectomy for neoplastic disease

BACKGROUND AND OBJECTIVES

This study analyzed persistent opioid use in opioid-naïve and nonopioid-naïve patients undergoing hepatectomy for neoplastic disease.

METHODS

A retrospective review was performed of a prospective database using inclusion criteria of hepatectomy for neoplastic disease from October 2013 to December 2017. Prescription data were collected from the North Carolina Controlled Substance Reporting System. Persistent opioid use was defined as patients who continued filling opioid prescriptions 90 days to 1 year after surgery. Patients who did not receive opioid prescriptions between 12 months and 31 days before surgery were defined as naïve.

RESULTS

The analysis included 75 surgeries on naïve and 58 surgeries on nonnaïve patients. 56% of naïve patients and 79% of nonnaïve patients developed persistent opioid use, respectively (p = .0056). Naïve patients received 2.24 ± 4.30 MMEs/day, while nonnaïve patients received 5.50 ± 5.98 MMEs/day during Postoperative days 90-360 (95% CI, 1.41-5.10; p < .001). Naïve patients with a lower Preoperative ECOG score were more likely to develop persistent opioid use (OR, 0.45; 95% CI, 0.21-0.99; p = .048).

CONCLUSION

More than half of naïve patients undergoing hepatectomy developed persistent opioid use within the first year, though significantly less than nonnaïve patients. Improved performance status was associated with an increased risk of persistent opioid use in naïve patients.

Oropharyngeal Carcinoma Treated with Surgery Alone: Outcomes and Predictors of Failure

OBJECTIVE

To analyze the oncologic outcomes and risk factors for recurrence in patients who underwent surgery for oropharyngeal squamous cell carcinoma (OPSCC), and in whom adjuvant therapy was not recommended or was declined.

METHODS

Retrospective cohort study of patients with OPSCC who were treated with transoral surgery only at a tertiary care academic medical center from April 2010 to March 2019.

RESULTS

Seventy-four patients met inclusion criteria. In 16, adjuvant therapy was recommended but declined. There were 8 recurrences, of which 6 had been given recommendations for adjuvant therapy. Of the 8 recurrences, 2 died, 2 are alive with disease, and 4 were successfully salvaged. Five patients died of unrelated causes. Lymphovascular invasion (LVI, P = .016) had a significant impact on recurrence, while other pathologic features of the primary tumor such as size, location, human papillomavirus (HPV) status, and margin status did not. Margins were classified as "positive" in 4 patients, "close" in 54, and "negative" in 16. There were 3 local recurrences (4.1%), each of whom had declined adjuvant therapy. Lymph node features such as N-stage (P = .0004), number of positive nodes (P = .0005), and presence of extra-nodal extension (ENE, P = .0042) had a statistically significant impact on relapse. Smoking history and surgical approach showed no significant impact on recurrence.

CONCLUSION

Patients who undergo surgery for HPV-positive OPSCC with negative margins, no PNI, no LVI, and ≤1 positive lymph node without ENE have low risk for recurrence. These patients can likely be safely treated with surgery alone. Patients with these risk factors who decline adjuvant therapy are at risk for recurrence, and should be monitored.

Utility of the Pectoral Nerve Block (PECS II) for Analgesia Following Transaxillary First Rib Section

BACKGROUND

The transaxillary approach to resection of the first rib is one of several operative techniques for treating thoracic outlet syndrome. Unfortunately, moderate to severe postoperative pain is anticipated for patients undergoing this particular operation. While opioids can be used for analgesia, they have well-described side effects that has led investigators to search for clinically relevant alternative analgesic modalities. We hypothesized that a regional analgesic procedure, commonly called a pectoral nerve (PECS II) block, which anesthetizes the second through sixth intercostal nerves as well as the long thoracic nerve and the medial and lateral pectoral nerves, would improve postoperative analgesia for patients undergoing a transaxillary first rib resection.

METHODS

We performed a retrospective study by reviewing the charts of all patients that had undergone a transaxillary first rib resection for thoracic outlet syndrome during the defined study period. Patients that received a PECS II block were compared to those that did not. The primary outcome was a comparison of numeric rating scale pain scores during the first 24 hours following the operation. Secondary outcomes included cumulative opioid consumption during the same time period.

RESULTS

Pain scores during the first 24 hours following the operation were not statistically different between groups (Block Group: 3.9 [2.1-5.3] [median (IQR 25-75%)] versus Non-block Group: 3.6 [2.4-4.1]; P = 0.40. In addition, opioid use through the first 24 hours after the operation was not significantly different (43.5 [22.0-81.0] [median morphine equivalents in mg's] versus 42.0 [12.5-75.0]; P = 0.53).

CONCLUSIONS

An ultrasound-guided PECS II nerve block did not reduce postoperative pain scores or opioid consumption for patients undergoing a transaxillary first rib resection. However, a prospective, randomized, study with improved power would be beneficial to further explore the potential utility of a PECS II block for patients presenting for this surgical procedure.

A Randomized Comparison of Positional Stability: The EZ-Blocker Versus Left-Sided Double-Lumen Endobronchial Tubes in Adult Patients Undergoing Thoracic Surgery

OBJECTIVE

To assess if there is a difference in the repositioning rate of the EZ-Blocker versus a left-sided double-lumen endobronchial tube (DLT) in patients undergoing thoracic surgery and one-lung ventilation.

DESIGN

Prospective, randomized.

SETTING

Single center, university hospital.

PARTICIPANTS

One hundred sixty-three thoracic surgery patients.

INTERVENTIONS

Patients were randomized to either EZ-Blocker or a DLT.

MEASUREMENTS AND MAIN RESULTS

The primary outcome was positional stability of either the EZ-Blocker or a left-sided double-lumen endobronchial tube, defined as the number of repositionings per hour of surgery and one-lung ventilation. Secondary outcomes included an ordinal isolation score from 1 to 3, in which 1 was poor, up to 3, which represented excellent isolation, and a visual analog postoperative sore throat score (0-100) on postoperative days (POD) one and two. Rate of repositionings per hour during one-lung ventilation and surgical manipulation in left-sided cases was similar between the two devices: 0.08 ± 0.15 v 0.11 ± 0.3 (p = 0.72). In right-sided cases, the rate of repositioning was higher in the EZ-Blocker group compared with DLT: 0.38 ± 0.65 v 0.09 ± 0.21 (p = 0.03). Overall, mean isolation scores for the EZ-Blocker versus the DLT were 2.76 v 2.92 (p = 0.04) in left-sided cases and 2.70 v 2.83 (p = 0.22) in right-sided cases. Median sore throat scores for left sided cases were 0 v 5 (p = 0.13) POD one and 0 v 5 (p = 0.006) POD two for the EZ-Blocker and left-sided DLT, respectively.

CONCLUSION

For right-sided procedures, the positional stability of the EZ-Blocker is inferior to a DLT. In left-sided cases, the rate of repositioning for the EZ-Blocker and DLT are not statistically different.

A comparison of the breathing apparatus deadspace associated with a supraglottic airway and endotracheal tube using volumetric capnography in young children

Background

Supraglottic airway (SGA) devices including the air-Q^® are being used with increasing frequency for anesthesia in infants and younger pediatric patients. To date, there is minimal research documenting the potentially significant airway deadspace these devices may contribute to the ventilation circuit when compared to an endotracheal tube (ETT). The aim of this study was to evaluate the airway apparatus deadspace associated with an air-Q^® versus an ETT in young children.

Methods

In a prospective cohort study, 59 patients between 3 months and 6 years of age, weighing between 5 and 20 kg, scheduled for outpatient urologic or general surgery procedures were recruited. An air-Q^® or ETT was inserted at the discretion of the attending anesthesiologist, and tidal volume, positive end expiratory pressure, respiratory rate, and end-tidal CO₂ were controlled according to protocol. Airway deadspace was recorded using volumetric capnography every 2 min for 10 min.

Results

Groups were similar in demographics. There was a significant difference in weight-adjusted deadspace volume between the air-Q^® and ETT groups, 4.1 ± 0.8 ml/kg versus 3.0 ± 0.7 ml/kg, respectively (P < 0.001). Weight-adjusted deadspace volume (ml/kg) increased significantly with decreasing weight for both the air-Q^® and ETT groups.

Conclusions

In healthy children undergoing positive pressure ventilation for elective surgery, the air-Q^® SGA introduces significantly greater airway deadspace than an ETT. Additionally, airway deadspace, and minute ventilation required to maintain normocarbia, appear to increase with decreasing patient weight irrespective of whether a SGA or ETT is used.

Primary care referrals to nephrology in patients with advanced kidney disease

OBJECTIVES

Optimizing care for patients with advanced kidney disease requires close collaboration between primary care physicians (PCPs) and nephrologists. Factors associated with PCP referral to nephrology were assessed in patients with estimated glomerular filtration rates (eGFRs) less than 30 mL/min/1.73 m2.

STUDY DESIGN

Electronic health record review at an integrated health care network.

METHODS

Factors associated with referral status were identified using Fisher's exact tests, t tests, and multivariable logistic regression.

RESULTS

Of 133,913 patients regularly seeing PCPs between October 2017 and September 2019, 1119 had a final eGFR less than 30 mL/min/1.73 m2 and were not on renal replacement therapy. Care was provided by 185 PCPs (61 practices). Analyses were restricted to the 97.1% (n = 1087) of patients who were African American or European American. Of these, 54.6% had not been referred to nephrology. Nonreferred patients had higher numbers of PCP visits (P = .004). In contrast, referred patients were younger, were more often African American, and had PCPs at the academic medical center (all P < .0001). Referred patients had more complex medical histories with higher Charlson Comorbidity Index scores, more hospitalizations, and greater numbers of inpatient days (all P < .0001). Analyses restricted to patients with serum creatinine concentration of at least 2 mg/dL yielded similar results. Age, number of hospitalizations, ancestry, academic physician, diabetic end-organ damage, peripheral vascular disease, and tumor status were independent predictors of nephrology referral.

CONCLUSIONS

Impediments to appropriately timed nephrology referrals persist in patients with high likelihoods of progression to end-stage kidney disease. Improved access to nephrology care should be rapidly addressed to meet targets in the 2019 Executive Order on Advancing American Kidney Health.

Examining Heterogeneity of Outcomes in a Weight Gain Prevention Program for Young Adults

OBJECTIVE

This study aimed to characterize young adults who experienced significant weight gains (> 10%) over 3 years in a weight gain prevention program.

METHODS

Secondary data analysis from the Study of Novel Approaches to Weight Gain Prevention (SNAP), a randomized trial comparing two self-regulation interventions and a control arm in young adults (18-35 years; BMI 21-30.9 kg/m² ), was used. Large Gainers (≥ 10% of their body weight; n = 48), Small Gainers (2.6%-9.9%; n = 149), and Weight Stable participants (± 2.5%; n = 143) were compared on dimensions affecting weight gain.

RESULTS

Differences in weight gain among the three groups were significant by year 1 and subsequently increased. Those who became Large Gainers were heavier at baseline and further below their highest weight, and they reported more weight cycling than Weight Stable, with Small Gainers intermediate. Neither study arm nor pregnancy explained weight change differences among the three groups. Large Gainers reported more depressive symptoms than Weight Stable at years 1 and 2. Large Gainers were less likely to weigh themselves at least weekly at 4 months, before differences in weight gain emerged, and at years 1 and 2.

CONCLUSIONS

Large Gainers (representing almost 10% of participants) could be identified early by greater weight issues at baseline and lower use of weight gain prevention strategies.

Blood Pressure Control and the Association With Diabetes Mellitus Incidence: Results From SPRINT Randomized Trial

The SPRINT (Systolic Blood Pressure Intervention Trial) demonstrated reduced cardiovascular outcomes. We evaluated diabetes mellitus incidence in this randomized trial that compared intensive blood pressure strategy (systolic blood pressure <120 mm Hg) versus standard strategy (<140 mm Hg). Participants were ≥50 years of age, with systolic 130 to 180 mm Hg and increased cardiovascular risk. Participants were excluded if they had diabetes mellitus, polycystic kidney disease, proteinuria >1 g/d, heart failure, dementia, or stroke. Postrandomization exclusions included participants missing blood glucose or ≥126 mg/dL (6.99 mmol/L) or on hypoglycemics. The outcome was incident diabetes mellitus: fasting blood glucose ≥126 mg/dL (6.99 mmol/L), diabetes mellitus self-report, or new use of hypoglycemics. The secondary outcome was impaired fasting glucose (100-125 mg/dL [5.55-6.94 mmol/L]) among those with normoglycemia (<100 mg/dL [5.55 mmol/L]). There were 9361 participants randomized and 981 excluded, yielding 4187 and 4193 participants assigned to intensive and standard strategies. There were 299 incident diabetes mellitus events (2.3% per year) for intensive and 251 events (1.9% per year) for standard, rates of 22.6 (20.2-25.3) versus 19.0 (16.8-21.5) events per 1000 person-years of treatment, respectively (adjusted hazard ratio, 1.19 [95% CI, 0.95-1.49]). Impaired fasting glucose rates were 26.4 (24.9-28.0) and 22.5 (21.1-24.1) per 100 person-years for intensive and standard strategies (adjusted hazard ratio, 1.17 [1.06-1.30]). Intensive treatment strategy was not associated with increased diabetes mellitus but was associated with more impaired fasting glucose. The risks and benefits of intensive blood pressure targets should be factored into individualized patient treatment goals. Clinical Trial Registration- URL: http://www.clinicaltrials.gov. Unique identifier: NCT01206062.

Case Start Time Affects Intraoperative Transfusion Rates in Adult Cardiac Surgery: A Single-Center Retrospective Analysis

OBJECTIVE

The goal of the study was to investigate the role time of day plays in perioperative outcomes. The authors examined intraoperative transfusion rates throughout the day in adult cardiac surgery patients. They hypothesized that the rate of transfusion changes with later case start times in scheduled cardiac surgery.

DESIGN

Retrospective observational study.

SETTING

Single academic medical center.

PARTICIPANTS

Adults undergoing cardiac surgery involving cardiopulmonary bypass.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The primary outcome was a composite variable of transfusion. The association between the time of day and the rate of transfusion was explored with a multivariate logistic regression to fit the effect of starting time as a cubic spline. There were 1,421 cases that met inclusion criteria. There were 1,220 cases that were matched for modeling. The estimated probability of a patient receiving a transfusion changed significantly with later case start times in the multivariable model after adjusting for initial hemoglobin, age, sex, height, ideal body weight, diabetes, peripheral vascular disease, stroke, chronic kidney disease, chronic obstructive pulmonary disease, duration of cardiopulmonary bypass, aortic cross clamp time, attending surgeon, and attending anesthesiologist (p = 0.032, C-statistic = 0.807, n = 1220). The estimated probability of receiving an intraoperative red blood cell transfusion increased with later case start times in the multivariable model (p = 0.027, C-statistic = 0.902, n = 1220). There was no difference in the probability of transfusion for plasma, cryoprecipitate, or platelets.

CONCLUSIONS

The observed rate of intraoperative blood product transfusion changed with later case start times in a multivariable model of scheduled cardiac surgery.

The development and validation of the laryngopharyngeal measure of perceived sensation

OBJECTIVES

Globus pharyngeus (GP) is described as the subjective sensation of having a "lump" in the throat in the absence of correlating physical findings or dysphagia. Historically, despite the frequency of patient complaints, GP has been difficult to quantify with current outcome measures. This is in large part due to lack of a user-friendly, modernized, objective patient-reported outcome measure (PROM) of symptom severity. The aim of this study is to develop a modernized, practical, validated PROM for evaluating GP symptom severity.

METHODS

The Laryngopharyngeal Measure of Perceived Sensation (LUMP questionnaire) was created in three phases: 1) item generation by an expert panel involving two laryngologists and two speech language pathologists developed from common patient-reported GP symptoms, with patient confirmation; 2) line-item reduction based on internal consistency and reliability; 3) and instrument validity, which was assessed by administering the questionnaire to patients complaining of GP as well as patients without GP.

RESULTS

A 19-item questionnaire was developed from an expert panel, which was then administered to 110 patients, 100 of whom met inclusion criteria. After statistical analysis, less internally consistent or relevant questions were removed, leaving eight items with an internal consistency (Cronbach alpha) of 0.892. When administered to 54 patients with GP versus 31 normal patients, the mean score was found to be higher in those with GP versus normal patients (P value <0.0001).

CONCLUSION

Preliminary results suggest the eight-item LUMP questionnaire is a valuable PROM for evaluating GP symptom severity.

LEVEL OF EVIDENCE

NA Laryngoscope, 2019.

Recurrence patterns after resection of retroperitoneal sarcomas: An eight-institution study from the US Sarcoma Collaborative

BACKGROUND AND OBJECTIVES

Resection of primary retroperitoneal sarcomas (RPS) has a high incidence of recurrence. This study aims to identify patterns of recurrence and its impact on overall survival.

METHODS

Adult patients with primary retroperitoneal soft tissue sarcomas who underwent resection in 2000-2016 at eight institutions of the US Sarcoma Collaborative were evaluated.

RESULTS

Four hundred and ninety-eight patients were analyzed, with 56.2% (280 of 498) having recurrences. There were 433 recurrences (1-8) in 280 patients with 126 (25.3%) being locoregional, 82 (16.5%) distant, and 72 (14.5%) both locoregional and distant. Multivariate analyses revealed the following: Patient age P = .0002), tumor grade (P = .02), local recurrence (P = .0003) and distant recurrence (P < .0001) were predictors of disease-specific survival. The 1-, 3-, and 5-year survival rate for patients who recurred vs not was 89.6% (standard error [SE] 1.9) vs 93.5% (1.8), 66.0% (3.2) vs 88.4% (2.6), and 51.8% (3.6) vs 83.9% (3.3), respectively, P < .0001. Median survival was 5.3 years for the recurrence vs 11.3+ years for the no recurrence group (P < .0001). Median survival from the time of recurrence was 2.5 years.

CONCLUSIONS

Recurrence after resection of RPS occurs in more than half of patients independently of resection status or perioperative chemotherapy and is equally distributed between locoregional and distant sites. Recurrence is primarily related to tumor biology and is associated with a significant decrease in overall survival.

Goals and Adverse Effects: Rate of Concordance Between Patients and Providers

PURPOSE

Adequate understanding of the goals and adverse effects of cancer treatment has important implications for patients' decision making, expectations, and mood. This study sought to identify the degree to which patients and clinicians agreed upon the goals and adverse effects of treatment (ie, concordance).

METHODS

Patients completed a demographic questionnaire, the National Comprehensive Cancer Network Distress Thermometer, the Medical Outcomes Study Social Support Survey, the Functional Assessment of Chronic Illness Therapy-Treatment Satisfaction-General questionnaire, the Functional Assessment of Chronic Illness Therapy-Spiritual Well-Being questionnaire, and a 13-item questionnaire about the goals and adverse effects of treatment. Providers completed a 12-item questionnaire.

RESULTS

One hundred patients (51 female) and 34 providers participated (questionnaire return rate mean difference, 5 days; SD, 16 days). Patient and provider dyads agreed 61% of the time regarding the intent of treatment. In cases of nonagreement, 36% of patients reported more optimistic therapy goals compared to providers. Patients and providers agreed 69% of the time regarding the patient's acknowledgement and understanding of adverse effects. Patients who reported an understanding of likely adverse effects endorsed significantly lower distress scores (mean, 2.5) than those who endorsed not understanding associated adverse effects (mean, 4.1; P = .008).

CONCLUSION

Timely data capturing of patient-provider dyadic ratings is feasible. A significant discrepancy exists between a substantial percentage of patients' and providers' views of the intent and adverse effects of treatment. Patients were almost always more optimistic about the intent of treatment. Higher rates of distress were noted in cases of discordance. Providers may benefit from conversational feedback from patients as well as other integrated feedback systems to inform them about patient understanding.

Use of Body Surface Area for Dosing of Vancomycin

OBJECTIVES

Vancomycin weight-based dosing regimens often fail to achieve therapeutic trough serum concentration in children ≤12 years of age and rigorous studies evaluating efficacy and safety of body surface area (BSA)-based dosing regimens have not been performed. We compared vancomycin trough serum concentrations in pediatric patients receiving a weight- or BSA-based dosing regimen.

METHODS

This was a single-center, retrospective study evaluating pediatric patients, ages 1 to 12 years, who received vancomycin from September 2012 to October 2015. Patients received a minimum of 3 consecutive doses at the same scheduled interval within a dosing regimen prior to a measured vancomycin serum trough concentration. The primary outcome was percentage of initial vancomycin trough concentrations ≥10 mg/L. The secondary outcomes were percentage of supratherapeutic, therapeutic, and subtherapeutic vancomycin serum concentration for all patients, including a subset of overweight and obese patients, and number of nephrotoxic occurrences.

RESULTS

BSA-based dosing regimens resulted in 50% of the initial vancomycin trough concentrations ≥ 10 mg/L compared with 17% for the weight-based dosing regimens (p < 0.0001). No statistically significant differences were noted between the 2 dosing regimens for supratherapeutic, therapeutic, or subtherapeutic trough concentrations for all patients, and for the subset of overweight and obese patients. Nephrotoxic occurrences were noted in 7% of the weight-based dosing regimens compared with none in the BSA-based dosing regimens.

CONCLUSIONS

A BSA-based vancomycin dosing regimen resulted in significantly more initial vancomycin trough concentrations ≥10 mg/L and trended towards higher initial vancomycin trough concentrations without observable nephrotoxicity.

JC Viruria Is Associated With Reduced Risk of Diabetic Kidney Disease

PURPOSE

African Americans who shed JC polyomavirus (JCV) in their urine have reduced rates of nondiabetic chronic kidney disease (CKD). We assessed the associations between urinary JCV and urine BK polyomavirus (BKV) with CKD in African Americans with diabetes mellitus.

METHODS

African Americans with diabetic kidney disease (DKD) and controls lacking nephropathy from the Family Investigation of Nephropathy and Diabetes Consortium (FIND) and African American-Diabetes Heart Study (AA-DHS) had urine tested for JCV and BKV using quantitative PCR. Of the 335 individuals tested, 148 had DKD and 187 were controls.

RESULTS

JCV viruria was detected more often in the controls than in the patients with DKD (FIND: 46.6% vs 32.2%; OR, 0.52; 95% CI, 0.29 to 0.93; P = 0.03; AA-DHS: 30.4% vs 26.2%; OR, 0.63; 95% CI, 0.27 to 1.48; P = 0.29). A joint analysis adjusted for age, sex, and study revealed that JC viruria was inversely associated with DKD (OR, 0.56; 95% CI, 0.35 to 0.91; P = 0.02). Statistically significant relationships between BKV and DKD were not observed.

MAIN CONCLUSIONS

The results from the present study extend the inverse association between urine JCV and nondiabetic nephropathy in African Americans to DKD. These results imply that common pathways likely involving the innate immune system mediate coincident chronic kidney injury and restriction of JCV replication. Future studies are needed to explore causative pathways and characterize whether the absence of JC viruria can serve as a biomarker for DKD in the African American population.

Evaluation of Chest Radiographs and Laboratory Testing during Melanoma Staging Procedures

Chest radiographs (CXRs) and laboratory testing have historically been performed as a part of low-risk melanoma (clinical stage 1/2) workup. This study evaluates the utility of routine CXRs and laboratory testing during the staging of clinical stage 1 and 2 melanoma patients. This study was approved by the Institutional Review Board at Wake Forest University. A database of sentinel lymph node biopsies performed for clinical stage 1 or 2 melanoma was used to identify early-stage melanoma patients. The medical records of patients with melanoma were reviewed and preoperative workup procedures were recorded. Four hundred sixty-three patients were reviewed. A total of 315 patients underwent a preoperative CXR, whereas 309 received some laboratory testing. After sentinel node biopsies, 168 patients had pathologic stage 1 disease, 103 stage 2, and 44 stage 3. None of the CXRs (0%) correctly identified metastatic melanoma. Suspicious locations on CXRs and laboratory testing did not lead to metastatic findings in any patient within a year. Metastatic melanoma was not found in any patient by screening with CXRs or laboratory testing during preoperative workup. We recommend not conducting CXRs or laboratory testing during workup for surgical melanoma patients because of charges and anxiety these tests can cause. CXRs, blood tests, and metabolic panels have historically been ordered for early melanoma patients, although debate remains on their efficacy. Surgical patient records were retrospectively reviewed for these tests and no benefit was found.

Evaluation of Chest Radiographs and Laboratory Testing during Melanoma Staging Procedures

Chest radiographs (CXRs) and laboratory testing have historically been performed as a part of low-risk melanoma (clinical stage 1/2) workup. This study evaluates the utility of routine CXRs and laboratory testing during the staging of clinical stage 1 and 2 melanoma patients. This study was approved by the Institutional Review Board at Wake Forest University. A database of sentinel lymph node biopsies performed for clinical stage 1 or 2 melanoma was used to identify early-stage melanoma patients. The medical records of patients with melanoma were reviewed and pre-operative workup procedures were recorded. Four hundred sixty-three patients were reviewed. A total of 315 patients underwent a preoperative CXR, whereas 309 received some laboratory testing. After sentinel node biopsies, 168 patients had pathologic stage 1 disease, 103 stage 2, and 44 stage 3. None of the CXRs (0%) correctly identified metastatic melanoma. Suspicious locations on CXRs and laboratory testing did not lead to metastatic findings in any patient within a year. Metastatic melanoma was not found in any patient by screening with CXRs or laboratory testing during preoperative workup. We recommend not conducting CXRs or laboratory testing during workup for surgical melanoma patients because of charges and anxiety these tests can cause. CXRs, blood tests, and metabolic panels have historically been ordered for early melanoma patients, although debate remains on their efficacy. Surgical patient records were retrospectively reviewed for these tests and no benefit was found.

Obesity is Associated with Higher Blood Pressure and Higher Levels of Angiotensin II but Lower Angiotensin-(1-7) in Adolescents Born Preterm

OBJECTIVES

To evaluate if obesity is associated with increased angiotensin II (Ang II) and decreased angiotensin-(1-7) or Ang-(1-7) in the circulation and urine among adolescents born prematurely.

STUDY DESIGN

In a cross-sectional analysis of 175 14-year-olds born preterm with very low birth weight, we quantified plasma and urinary Ang II and Ang-(1-7) and compared their levels between subjects with overweight/obesity (body mass index ≥85th percentile, n = 61) and those with body mass index <85th percentile (n = 114) using generalized linear models, adjusted for race and antenatal corticosteroid exposure.

RESULTS

Overweight/obesity was associated with higher systolic blood pressure and a greater proportion with high blood pressure. After adjustment for confounders, overweight/obesity was associated with an elevated ratio of plasma Ang II to Ang-(1-7) (β: 0.57, 95% CI 0.23-0.91) and higher Ang II (β: 0.21 pmol/L, 95% CI 0.03-0.39) but lower Ang-(1-7) (β: -0.37 pmol/L, 95% CI -0.7 to -0.04). Overweight/obesity was associated with a higher ratio of urinary Ang II to Ang-(1-7) (β: 0.21, 95% CI -0.02 to 0.44), an effect that approached statistical significance.

CONCLUSIONS

Among preterm-born adolescents, overweight/obesity was associated with increased Ang II but reduced Ang-(1-7) in the circulation and the kidney as well as higher blood pressure. Obesity may compound the increased risk of hypertension and cardiovascular disease in individuals born prematurely by further augmenting the prematurity-associated imbalance in the renin-angiotensin system.

A National Cancer Database-based nomogram to predict lymph node metastasis in penile cancer

OBJECTIVE

To evaluate the predictive nature of several clinicopathological variables by developing a nomogram predictive for lymph node-positive disease using the National Cancer Database cohort of patients with squamous cell carcinoma of the penis.

METHODS

Stepwise logistic regression was used to find the best-fit model; remaining clinical variables were used to create a nomogram to predict the probability of lymph node-positive disease.

RESULTS

On multivariate analysis, high pathological grade (3-4 vs 1: odds ratio [OR] 3.27, 95% confidence interval [CI] 1.70-6.29; 2 vs 1: OR 2.58, 95% CI 1.39-4.79 [P = 0.002]), lymphovascular invasion (OR 2.49, 95% CI 1.61-3.84 [P < 0.001]), and positive clinical lymph node status (N1 vs N0: OR 20.0, 95% CI 11.4-35.7; N2 vs N0: OR 27.8, 95% CI 14.1-55.6; N3 vs N0: OR 49.2, 95% CI 14.8-162.8 [P < 0.001]) were predictors of lymph node metastasis in penile cancer. The bootstrap-corrected concordance index of this nomogram was 0.880.

CONCLUSION

Using tumour grade, tumour lymphovascular invasion and clinical lymph node status, we developed a nomogram highly predictive of pathologial lymph node metastasis that, after further external validation, could be helpful in the surgical decision-making process.

Effect of Negative Pressure Wound Therapy on Wound Complications Post-Pancreatectomy

Surgical site infection (SSI) and incisional hernia are common complications after major pancreatectomy. We investigated the effects of negative pressure wound therapy (NPWT) on short- and long-term wound outcomes in patients undergoing pancreatectomy. A randomized controlled trial comparing the effect of NPWT with standard surgical dressing (SSD) on wounds was performed in 265 patients undergoing open gastrointestinal resections from 2012 to 2016. We performed a subset analysis of 73 patients who underwent pancreatectomy. Wound complications in the first 30 days and incisional hernia rates were assessed. There were 33 (45%) female patients in the study and the average BMI was 27.6. The pancreaticoduodectomy rate was 68 per cent, whereas 27 per cent of patients underwent distal or subtotal pancreatectomy, and 4 per cent total pancreatectomy. Incisional hernia rates were 32 per cent and 14 per cent between the SSD and NPWT groups, respectively (P = 0.067). In the SSD (n = 37) and NPWT (n = 36) cohorts, the superficial SSI, deep SSI, seroma, and dehiscence rates were 16 per cent and 14 per cent (P > 0.99), 5 per cent and 8 per cent (P = 0.67), 16 per cent and 11 per cent (P = 0.74), and 5 per cent and 3 per cent (P ≥ 0.99), respectively. After adjusting for pancreatic fistula and delayed gastric emptying, no statistically significant differences in the primary outcomes were observed. These findings were true irrespective of the type of resection performed. Short- and long-term wound complications were not improved with NPWT. We observed a trend toward decreased incisional hernia rates in patients treated with NPWT. Owing to the multifactorial nature of wound complications, it is yet to be determined which cohorts of pancreatectomy patients will benefit from NPWT.

The HEART Pathway Randomized Controlled Trial One-year Outcomes

OBJECTIVE

The objective was to determine the impact of the HEART Pathway on health care utilization and safety outcomes at 1 year in patients with acute chest pain.

METHODS

Adult emergency department (ED) patients with chest pain (N = 282) were randomized to the HEART Pathway or usual care. In the HEART Pathway arm, ED providers used the HEART score and troponin measures (0 and 3 hours) to risk stratify patients. Usual care was based on American College of Cardiology/American Heart Association guidelines. Major adverse cardiac events (MACE-cardiac death, myocardial infarction [MI], or coronary revascularization), objective testing (stress testing or coronary angiography), and cardiac hospitalizations and ED visits were assessed at 1 year. Randomization arm outcomes were compared using Fisher's exact tests.

RESULTS

A total of 282 patients were enrolled, with 141 randomized to each arm. MACE at 1 year occurred in 10.6% (30/282): 9.9% in the HEART Pathway arm (14/141; 10 MIs, four revascularizations without MI) versus 11.3% in usual care (16/141; one cardiac death, 13 MIs, two revascularizations without MI; p = 0.85). Among low-risk HEART Pathway patients, 0% (0/66) had MACE, with a negative predictive value (NPV) of 100% (95% confidence interval = 93%-100%). Objective testing through 1 year occurred in 63.1% (89/141) of HEART Pathway patients compared to 71.6% (101/141) in usual care (p = 0.16). Nonindex cardiac-related hospitalizations and ED visits occurred in 14.9% (21/141) and 21.3% (30/141) of patients in the HEART Pathway versus 10.6% (15/141) and 16.3% (23/141) in usual care (p = 0.37, p = 0.36).

CONCLUSIONS

The HEART Pathway had a 100% NPV for 1-year safety outcomes (MACE) without increasing downstream hospitalizations or ED visits. Reduction in 1-year objective testing was not significant.

Effect of Negative Pressure Wound Therapy on Wound Complications Post-Pancreatectomy

Surgical site infection (SSI) and incisional hernia are common complications after major pancreatectomy. We investigated the effects of negative pressure wound therapy (NPWT) on short-and long-term wound outcomes in patients undergoing pancreatectomy. A randomized controlled trial comparing the effect of NPWT with standard surgical dressing (SSD) on wounds was performed in 265 patients undergoing open gastrointestinal resections from 2012 to 2016. We performed a subset analysis of 73 patients who underwent pancreatectomy. Wound complications in the first 30 days and incisional hernia rates were assessed. There were 33 (45%) female patients in the study and the average BMI was 27.6. The pancreaticoduodectomy rate was 68 per cent, whereas 27 per cent of patients underwent distal or subtotal pancreatectomy, and 4 per cent total pancreatectomy. Incisional hernia rates were 32 per cent and 14 per cent between the SSD and NPWT groups, respectively (P = 0.067). In the SSD (n = 37) and NPWT (n = 36) cohorts, the superficial SSI, deep SSI, seroma, and dehiscence rates were 16 per cent and 14 per cent (P > 0.99), 5 per cent and 8 per cent (P = 0.67), 16 per cent and 11 per cent (P = 0.74), and 5 per cent and 3 per cent (P ≥ 0.99), respectively. After adjusting for pancreatic fistula and delayed gastric emptying, no statistically significant differences in the primary outcomes were observed. These findings were true irrespective of the type of resection performed. Short- and long-term wound complications were not improved with NPWT. We observed a trend toward decreased incisional hernia rates in patients treated with NPWT. Owing to the multifactorial nature of wound complications, it is yet to be determined which cohorts of pancreatectomy patients will benefit from NPWT.

Renal function and blood pressure are altered in adolescents born preterm

BACKGROUND

Preterm birth increases the risk of hypertension and kidney disease. However, it is unclear when changes in blood pressure (BP) and renal function become apparent and what role obesity and sex play. We hypothesized adolescents born preterm have higher BP and worse kidney function compared to term in an obesity- and sex-dependent manner.

METHODS

Cross-sectional analysis of 14-year-olds born preterm with very low birth weight (n = 96) compared to term (n = 43). We used generalized linear models to estimate the associations among preterm birth and BP, estimated glomerular filtration rate (eGFR), and ln (x) urinary albumin-to-creatinine ratio (ACR), stratified by overweight/obesity (OWO, body mass index (BMI) ≥ 85th percentile) and sex.

RESULTS

Compared to term, preterm-born adolescents had higher systolic blood pressure (SBP) and diastolic blood pressure (DBP) (adjusted β (aβ) 3.5 mmHg, 95% CI - 0.1 to 7.2 and 3.6 mmHg, 95% CI 0.1 to 7.0), lower eGFR (β - 8.2 mL/min/1.73 m², 95% CI - 15.9 to - 0.4), and higher ACR (aβ 0.34, 95% CI - 0.04 to 0.72). OWO modified the preterm-term difference in DBP (BMI < 85th percentile aβ 5.0 mmHg, 95% CI 0.7 to 9.2 vs. OWO 0.2 mmHg, 95% CI - 5.3 to 5.6) and ACR (OWO aβ 0.72, 95% CI 0.15 to 1.29 vs. BMI < 85th percentile 0.17, 95% CI - 0.31 to 0.65). Sex modified the preterm-term ACR difference (female aβ 0.52, 95% CI 0.001 to 1.04 vs. male 0.18, 95% CI - 0.36 to 0.72).

CONCLUSIONS

Prematurity was associated with higher BP and reduced renal function that were detectable in adolescence. OWO and sex may modify the strength of these relationships.

Single-Injection Adductor Canal Block With Multiple Adjuvants Provides Equivalent Analgesia When Compared With Continuous Adductor Canal Blockade for Primary Total Knee Arthroplasty: A Double-Blinded, Randomized, Controlled, Equivalency Trial

BACKGROUND

Peripheral nerve blockade is used to provide analgesia for patients undergoing total knee arthroplasty. This study compared a single-injection adductor canal block (SACB) with adjuvants to continuous adductor canal blockade (CACB). The hypothesis was that the 2 groups would have equivalent analgesia at 30 hours after neural blockade.

METHODS

This was a double-blinded, randomized, controlled, equivalency trial. Sixty patients were randomized to either the SACB group (20 mL of 0.25% bupivacaine, 1.67 mcg/mL of clonidine, 2 mg of dexamethasone, 150 mcg of buprenorphine, and 2.5 mcg/mL of epinephrine) or the CACB group (20 mL 0.25% of bupivacaine injection with 2.5 mcg/mL of epinephrine followed by an 8 mL/h infusion of 0.125% bupivacaine continued through postoperative day 2). The primary outcome was movement pain scores at 30 hours using the numeric rating scale (NRS). The secondary outcomes included serial postoperative NRS pain scores (rest and movement every 6 hours), opioid consumption, time to first opioid administration, ability to straight leg raise, patient satisfaction, length of stay, and the incidence of nausea/vomiting.

RESULTS

An intention-to-treat analysis included 59 patients. The NRS pain scores with movement were equivalent at 30 hours (SACB 5.5 ± 2.8 vs CACB 5.7 ± 2.9 [mean NRS ± standard deviation]; mean difference 0.2 [-1.5 to 1.0 {90% confidence interval}]). All NRS pain scores were equivalent until 42 hours (rest) and 48 hours (rest and movement) with the CACB group having lower pain scores. Other secondary outcomes were not statistically different.

CONCLUSION

An SACB provides equivalent analgesia for up to 36 hours after block placement when compared with a CACB for patients undergoing total knee arthroplasty, though a CACB was favored at 42 hours and beyond.

Volumetric bone mineral density of the spine predicts mortality in African-American men with type 2 diabetes

The study showed that in African-American men with type 2 diabetes mellitus (T2D), vertebral volumetric bone mineral density (vBMD) predicts all-cause mortality, independent of other risk factors for death.

INTRODUCTION

Compared to European Americans, African Americans have lower rates of osteoporosis and higher rates of T2D. The relationships between BMD and fractures with mortality are unknown in this population. The aim of this study was to determine relationships between vertebral fractures and vertebral vBMD and mortality in African Americans with T2D.

METHODS

Associations between vertebral fractures and vBMD with all-cause mortality were examined in 675 participants with T2D (391 women and 284 men) in the African American-Diabetes Heart Study (AA-DHS). Lumbar and thoracic vBMD were measured using quantitative computed tomography (QCT). Vertebral fractures were assessed on sagittal CT images. Associations of vertebral fractures and vBMD with all-cause mortality were determined in sex-stratified analyses and in the full sample. Covariates in a minimally adjusted model included age, sex, BMI, smoking, and alcohol use; the full model was adjusted for those variables plus cardiovascular disease, hypertension, coronary artery calcified plaque, hormone replacement therapy (women), African ancestry proportion, and eGFR.

RESULTS

After mean 7.6 ± 1.8-year follow-up, 59 (15.1%) of women and 58 (20.4%) of men died. In men, vBMD was inversely associated with mortality in the fully adjusted model: lumbar hazard ratio (HR) per standard deviation (SD) = 0.70 (95% CI 0.52-0.95, p = 0.02) and thoracic HR per SD = 0.71 (95% CI 0.54-0.92, p = 0.01). Only trends toward association between vBMD and mortality were observed in the combined sample of men and women, as significant associations were absent in women. Vertebral fractures were not associated with mortality in either sex.

CONCLUSIONS

Lower vBMD was associated with increased all-cause mortality in African-American men with T2D, independent of other risk factors for mortality including subclinical atherosclerosis.

Usefulness of Serial 12-Lead Electrocardiograms in Predicting 30-Day Outcomes in Patients With Undifferentiated Chest Pain (the ASAP CATH Study)

An initial electrocardiogram (ECG) and serial troponin measurements are both independently and incrementally predictive of acute coronary syndrome in patients presenting with undifferentiated chest pain in the Emergency Department (ED). However, it is unclear if serial (ECGs) add significant to the contemporary diagnostic evaluation of this patient group. The ASAP CATH study was a single center, prospective study that enrolled patients presenting to an ED with undifferentiated chest pain. In addition to standard clinical evaluation, serial ECGs were performed at 90-minute intervals to evaluate whether serial changes suggestive of ischemia developed (Q waves, ST elevation or depression, or T-wave inversion). Total 365 subjects were enrolled from March 2014 to May 2015. Serial ECG changes developed in 6.6% (n = 24 of 365), the most common being the development of T-wave inversion (66.7%, n = 16 of 24). The sensitivity and positive predictive value of serial ECG changes were poor (<30%), with a less areas under the curve (0.55) compared with serial troponins alone (0.83). The addition of serial ECG changes to Thrombolysis In Myocardial Infarction risk scoring showed a decrease in the net reclassification index for major adverse cardiovascular events (-0.04, p <0.1) and was not significant for the prediction of major adverse cardiovascular events and/or acute coronary syndrome in 30 days (-0.003, p = 0.94). In conclusion, routine serial ECG evaluation for patients presenting with undifferentiated chest pain in the ED may not significantly improved diagnostic prognosis beyond current standard evaluation modalities.

Psoas and paraspinous muscle index as a predictor of mortality in African American men with type 2 diabetes mellitus

AIM

Recent studies revealed a correlation between skeletal muscle mass index and density with longevity; these studies largely evaluated appendicular skeletal muscles in older Caucasians. This retrospective cohort study assessed the association between axial skeletal muscles size and density with survival in African Americans with type 2 diabetes mellitus.

METHODS

Psoas and paraspinous muscle mass index (cross sectional area/height²) and radiographic density (in Hounsfield Units) were measured using computed tomography in African American-Diabetes Heart Study participants, 314 women and 256 men, with median (25th, 75th quartile) age 55.0(48.0, 62.0) and 57.0(50.0, 64.0) years, respectively. Covariates in fully-adjusted model included age, sex, BMI, smoking, hormone replacement therapy (women), cardiovascular disease, hypertension, coronary artery calcified plaque mass, carotid artery calcified plaque mass, and African ancestry proportion.

RESULTS

After median of 7.1(5.9, 8.2) years follow-up, 30(9.6%) of women and 49(19.1%) of men were deceased. In fully-adjusted models, psoas muscle mass index and paraspinous muscle mass index were inversely associated with mortality in men (psoas muscle mass index, hazard ratio [HR] = 0.61, P = 0.004; paraspinous muscle mass index, HR = 0.64, P = 0.004), but not in women. Psoas and paraspinous muscle densities did not associate with all-cause mortality. A penalized Cox regression that involved all covariates and predictors associated with mortality showed that only paraspinous muscle mass index remained a significant predictor of mortality (HR = 0.65, P = 0.02).

CONCLUSION

Independent from established risk factors for mortality, higher psoas and paraspinous muscle index associate with reduced all-cause mortality in middle-aged African American men with type 2 diabetes mellitus.

Perineural dexamethasone successfully prolongs adductor canal block when assessed by objective pinprick sensory testing: A prospective, randomized, dose-dependent, placebo-controlled equivalency trial

STUDY OBJECTIVE

To determine whether perineural dexamethasone prolongs peripheral nerve blockade (PNB) when measured objectively; and to determine if a 1 mg and 4 mg dose provide equivalent PNB prolongation compared to PNB without dexamethasone.

SETTING

Multiple studies have reported that perineural dexamethasone added to local anesthetics (LA) can prolong PNB. However, these studies have relied on subjective end-points to quantify PNB duration. The optimal dose remains unknown. We hypothesized that 1 mg of perineural dexamethasone would be equivalent in prolonging an adductor canal block (ACB) when compared to 4 mg of dexamethasone, and that both doses would be superior to an ACB performed without dexamethasone.

DESIGN

This was a prospective, randomized, double-blind, placebo-controlled equivalency trial involving 85 patients undergoing a unicompartmental knee arthroplasty.

INTERVENTIONS

All patients received an ACB with 20 ml of 0.25% bupivacaine with 1:400,000 epinephrine. Twelve patients had 0 mg of dexamethasone (placebo) added to the LA mixture; 36 patients had 1 mg of dexamethasone in the LA; and 37 patients had 4 mg of dexamethasone in the LA.

MEASUREMENTS

The primary outcome was block duration determined by serial neurologic pinprick examinations. Secondary outcomes included time to first analgesic, serial pain scores, and cumulative opioid consumption.

MAIN RESULTS

The 1 mg (31.8 ± 10.5 h) and 4 mg (37.9 ± 10 h) groups were not equivalent, TOST [Mean difference (95% CI); 6.1 (-10.5, -2.3)]. Also, the 4 mg group was superior to the 1 mg group (p-value = 0.035), and the placebo group (29.7 ± 6.8 h, p-value = 0.011). There were no differences in opioid consumption or time to analgesic request; however, some pain scores were significantly lower in the dexamethasone groups when compared to placebo.

CONCLUSION

Dexamethasone 4 mg, but not 1 mg, prolonged the duration of an ACB when measured by serial neurologic pinprick exams.

CLINICAL TRIAL REGISTRATION

NCT02462148.

Outcomes of Below-the-Knee Amputations for Chronic Lower Extremity Pain

The study evaluated the physical,mental, and functional outcomes following below-the-knee amputation (BKA) for management of chronic, debilitating lower extremity pain. The hypothesis was that patients who undergo a BKA to alleviate chronic pain achieve a greater level of function, experience decreased pain, and benefit from improved health-related quality of life. Patients who received a BKA attended an orthopaedic clinic and completed questionnaires examining their overall health, functional status, mental health, and pain. Thirty-seven patients were identified as eligible for study participation; 15 agreed to participate. Although most participants continued to experience pain in their residual limb after BKA, they reported their pain decreased to a manageable level. Participants experienced a statistically significant improvement in their perceived physical health. The authors believe a BKA for chronic pain is a reasonable treatment option for patients who continue to experience lower extremity pain after failed medical and surgical management of chronic pain. (Journal of Surgical Orthopaedic Advances 26(4):200-205, 2017).

FGF23 Concentration and APOL1 Genotype Are Novel Predictors of Mortality in African Americans With Type 2 Diabetes

OBJECTIVE

Cardiovascular and renal complications contribute to higher mortality in patients with diabetes. We assessed novel and conventional predictors of mortality in African American-Diabetes Heart Study (AA-DHS) participants.

RESEARCH DESIGN AND METHODS

Associations between mortality and subclinical atherosclerosis, urine albumin-to-creatinine ratio (UACR), estimated glomerular filtration rate (eGFR), plasma fibroblast growth factor 23 (FGF23) concentration, African ancestry proportion, and apolipoprotein L1 genotypes (APOL1) were assessed in 513 African Americans with type 2 diabetes; analyses were performed using Cox proportional hazards models.

RESULTS

At baseline, participants were 55.6% female with median (25th, 75th percentile) age 55 years (49.0, 62.0), diabetes duration 8 years (5.0, 13.0), glycosylated hemoglobin 60.7 mmol/mol (48.6, 76.0), eGFR 91.3 mL/min/1.73 m² (76.4, 111.3), UACR 12.5 mg/mmol (4.2, 51.2), and coronary artery calcium 28.5 mg Ca²⁺ (1.0, 348.6); 11.5% had two APOL1 renal-risk variants. After 6.6-year follow-up (5.8, 7.5), 54 deaths were recorded. Higher levels of coronary artery calcified plaque, carotid artery calcified plaque, albuminuria, and FGF23 were associated with higher mortality after adjustment for age, sex, and African ancestry proportion. A penalized Cox regression that included all covariates and predictors associated with mortality identified male sex (hazard ratio [HR] 4.17 [95% CI 1.96-9.09]), higher FGF23 (HR 2.10 [95% CI 1.59-2.78]), and absence of APOL1 renal-risk genotypes (HR 0.07 [95% CI 0.01-0.69]) as the strongest predictors of mortality.

CONCLUSIONS

Accounting for conventional risk factors, higher FGF23 concentrations and APOL1 non-renal-risk genotypes associated with higher mortality in African Americans with diabetes. These data add to growing evidence supporting FGF23 association with mortality; mechanisms whereby these novel predictors impact survival remain to be determined.

Antenatal corticosteroids and cardiometabolic outcomes in adolescents born with very low birth weight

BackgroundExposure to antenatal corticosteroids (ANCS) is associated with adverse cardiometabolic outcomes in animal models; however, long-term outcomes in clinical studies are not well characterized. We hypothesized that exposure to ANCS would be associated with markers of increased cardiometabolic risk in adolescents born with very low birth weight (VLBW).MethodsIn an observational cohort of 186 14-year-old adolescents born with VLBW, we measured resting blood pressure (BP), BP response to cold, ambulatory BP, and anthropometrics; performed dual-energy X-ray absorptiometry; and analyzed blood samples for uric acid, cholesterol, glycated hemoglobin, and high-sensitivity C-reactive protein. Multivariate analyses were used to evaluate associations with ANCS, adjusting for race, sex, and maternal hypertensive pregnancy.ResultsThere were no ANCS group differences in BP measures or blood biomarkers. Compared with adolescents unexposed to ANCS, those exposed to ANCS were taller (exposed-unexposed mean difference 3.1 cm (95% confidence interval (CI) 0.7, 5.5)) and had decreased waist-to-height ratio (exposed-unexposed mean difference -0.03 (95% CI -0.058, -0.002)). Males exposed to ANCS had lower total cholesterol (exposed-unexposed mean difference -0.54 mmol/l (95%CI -0.83, -0.06)).ConclusionAmong adolescents born with VLBW, ANCS exposure was not associated with markers of increased cardiometabolic risk.