Aggressive Management Research Articles

Fifteen-year follow-up and impact of age and sex on cardiovascular outcomes in diabetes and non-diabetes patients without CAD

Abstract Background In the absence of angiographically-detectable coronary artery disease (CAD), patients with diabetes have a risk of myocardial infarction that is comparable to patients without diabetes, while still having higher risks of ischemic stroke and all-cause mortality when followed for up to 10 years. In the current study we extended follow-up to 15 years and, additionally, examined the impact of age and sex on cardiovascular risk in diabetes and non-diabetes patients without CAD. Purpose To examine the cardiovascular risk and mortality associated with age and sex in diabetes and non-diabetes patients without CAD. Methods We included every patient with no or mild CAD when examined by coronary angiography in Western Denmark from 2003-2021 with and without diabetes. We performed age-stratified (<65 year, 65-74 years, and ≥75 years) and sex-stratified analyses. Patients were followed for up to 15 years. Outcomes were myocardial infarction, ischemic stroke, and all-cause death. We estimated adjusted hazard ratios (aHR) using Cox regression. Results We included 60,712 patients without angiographically detectable CAD, of whom 7,690 (12.6%) had diabetes. Median age was 62 years and 51% were men. Median follow-up was 9 years ((inter-quartile range 6-13)). Diabetes was associated with an increased 15-year risk of myocardial infarction (5.8% versus 4.1% aHR 1.30, 95% CI 1.13-1.50), ischemic stroke (8.1% vs 4.0%, aHR 1.87, 95% CI 1.66-2.10), and all-cause death (46.2% vs 33.1%, aHR 1.66, 95% CI 1.58-1.73) compared to patients without diabetes. The relative risk associated with diabetes declined by age (Figure 1), while there was no sex-dependent difference associated with diabetes (Figure 2). Conclusions At 15-year follow-up, diabetes patients without angiographically-detectable CAD at baseline had a relatively small increased risk of myocardial infarction but a substantial increased risk of ischemic stroke and all-cause mortality. Furthermore, the relative importance of diabetes decreased with age, while being independent of sex. These results support that aggressive multifactorial cardiovascular risk management, even in the absence of CAD and independently of age and sex, should be initiated when diabetes is diagnosed.Figure 1Figure 2

Impact of systemic lupus erythematosus on outcomes in patients hospitalized with acute decompensated heart failure with reduced and preserved ejection fraction: a national inpatient sample study (2016)

Abstract Background Systemic lupus erythematosus (SLE) is known to have an impact on cardiovascular outcomes, but its effect on patients with acute decompensated heart failure (ADHF) with reduced and preserved ejection fraction is not well understood. This study aims to investigate the impact of SLE on in-hospital outcomes in patients with ADHF. Methods This retrospective cohort study analyzed data from the United States National Inpatient Sample Database from 2016 to 2020. Patients hospitalized with ADHF with reduced and preserved ejection fraction were identified using ICD-10 codes and then categorized based on SLE diagnosis. Mortality and in-hospital complications were analyzed using multivariate logistic regression. Results Out of 10,700,000 ADHF hospitalizations, 0.61% (65,270) were associated with SLE. Compared to patients without SLE, those with SLE were younger (61 vs 72 years old, p<0.001), more likely to be female (85% vs 48%, p<0.001), had longer lengths of stay (coefficient: 0.23; p 0.005), and lower total hospital charges (coefficient: -$5,207; p<0.001). Patients with SLE had lower rates of cardiogenic shock, acute MI, and ischemic stroke (Figure 1). However, they had higher odds of in-hospital mortality, gastrointestinal bleeding, blood transfusion, pericardial complications, and AKI. No significant differences were found in respiratory failure and intracranial hemorrhage rates between the two cohorts. Conclusions This study suggests that the presence of SLE in patients hospitalized with ADHF is associated with worse in-hospital outcomes, including higher rates of all-cause mortality, gastrointestinal bleeding, blood transfusion, pericardial complications, and AKI. However, patients with SLE had lower rates of cardiogenic shock, acute MI, and ischemic stroke compared to those without SLE. These findings highlight the importance of early recognition and aggressive management of SLE in patients with ADHF to improve outcomes. Further research is needed to identify potential interventions that could improve the outcomes of this high-risk population.

Abstract 13027: Hospital Outcomes and Predictors of Spontaneous Coronary Artery Dissection With Concurrent Ventricular Arrhythmias

Background: While spontaneous coronary artery dissection (SCAD) patients can present with ventricular arrhythmias (VAs), the in-hospital outcomes among these patients are not well-established. Objective: This study aimed to analyze the in-hospital outcomes of patients with SCAD and concurrent VAs, and to determine the predictors of VAs occurrence in this population. Methods: Using the Nationwide Readmissions Database, our study included patients aged 18 years or older who had SCAD between 2017 and 2020. We categorized the cohort into two groups depending on the presence of VAs during hospitalization. The in-hospital outcomes were assessed between two groups. Through multivariable analysis, we further analyzed the predictors of VAs occurrence among SCAD patients. Results: Our study included 160 (13.45%) SCAD patients with concurrent VAs and 1,030 (86.55%) SCAD patients without concurrent VAs between 2017 and 2020. SCAD patients with concurrent VA were associated with higher rates of early mortality (11.88% vs. 2.04%, p<0.01), prolonged index hospital stay (≥7 days) (31.25% vs. 12.82%, p<0.01), and non-home discharge (21.88% vs. 6.50%, p<0.01). The length of hospital stay was longer in the SCAD with concurrent VAs group (6.93 days vs. 3.73 days, p<0.01), and the median cumulative cost of hospitalization was also higher in this group ($31,450 vs. $14,664, p<0.01). SCAD with concurrent VAs patients also had poorer in-hospital adverse events. In multivariable analysis, the independent predictors for VAs occurrence among SCAD patients were chronic liver disease (aOR: 2.18; 95% CI: 1.15- 4.12, p=0.02) and heart failure (aOR: 3.40; 95%CI: 2.30- 5.02, p<0.01). Conclusion: Ventricular arrhythmias among SCAD patients were associated with poorer in-hospital outcomes. Heart failure and chronic liver disease were the predictors of VAs in SCAD patients. This highlights the importance of closely monitor and aggressive VAs management among these high-risk patients.

Abstract 18886: Rare but Fatal: Thrombus Formation and Cerebral Infarction Following Atrial Fibrillation Ablation

Introduction: Atrial fibrillation (AF) ablation has become increasingly common as a first line treatment for young, healthy patients and recurrent AF. While the procedures are effective and safe with a mortality rate of <0.1%, it can be associated with fatal complications. Case Presentation: A 74-year-old male with a history of AF status post epicardial ablation, ascending and thoracic aortic aneurysm, hypertension, dilated cardiomyopathy, sick sinus syndrome and alcohol use presented with left hemiparesis and left sided facial droop. He had undergone radiofrequency ablation about 3 weeks prior. Initial evaluation for stroke with computed tomography (CT) of head and CT angiography (CTA) of head/neck was negative. He was intubated for airway protection. Upon insertion of the nasogastric tube, it had dark blood concerning for an upper gastrointestinal bleed. The hospital course was complicated by sinus bradycardia and severe hypotension requiring dopamine and norepinephrine infusions. Repeat CTA head/neck demonstrated new evolving infarcts in the left middle cerebral artery (MCA), left posterior cerebral artery and right MCA territories. During an esophagogastroduodenoscopy to rule out atrioesophageal fistula, patient had a vasovagal episode which resolved with epinephrine. Subsequent transesophageal echocardiogram (TEE) demonstrated an echogenic long protruding thrombus extending across the iatrogenic atrial septal defect from the right atrium to the posterior wall of the left atrium, attached near the ostium of the right lower pulmonary vein. Repeat CT head multiple new areas concerning for developing infarctions and pneumocephalus. Given his overall grim prognosis, the patient was transitioned to comfort care. Conclusions: As ablative procedures for management of AF become more prevalent, it is imperative to maintain a high clinical suspicion for rare but fatal complications which require prompt diagnosis and early aggressive management.

A descriptive study on the risk factors of preterm birth with its maternal and fetal outcomes at a tertiary care hospital

Background: India contributes to greatest number of preterm births all over the world. The global annual prevalence of preterm birth ranges from 9-12%. It is the most common indication for antenatal hospitalization and is the leading cause for under-five mortality. Aims and objectives were to study the incidence, risk factors, clinical presentation, effectiveness of timely intervention and, maternal and fetal outcomes of preterm birth. Methods: A Prospective hospital based cross-sectional study was done from February 2021 to February 2022. Results: The incidence of preterm labour in the study was 24%. Majority of cases presented with symptoms of UTI (47%), vaginal discharge (43%) and leaking per vagina (13%). Infections were the most common aetiology, 40% of cases had positive urine and vaginal swab culture. The most common neonatal complications were respiratory distress syndrome (7%) and neonatal sepsis (7%), others included seizures (2%), birth asphyxia (1%), enterocolitis (1%), hypoxic ischemic encephalopathy (1%), intracranial hemorrhage (1%), meningitis (1%) and pulmonary hemorrhage (1%). 5% of neonatal deaths were noted. Conclusions: Urogenital infections were the commonest etiology for the onset of preterm labour, followed by gestational hypertensive disorders, previous history of preterm birth and anaemia in pregnancy. We conclude that in established preterm labour, aggressive management with antenatal corticosteroids, Magnesium sulphate for neuroprotection when indicated, antibiotic coverage and use of tocolytics with early in-utero transfer of mother to centres with equipped neonatal care units will improve the neonatal outcome.

Clonal Hematopoiesis Is Associated with Cardiovascular Disease Risk and Worse Survival after Autologous Hematopoietic Cell Transplantation for Lymphoma

Introduction: Autologous hematopoietic cell transplantation (HCT) is an effective treatment for patients with relapsed or refractory lymphoma, and use of HCT has contributed to a growing number of survivors. Despite these improvements in outcomes, long-term survivors of lymphoma are at high risk of developing clinically significant cardiovascular disease (CVD) which, to date, has largely been attributed to pre-HCT cardiotoxic therapeutic exposures (e.g. anthracyclines, radiation) and modifiable risk factors (e.g. hypertension, diabetes, dyslipidemia) after HCT. In the general population, clonal hematopoiesis of indeterminate potential (CHIP), which refers to clonal expansion of hematopoietic stem cells with somatic mutations, has been associated with aging-related health conditions including CVD. Accumulating data suggests CHIP is more prevalent in cancer patients compared to age-matched controls, due in part to clonal selection after genotoxic stressors. There is a paucity of information about the association between CHIP and CVD after HCT, including its interaction with modifiable risk factors and subsequent impact on survival after HCT. Methods: This was a retrospective cohort study of 861 consecutive patients who underwent autologous HCT for lymphoma between 2010 and 2016, with available pre-HCT DNA obtained from peripheral blood stem cells. We performed targeted exome sequencing of DNA (92 pre-defined gene panel with 1000x sequencing depth) to determine the presence of CHIP (variant allele frequency ≥2%). CVD outcomes of interest included de novo heart failure, coronary artery disease and stroke after HCT. Five-year cumulative incidence of CVD was calculated taking into consideration competing risk of death. Fine-Gray multivariable regression was used to evaluate the association between CHIP and CVD, adjusting for demographic, clinical and therapeutic factors. The Kaplan-Meier method was used to examine the effect of CHIP on overall survival after HCT. Results: Median age at HCT was 55.7 years (range 18.4-78.1 years); 63.3% were male; race/ethnicity: non-Hispanic White (56.9%), Hispanic (26.1%), Asian (10.8%), Black (5.1%); 78.0% had non-Hodgkin lymphoma; comorbidities at HCT: hypertension (32.1%), dyslipidemia (16.4%), diabetes (10.1%), high (≥3) HCT-comorbidity index (CI) score (46.1%). Nearly all patients (94.3%) had received anthracycline-based chemotherapy prior to HCT, and 63.3% were treated with cumulative dose ≥300mg/m 2; 6% had chest radiotherapy. Overall, 186 patients (21.7% of the cohort) had at least one CHIP variant and 57 (6.6%) had ≥2 variants. DNMT3A, PPM1D, TET2 and TP53 were the most frequently mutated genes. In total, 74 patients developed CVD within five years from HCT. The 5-year cumulative incidence of CVD was significantly higher in patients with CHIP (20.9% vs 9.1%, p<0.001), compared to those without CHIP, and there was a graded relationship between number of CHIP variants and incidence of CVD. In the adjusted (age, cancer diagnosis, HCT-CI, modifiable cardiovascular risk factors) multivariable model, CHIP was significantly and independently associated with a nearly two-fold (HR: 1.8, 95% CI=1.1-3.1; P=0.020) risk of CVD, as well as the individual outcome of heart failure (HR: 2.3, 95%CI=1.3-4.3; P=0.008). Patients who had both CHIP and hypertension had a 3-fold (HR: 3.0, 95%CI=1.4-6.5, p=0.006) risk of CVD (reference: no CHIP, no hypertension). Overall 5-year survival after HCT was significantly worse in patients with CHIP, compared to those without CHIP (47.2% vs 68.2%, p<0.001; adjusted HR: 1.9, 95%CI=1.4-2.6), attributed to the higher burden of non-relapse mortality in patients with CHIP. Conclusions: In this well-characterized and demographically diverse cohort of lymphoma patients undergoing HCT, CHIP was highly prevalent and associated with a significantly higher risk of CVD after HCT, with the highest risk among those with CHIP and hypertension. We confirmed the poor overall survival rate in patients with CHIP, independent of patient and disease-related risk factors. These findings highlight the potential role of CHIP as a novel biomarker to better define CVD risk in patients with lymphoma prior to HCT, setting the stage for better screening and implementation of interventions (e.g., aggressive management of modifiable risk factors) to reduce the risk of CVD and to ultimately improve long-term health outcomes after HCT.

Abstract 106: CHANTER Syndrome: A Case Report Of A 59 Year Old Man With Positive Outcome

Introduction Cerebellar, Hippocampal, and Basal Nuclei Transient Edema with Restricted Diffusion (CHANTER) syndrome was first described in 2019 [1] as a pattern of radiographic findings that are distinct from ischemic, anoxic, or toxic brain injury. Pathophysiology is still uncertain, but some proposed theories include a primary metabolic etiology or a mitochondrial failure of gray matter. Clinically, patients typically present with altered level of consciousness. Radiographically, diffusion weighted imaging shows restriction in the bilateral hippocampi, bilateral cerebelli, and basal nuclei. The cerebral cortex, thalamus, and subcortical white matter are usually spared. Despite the morbid clinical picture on presenation, positive outcomes were reported with early intervention. We describe a case of CHANTER syndrome in a 59 year old man with history of illicit substance abuse. Methods Case report with electronic medical record review. Results 59‐year‐old man with history of illicit substance abuse including cocaine, opioid, and phencyclidine presented to the hospital after being found down at a drug store. Patient did not respond to Naloxone and was eventually intubated due to respiratory compromise. Non‐contrast CT head showed hypoattenuation of the bilateral cerebellar hemispheres with mild effacement of the fourth ventricle. MRI brain showed diffusion signal abnormalities with corresponding T2 FLAIR hyperintensities in the bilateral cerebellar hemispheres, bilateral hippocampi, and bilateral basal ganglia with some involvement of the left occipital lobe suggestive of CHANTER syndrome. As vasogenic edema worsened, hydrocephalus ensued requiring administration of hypertonic saline and eventual external ventricular drain (EVD) insertion in the neurocritical care unit. Despite initial improvement in his level of consciousness after the EVD insertion, his intracranial pressure (ICP) continued to increase and midazolam and ketamine infusion drips were added. A fine balance between lowering the ICP and avoiding respiratory suppresion with sedating infusions was maintained. Consecutive MRI brain images over the course of the following 4 weeks of his stay showed decrease of the abnormal diffusion weighted imaging signal along with improvement in his overall mental status and eventual discharge 12 weeks from his initial presentation. Conclusion This case further strengthens the relationship between CHANTER syndrome and illicit substance use as a likely etiology along with other cases in the literature. Aggressive management in the neurocritical care to control vasogenic edema and avoid ICP elevation is essential to give patients the highest chance of recovery. Clinical improvement At least partial reversal of the radiographic findings of CHANTER syndrome can be attained with treatment, however, unclear if complete reversal is possible.

Abstract 225: Rescue Stenting for Posterior Circulation Strokes

Introduction Intracranial atherosclerotic disease (ICAD) is associated with up to 32% of posterior circulation strokes.1 ICAD‐related strokes are at high risk for re‐occlusion following MT. Rescue treatment with stenting, balloon angioplasty, and/or intraarterial thrombolysis or antiplatelets are often required to treat the underlying stenosis. However, these rescue treatments are associated with their own risks.2,3 The SAMMPRIS trial reported that percutaneous transluminal angioplasty and stenting (PTAS) was associated with inferior outcomes compared to aggressive medical management alone but it is unclear whether these findings are generalizable to LVO strokes.4 Recent literature has reported clinical benefits associated with rescue stenting in the setting of ICAD‐related MT‐refractory strokes.5 However, most of the existing literature focuses on anterior circulation. This meta‐analysis aims to analyze the literature regarding the efficacy and safety of post‐thrombectomy PTAS in ICAD‐related posterior circulation strokes. Methods The search strategy was developed following the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses (PRISMA) guidelines.6 Using the common evidence medicine framework PICOS (Patient Population, Intervention, Control/Comparison, Outcome, and Study type), we specified our research question: “In patients with posterior circulation AIS who underwent endovascular thrombectomy but failed to recanalize or who had severe stenosis, is PTAS an effective and safe rescue treatment option?” An electronic search of PubMed, EMBASE, Cochrane and OVID databases was performed from date of database inception to March 2023. Data was collected and analyzed using “Meta” package in RStudio.7 Outcomes of interest included 90 day modified Rankin score (mRS) and 90‐day mortality. Results A total of 10 studies were collected, but only 7 double‐arm studies involving 965 participants were included in this analysis. Among these patients, 544 underwent rescue stenting, while 421 were control patients. In a common effects meta‐analysis, patients who underwent stenting were more likely to have an mRS ≤ 2 at 90 days (OR 1.73, 95% CI [1.25 – 2.37]; p < 0.001) and lower odds of mortality at 90 days (OR 0.31, 95% CI [0.23 – 0.42]; p < 0.001). Additionally, patients undergoing stenting were less likely to have symptomatic intracranial hemorrhage (sICH) (OR 0.34, 95% CI [0.17 ‐ 0.67]; p = 0.002). Furthermore, the stenting group showed significantly higher odds of achieving a modified treatment in cerebral ischemia score (mTICI) of 2b‐3 when compared to the control group (OR 11.32, 95% CI [6.54 ‐ 19.59]; p < 0.001). Conclusion PTAS appears to be an effective and safe treatment for ICAD after MT in the posterior circulation both improving likelihood of good outcomes and overall survival. Given the uncertainty of applying the results of the SAMMPRIS trial to LVOs, further research is needed to better assess the efficacy and safety of PTAS in this patient population.

Risk factors associated with progression from papilloedema to optic atrophy: results from a cohort of 113 patients

BackgroundThe aim of this study was to assess the risk factors for atrophic progression of patients with papilloedema secondary to intracranial hypertension, using optical coherence tomography parameters.MethodsA retrospective study was...

Measuring Emergency Department Staff Perceptions of Causes and Management of Violence.

Half of all reported violent incidents in health care settings occur in the emergency department (ED) placing all staff members at risk. However, research typically does not include all ED work groups or validated measures beyond nurses and physicians. The aims of this study were to (a) validate an established instrument measuring perceptions of causes of violence and attitudes toward managing violence within an inclusive workforce sample; and (b) explore variation in perceptions, attitudes, and incidence of violence and safety to inform a violence prevention program. This is an investigator-initiated single-site cross-sectional survey design assessing the psychometric properties of the Management of Aggression and Violence Attitude Scale (MAVAS) within a convenience sample (n = 134). Construct validity was assessed using exploratory factor analysis and reliability was evaluated by the Cronbach's α estimation. Descriptive, correlational, and inferential estimates explored differences in perceptions, attitudes, and incidence of violence and safety. Exploratory factor analysis indicated validity of the MAVAS with a seven-factor model. Its internal consistency was satisfactory overall (Cronbach's α= 0.87) and across all subscales (Cronbach's α values = 0.52-0.80). Significant variation in incidence of physical assault, perceptions of safety, and causes of violence was found between work groups. The MAVAS is a valid and reliable tool to measure ED staff members' perceptions of causes of violence and attitudes toward managing violence. In addition, it can inform training according to differences in work group learner needs.

Asset Volatility and Financial Sustainability

This study observes how companies’ fundamental-based asset volatility impacts their financial sustainability. Accounting literature documents that net assets value accumulates previous earnings management. The asset balance change reflects biased earnings measurement, and abnormal asset fluctuation signals aggressive earnings management. This paper uses delisting as a proxy to observe how asset volatility can interact with abnormal earnings fluctuation to impact firms’ sustainability. The study uses two groups of regression and a Principal Component Analysis (PCA) Logistic Regression approach to observe how asset volatility impacts companies’ delisting risk. It borrows the Six Sigma methodologies to measure the volatility of financial statement items. Then the PCA analysis reduces the data dimensions to twelve factors. The analysis shows that assets’ abnormal fluctuation is a risk signal concurring with the extant earnings management literature. One takeaway from this study is that companies must disclose detailed explanations if asset volatility is beyond a red line. As Statement of Financial Accounting Standards (SFAS) 151 requires direct disclosure of abnormal excess capacity costs, companies must disclose abnormal asset volatility. The paper contributes to the literature from two perspectives. First, this paper captures firms’ sustainability from the accounting perspective with fundamental measures from quarterly financial reports. It provides a comprehensive way to detect aggressive earnings management risks. Second, the PCA logistic regression model offers a comprehensive analysis to derive useful information from many attributes.

The Role of Lipid-Lowering Therapy in Post-Stroke Patients: Update and Recommendations.

Stroke is the second leading cause of death and disability-adjusted life years worldwide, and the global lifetime risk of stroke is rising. Moreover, patients with a prior stroke are at high risk of recurrent events. We aimed at reviewing the evidence supporting aggressive secondary prevention strategies for lipid-lowering treatment in this population. Statins are the key players in such aggressive management; however, stroke survivors remain at significant residual risk suggesting the need for both better implementation of statin use as well as additional lipid lowering therapies. Newer drugs have become available and represent important tools in the management of patients with prior ischemic stroke. The role of lipid lowering treatment in hemorrhagic stroke is more controversial, given epidemiological data linking low lipid levels with increased risk of first and recurrent events. Aggressive secondary prevention strategies, including lipid lowering treatments, have proven to mitigate the risk of recurrent events in post-stroke patients. The tools available for treating such high-risk population have expanded beyond statins, and clinicians should familiarize themselves with them.

Legal Study of Anti-Monopoly Activities and Fair Business Competition in the Business World

The goal of this study is The purpose of this writing is to learn about the law of fair business competition, as well as to understand the legal rules against monopoly activities and unfair business competition in the business world, while the benefits that can be obtained from the results of this research are beneficial for practitioners of law, particularly in the legal regulation of business competition in companies, and can be used as study material for legal arrangements in the event of monopoly activities and unfair business competition. The author defines the issue as follows: What is the objective of fair business competition legislation, and what are the legal regulations in the business sector against monopolistic activities and unfair business competition? The study's findings indicate that in the business world, business rivalry is unavoidable; in order for products and businesses to exist, organizations must fight to gain the market. Business rivalry is an unavoidable need at this time, owing to the rising number of firms that have been founded and the more aggressive management of corporations in marketing their products to the market in order to increase profits. The goal of business competition law is to ensure that an economy is based on business competition, with the assumption that through fair business competition, producers will strive to achieve consumer satisfaction through quality products, low prices, and the use of the fewest production resources possible.

Two pediatric observations of spinal extradural arteriovenous fistulas presenting with epidural hemorrhages and cord compression.

We report two cases of acute spinal cord compression in children with low-flow spinal epidural arteriovenous fistulas (SEAVFs) and discuss the clinical presentation and management of these vascular anomalies. While most low-flow SEAVFs without radiculomedullary drainage are benign lesions typically diagnosed incidentally, we suggest that asymptomatic lesions may warrant aggressive management in specific circumstances, including lesions diagnosed at an early age or in patients under anticoagulation therapy. Our observations also emphasize that patients with a "spontaneous" epidural hemorrhage should undergo dedicated preoperative or postoperative vascular imaging to identify a possible underlying vascular anomaly.

Femur Fractures in 5 Individuals With Pantothenate Kinase-associated Neurodegeneration: The Role of Dystonia and Suggested Management.

Pantothenate kinase-associated neurodegeneration (PKAN) is a rare, neurodegenerative disorder that manifests with progressive loss of ambulation and refractory dystonia, especially in the early-onset classic form. This leads to osteopenia and stress on long bones, which pose an increased risk of atraumatic femur fractures. The purpose of this study is to describe the unique challenges in managing femur fractures in PKAN and the effect of disease manifestations on surgical outcomes. A retrospective case review was conducted on 5 patients (ages 10 to 20y) with PKAN with a femur fracture requiring surgical intervention. Data regarding initial presentation, surgical treatment, complications, and outcomes were obtained. All patients were non-ambulatory, with 4 of 5 patients sustaining an atraumatic femur fracture in the setting of dystonia episode. One patient had an additional contralateral acetabular fracture. Postoperatively, 4 of the 5 patients sustained orthopaedic complications requiring surgical revision, with 3 of these secondary to dystonia. Overall, 4 required prolonged hospitalization in the setting of refractory dystonia. Femur fractures in PKAN present distinct challenges for successful outcomes. A rigid intramedullary rod with proximal and distal interlocking screws is most protective against surgical complications associated with refractory dystonia occurring during the postoperative period. Multidisciplinary planning for postoperative care is essential and may include aggressive sedation and pain management to decrease the risk of subsequent injuries or complications. Level IV.

Prevalence and Determinants of Endothelial Dysfunction among Adults Living with HIV in Northwest Nigeria.

Endothelial dysfunction constitutes an early pathophysiological event in atherogenesis and cardiovascular disease. This study aimed to assess the prevalence, determinants, and degree of endothelial dysfunction in antiretroviral therapy (ART)-treated people living with HIV (PLWH) in northwestern Nigeria using brachial flow-mediated dilatation (FMD). This was a comparative, cross-sectional study. A total of 200 ART-treated adults living with HIV with no evidence of kidney disease were compared with 200 HIV-negative participants attending a tertiary hospital in Kano, Nigeria, between September 2020 and May 2021. Endothelial function was evaluated by measuring FMD with a high-resolution vascular ultrasound transducer. FMD was calculated as the ratio of the brachial artery diameter after reactive hyperemia to baseline diameter and expressed as a percentage of change. Blood and urine samples were obtained from participants in both arms. Urine albumin-to-creatinine ratio (uACR) was calculated using the 2021 CKD-EPI estimated glomerular filtration rate (eGFR) creatinine-cystatin C equation without the race variable, and low-density lipoprotein (LDL) cholesterol was measured using enzymatic method. The overall mean age (± standard deviation) of the study participants was 42 ± 11 years. Participants in the comparison arm were younger than PLWH (38 ± 11 versus 46 ± 10 years, respectively). The median (interquartile range) uACR was 41.6 (23.2-162.9) mg/g for the ART-treated PLWH versus 14.5 (7.4-27.0) mg/g for healthy controls. PLWH had a significantly lower mean percent FMD when compared to HIV-negative participants (9.8% ± 5.4 versus 12.1% ± 9.2, respectively). Reduced FMD was independently associated with HIV infection (β = -2.83%, 95% CI, -4.44% to -1.21%, p = 0.001), estimated glomerular filtration rate (β = -0.04%, 95% CI, -0.07% to -0.01%, p = 0.004) and LDL cholesterol (β = -1.12%, 95% CI, -2.13% to -0.11%, p = 0.029). HIV-positive status, lower estimated GFR, and higher LDL cholesterol levels were independently associated with endothelial dysfunction. Future prospective studies with larger cohorts of persons living with HIV (and age- and sex-matched HIV-negative controls) are needed to gain further insight into these important findings. In the interim, aggressive management of modifiable risk factors is warranted.

Prognosis and Treatment Outcomes of Bone Metastasis in Gallbladder Adenocarcinoma: A SEER-Based Study.

Gallbladder carcinoma (GBC) is a rare, aggressive malignancy comprising 0.5% of gastrointestinal cancers. It has poor survival outcomes due to its insidious onset, lack of standardized screening, and limited therapies. Advanced-stage diagnosis with liver, lymph node, and peritoneal metastasis is common, while bone metastasis is rare. The knowledge on bone metastasis in GBC is limited to case reports and small series, and its clinical significance is largely unexplored. The study extracted the demographic and clinical variables of patients with metastatic (M1) gallbladder adenocarcinoma from the Surveillance, Epidemiology, and End Results (SEER) database between 2011 and 2020. Descriptive statistics were used to analyze the demographic characteristics. The multivariate Cox regression analysis was used to calculate the hazard ratio. The overall survival (OS) was assessed using the Kaplan-Meier method, and the log-rank test was utilized to compare the survival between the groups. A total of 2724 patients were included in the study. A total of 69% of the patients were female, and the median age was 68 (range 24-90+). A total of 7.4% of the patients had bone metastasis on diagnosis. The multivariate Cox analysis identified bone metastasis as an independent mortality risk factor in metastatic GBC (HR 1.50, p < 0.001). The patients were divided into two age groups: a younger age group (18-74 years) and an older age group (75+ years). In the younger group, the median OS with and without bone metastasis was 3 and 5 months, respectively (p < 0.0001). In the older age group, there was no significant difference in the OS between the patients with and without bone metastasis (p = 0.35). In the younger group who were treated with chemotherapy, the patients with bone metastasis had a significantly worse OS (median OS 5 months vs. 8 months, p < 0.0001). In the untreated group, the patients with bone metastasis in the younger age group had a significantly worse OS (median OS 1 month vs. 2 months, p = 0.014). In the patients with bone metastasis, those who did not receive chemotherapy had a significantly worse OS than those who were treated with chemotherapy in both age groups (younger age group: median OS 1 month vs. 5 months, p < 0.0001 and older age group: median OS 1 month vs. 5 months, p = 0.041). Our findings suggest that the presence of bone metastasis in gallbladder adenocarcinoma is an independent prognostic factor associated with unfavorable survival outcomes in the younger age group (18-74 years). However, in the older age group (75+ years), the presence of bone metastasis did not impact the survival. Treatment with chemotherapy was associated with extended survival in all patients. Thus, early detection and aggressive management of bone metastasis, including the consideration of chemotherapy, may be crucial in improving the OS and quality of life for individuals with gallbladder adenocarcinoma.

Exploring Growth Failure in Neonates With Enterostomy

Aim of the studyNeonatal enterostomy is a known risk for growth failure. We hypothesized that episodes of inflammation may drive a catabolic state, exploring this by assessing serum biochemistry alongside growth trajectory in enterostomy patients. MethodsA retrospective analysis of infants with histologically confirmed NEC from 01/2012–07/2021 in a tertiary neonatal surgical centre was performed. Change in weight-for-age Z-score (ΔZ) between stoma formation and closure was calculated. Serum CRP (C-reactive protein), urea, and creatinine levels were recorded and duration of elevated levels calculated as Area Under Curve (AUC). We examined for trends of serum levels rising together using intersecting moving averages. Spearman's correlation analysis was performed, while multivariable linear regression examined factors associated with ΔZ. Results79 neonates were included. At stoma formation, median Z-score was −1.42 [range −4.73, +1.3]. Sixty-two patients (78 %) had a fall in Z-score during their time with a stoma, 16 (20 %) had a ΔZ less than −2. Urea AUC was significantly univariably correlated with ΔZ and remained statistically significant in a multivariable model (Exp(B) x 100 = −0.57[−1, −0.09]; p = 0.022). The number of biomarker peaks correlated significantly with ΔZ for urea (r = −0.25; p = 0.025) and CRP (r = −0.35; p = 0.0017) but not Creatinine (r = −0.21; p = 0.066). Analysing the number of peaks of any combination of variables coinciding was consistently significantly correlated negatively with ΔZ (r = −0.29 to −0.27; p ≤ 0.016 for all). ConclusionOur data shows that infants who were more severely affected by growth failure had more frequent and severe uremia while they had a stoma (suggesting a catabolic state). Disturbances in urea were commonly associated with CRP, suggesting that inflammation is a significant factor in growth failure in these infants. These findings promote aggressive management of sepsis in these infants, as well as suggesting an earlier closure of stoma to minimise their “at-risk”’ period.

Role of aggressive locoregional surgery in treatment strategies for ipsilateral supraclavicular lymph node metastasis of breast cancer: a real-world cohort study.

Background: Breast cancer patients with synchronous ipsilateral supraclavicular lymph node metastases (ISLNM) have unfavorable prognoses. The role of supraclavicular lymph node dissection (SLND) as a surgical intervention in the treatment of this condition remains controversial. In this study, we aimed to evaluate the prognostic factors associated with breast cancer with ISLNM and to assess the potential impact of aggressive locoregional surgical management on patient outcomes. Methods: We conducted a retrospective analysis of 250 breast cancer patients with ISLNM who were treated with curative intent at our institution between 2000 and 2020. The cohort was stratified into groups based on the extent of axillary surgery. The first group, comprising 185 patients, underwent level I/II axillary dissection. The second group, consisting of 65 patients, underwent aggressive locoregional surgery, including levels I/II/III (infraclavicular) dissection in 37 patients and levels I/II/III + SLND in 28 patients. Our study evaluated overall survival (OS) and disease-free survival (DFS) as primary endpoints, and locoregional recurrence-free survival (LRRFS) and distant metastasis-free survival (DMFS) as secondary endpoints. Results: The median follow-up time among all patients was 5.92years (1.05-15.36years). The 5-year OS rate was 71.89%, while the DFS rate, LRRFS rate, and DMFS rates were 59.25%, 66.38%, and 64.98%, respectively. A significant difference in OS, DFS, LRRFS, and DMFS was observed between the second group and the first group (p < 0.01). No beneficial impact on recurrence, metastasis, or survival outcomes was observed in the levels I/II/III + SLND group compared to the levels I/II/III dissection group. Multivariate logistic regression analysis revealed that levels I/II/III ± SLND surgery and T stage were associated with OS (p = 0.006 and p = 0.026), while levels I/II/III ± SLND surgery, ER+/HER2-, and histologic grade were associated with DFS (p = 0.032, p = 0.001, p = 0.032). Conclusion: Breast cancer with ISLNM may be considered a locoregional disease, requiring a combination of systemic and local therapies. Aggressive locoregional surgery has been shown to positively impact recurrence, metastasis, and survival outcomes. This approach may provide improved management of the ISLNM for breast cancer patients.

Does Aggressive Intraoperative Thermal Management Improve Outcome?

Does Aggressive Intraoperative Thermal Management Improve Outcome?