Clinical Categories Research Articles

Prosigna Assay for Treatment Decisions in Early Breast Cancer: A Decision Impact Study.

Introduction: Therapeutic decisions in early breast cancer are based on clinico-pathological features which are subject to intra- and inter-observer variability. This single-center decision impact study aimed to evaluate the effects of the Prosigna assay on physicians' adjuvant treatment choices. Methods: Between 09/2017 and 02/2018, formalin-fixed tumor samples from 52 newly diagnosed, postmenopausal, hormone receptor-positive, HER2-negative breast cancer (T1-T2; pN0-N1a) patients were analyzed. Pre-test clinical judgements and Prosigna test results were compared. Results: The mean age was 59 (42-77). Invasive ductal carcinoma (79.2%), grade 2 (52.8%) and T1c-N0 tumors (43.4%) were represented. There was 40.4% discordance between the pre- and post-test risk of recurrences. No significant change was observed in the clinical intermediate risk category, while there was a net reclassification of low-risk patients into a high Prosigna recurrence risk group. In addition, clinically determined intrinsic subtypes were 34.6% discordant with the Prosigna results, which is largely driven by the reclassification of the luminal A tumors into the Prosigna-assessed luminal B group. Before the Prosigna test, endocrine treatment was the primary choice in 20 patients (39.2%), and chemotherapy was recommended to 31 patients (60.8%). Overall, the Prosigna assay led to a change in treatment choice for one patient. Conclusions: Although conventional risk assessment methods are relatively inexpensive with shorter turnaround times, their accuracy and value for risk reduction are suboptimal. According to our results, the Prosigna assay was found to be a relevant tool for the clinical decision making process. Long-term follow-up of these patients will elucidate the potential benefits of using multigene molecular tests as biomarkers for treatment.

Transdiagnostic depression severity and its relationship to global and prefrontal-amygdala structural properties in people with major depression and post-traumatic stress disorder.

While some studies have used a transdiagnostic approach to relate depression to metabolic or functional brain alterations, the structural substrate of depression across clinical diagnostic categories is underexplored. In a cross-sectional study of 52 patients with major depressive disorder and 51 with post-traumatic stress disorder, drug-naïve, and spanning mild to severe depression severity, we examined transdiagnostic depressive correlates with regional gray matter volume and the topological properties of gray matter-based networks. Locally, transdiagnostic depression severity correlated positively with gray matter volume in the right middle frontal gyrus and negatively with nodal topological properties of gray matter-based networks in the right amygdala. Globally, transdiagnostic depression severity correlated positively with normalized characteristic path length, a measure implying brain integration ability. Compared with 62 healthy control participants, both major depressive disorder and post-traumatic stress disorder patients showed altered nodal properties in regions of the fronto-limbic-striatal circuit, and global topological organization in major depressive disorder in particular was characterized by decreased integration and segregation. These findings provide evidence for a gray matter-based structural substrate underpinning depression, with the prefrontal-amygdala circuit a potential predictive marker for depressive symptoms across clinical diagnostic categories.

Postural stability after operative reconstruction of the AFTL in chronic ankle instability comparing three different surgical techniques.

Chronic lateral ankle instability is a relatively frequent consequence after acute ankle sprain. In case of unsuccessful conservative treatment, surgical therapy is recommended to prevent osteoarthritis of the ankle joint. To date, different surgical methods have evolved. Yet, it remains unclear which approach reveals the best results. We hypothesized that the modified Broström-Gould procedure with suture anchor ligament fixation leads to superior postoperative results compared to the Broström-Gould procedure or the periosteal flap technique. In a prospective study, we examined the three surgical techniques. For this purpose, we performed a matched-pair analysis with four groups according to age, sex, and body mass index: periosteal flap technique (G1), Broström-Gould procedure (G2), modified Broström-Gould procedure with suture anchor ligament fixation (G3), and a control group (G4). Results were compared with the American Orthopaedic Foot & Ankle Society (AOFAS) score, a functional analysis as well as measuring postural stability with the Biodex balance system. No significant differences were found between all four groups concerning AOFAS score, functional results, as well as postural stability. All three surgical methods revealed satisfactory results. No significant differences could be detected in clinical and functional categories. The Broström-Gould method as well as the modified procedure with anchor can be recommended as surgical therapy for chronic lateral ankle instability. Additional anchors do not seem to have a significant positive impact on the results.

Oncological outcomes after radical prostatectomy of localized prostate cancer: stratified by magnetic resonance imaging and risk classification

BackgroundWe investigated whether combining T2-weighted magnetic resonance imaging (MRI) findings and clinical risk categories improves upon established prognostic indicators of oncological outcomes in prostate cancer. MethodsPatients who underwent radical prostatectomy, but not preoperative hormone therapy, radiotherapy, or chemotherapy, for localized prostate cancer at Seoul National University Bundang Hospital from October 2007 to April 2016 were included. MRIs were classified according to the Prostate Imaging-Reporting and Data System (PI-RADS). Patients were divided into the following five groups: 1, no focal suspicious lesion; 2, organ-confined suspicious lesion PI-RADS ≤3; 3, organ-confined suspicious lesion PI-RADS 4 or 5; 4, suspicious lesion with extraprostatic extension (EPE), no seminal vesicle invasion (SVI); 5, suspicious lesion with EPE and SVI. Risk classified according to the National Comprehensive Cancer Network (NCCN) and MRI findings were combined to analyze survival curves for biochemical recurrence (BCR)-free and metastasis-free survival. The area under a time-dependent receiver operating characteristic was analyzed for event prediction after 5 years. ResultsWe analyzed 1,290 patients. In multivariate Cox regression models, PI-RADS ≥4 (hazard ratio [HR] 2.33, P < 0.001), EPE (HR 1.46, P = 0.027), SVI (HR 5.03, P < 0.001) and NCCN high-risk (HR 2.33, 95% CI 1.66-3.26, P < 0.001) were associated with BCR. For metastasis, EPE (HR 2.33, P = 0.047), SVI (HR 13.08, P < 0.001) and NCCN high-risk (HR 2.78, P = 0.026) were independent risk factors. Depending on MRI group, BCR-free survival significantly decreased in NCCN intermediate-risk (P = 0.001) and high-risk (P < 0.001) groups, and metastasis-free survival decreased in the intermediate-risk group (P = 0.39) and significantly decreased in the high-risk (P < 0.001) group. Adding MRI group to NCCN risk classification significantly improved the predictive accuracy for BCR in comparison with NCCN risk classification alone (P = 0.042), but not for metastasis (P = 0.012). ConclusionCombining prostate MRI with NCCN risk classification improves the prediction value of BCR following radical prostatectomy for localized prostate cancer.

Clinical and pathological characterization of tebentafusp-associated skin toxicity: A cohort study with 33 patients

BackgroundTebentafusp is a novel treatment for patients with metastatic uveal melanoma and often causes cutaneous side effects. ObjectivesThe aim of this study was to better characterize these heterogenous cutaneous side effects. MethodsThis prospective cohort study evaluated all patients from a tertiary hospital center who were treated with tebentafusp between January 2019 and June 2023 clinically and assessed skin biopsies histologically. ResultsIn total, 33 patients were analysed. Skin toxicity was observed in 78.8% of patients and was classified in five clinical categories: 1) symmetrical erythematous patches (83.8%), 2) hemorrhagic macules (11.8%), 3) urticarial lesions (7.4%), 4) bullous lesions (1.5%) and 5) skin (8.5%) and hair depigmentation (11.4%). Histopathologic features were focal lymphocytic interface dermatitis with epidermal infiltration of CD8-positive lymphocytes. Patients with skin reactions had a significantly longer median overall survival compared to patients without any cutaneous events (34 versus 4 months, p<0.001). LimitationMonocentric study with a limited number of patients. ConclusionTebentafusp frequently induced cutaneous reactions. Pathogenesis is likely due to binding of tebentafusp to stimulated melanocytes in the skin followed by infiltration and activation of lymphocytes. Development of treatment induced skin reactions may be associated with survival benefit.

Association of pathogenic determinants of Fusobacterium necrophorum with bacteremia, and Lemierre’s syndrome

Fusobacterium necrophorum is a Gram-negative anaerobic bacterium responsible for localized infections of the oropharynx that can evolve into bacteremia and/or septic thrombophlebitis of the jugular vein or peritonsillar vein, called Lemierre’s syndrome. To identify microbial genetic determinants associated with the severity of this life-threatening disease, 70 F. necrophorum strains were collected and grouped into two categories according to the clinical presentation: (i) localized infection, (ii) bacteremia with/without Lemierre’s syndrome. Comparative genomic analyses revealed two clades with distinct genetic content, one clade being significantly enriched with isolates from subjects with bacteremia. To identify genetic determinants contributing to F. necrophorum pathogenicity, genomic islands and virulence factor orthogroups (OVFs) were predicted. The presence/absence profiles of OVFs did not group isolates according to their clinical category, but rather according to their phylogeny. However, a variant of lktA, a key virulence factor, with a frameshift deletion that results in two open reading frames, was associated with bacteremia. Moreover, a genome-wide association study identified three orthogroups associated with bacteremic strains: (i) cas8a1, (ii) a sodium/solute symporter, and (iii) a POP1 domain-containing protein. Further studies must be performed to assess the functional impact of lktA mutation and of these orthogroups on the physiopathological mechanisms of F. necrophorum infections.

Diagnostic value of CEUS combined with C-TIRADS for indeterminate FNA cytological thyroid nodules.

To investigate the diagnostic value of CEUS combined with C-TIRADS for indeterminate FNA cytological thyroid nodules. The clinical data, ultrasonic images, C-TIRADS categories and CEUS images of 192 patients with indeterminate FNA cytological thyroid nodules confirmed by the surgical pathology were analyzed retrospectively. The diagnostic efficacy of CEUS, C-TIRADS and CEUS-TIRADS were calculated. The AUCs of CEUS, C-TIRADS and CEUS-TIRADS were 0.905 (95% CI: 0.862∼0.949), 0.881 (95% CI: 0.825∼0.938) and 0.954 (95% CI: 0.922∼0.986), respectively. The sensitivity, specificity, PPV, NPV, accuracy, LR- and LR+ were 84.7% (116/137), 85.5% (47/55), 93.5% (116/124), 69.1% (47/68), 84.9% (163/192), 0.179, 5.82 and 84.7% (116/137), 83.6% (46/55), 92.8% (116/125), 68.7% (46/67), 84.4% (162/192), 0.183, 5.17, 92.7% (127/137), 89.1% (49/55), 95.5% (127/133), 83.1% (49/59), 91.7% (176/192), 0.082, and 8.50, respectively. Compared with CEUS and C-TIRADS, CEUS-TIRADS had improved the AUC, sensitivity and accuracy (all P < 0.05). CEUS and C-TIRADS had high diagnostic values in indeterminate FNA cytological thyroid nodules. CEUS-TIRADS improved AUC, diagnostic sensitivity and accuracy, and helped to distinguish indeterminate FNA cytological nodules.

Exome sequencing reveals neurodevelopmental genes in simplex consanguineous Iranian families with syndromic autism

Background and objectiveAutosomal recessive genetic disorders pose significant health challenges in regions where consanguineous marriages are prevalent. The utilization of exome sequencing as a frequently employed methodology has enabled a clear delineation of diagnostic efficacy and mode of inheritance within multiplex consanguineous families. However, these aspects remain less elucidated within simplex families.MethodsIn this study involving 12 unrelated simplex Iranian families presenting syndromic autism, we conducted singleton exome sequencing. The identified genetic variants were validated using Sanger sequencing, and for the missense variants in FOXG1 and DMD, 3D protein structure modeling was carried out to substantiate their pathogenicity. To examine the expression patterns of the candidate genes in the fetal brain, adult brain, and muscle, RT-qPCR was employed.ResultsIn four families, we detected an autosomal dominant gene (FOXG1), an autosomal recessive gene (CHKB), and two X-linked autism genes (IQSEC2 and DMD), indicating diverse inheritance patterns. In the remaining eight families, we were unable to identify any disease-associated genes. As a result, our variant detection rate stood at 33.3% (4/12), surpassing rates reported in similar studies of smaller cohorts. Among the four newly identified coding variants, three are de novo (heterozygous variant p.Trp546Ter in IQSEC2, heterozygous variant p.Ala188Glu in FOXG1, and hemizygous variant p.Leu211Met in DMD), while the homozygous variant p.Glu128Ter in CHKB was inherited from both healthy heterozygous parents. 3D protein structure modeling was carried out for the missense variants in FOXG1 and DMD, which predicted steric hindrance and spatial inhibition, respectively, supporting the pathogenicity of these human mutants. Additionally, the nonsense variant in CHKB is anticipated to influence its dimerization – crucial for choline kinase function – and the nonsense variant in IQSEC2 is predicted to eliminate three functional domains. Consequently, these distinct variants found in four unrelated individuals with autism are likely indicative of loss-of-function mutations.ConclusionsIn our two syndromic autism families, we discovered variants in two muscular dystrophy genes, DMD and CHKB. Given that DMD and CHKB are recognized for their participation in the non-cognitive manifestations of muscular dystrophy, it indicates that some genes transcend the boundary of apparently unrelated clinical categories, thereby establishing a novel connection between ASD and muscular dystrophy. Our findings also shed light on the complex inheritance patterns observed in Iranian consanguineous simplex families and emphasize the connection between autism spectrum disorder and muscular dystrophy. This underscores a likely genetic convergence between neurodevelopmental and neuromuscular disorders.

Resting energy expenditure in women with polycystic ovary syndrome.

Is resting energy expenditure (REE) altered in women with polycystic ovary syndrome (PCOS)? Women with PCOS have a reduction in REE, when corrected for fat-free mass, independent of PCOS clinical phenotypes and BMI categories. Obesity is an important issue in women with PCOS, in terms of frequency and pathophysiological implications. It has been hypothesized that obesity may be favoured by alterations in REE, but the studies have been limited and conflicting. This case-control study was a comparison of 266 women with PCOS and 51 healthy controls, recruited in the Verona 3P study from 2010 to 2021. Women with PCOS diagnosed by the Rotterdam criteria, with normal thyroid function and no interfering medications, were referred to the outpatient clinic of a tertiary care centre of endocrinology and metabolism for a measurement of REE. Healthy controls were recruited in the same period and submitted to the same procedure. In all subjects, REE was measured by indirect calorimetry and serum androgens were measured by LC-MS/MS. In women with PCOS, insulin sensitivity was assessed using the hyperinsulinemic-euglycemic clamp. REE was similar in women with PCOS and controls. However, REE corrected for fat-free mass (REE/FFM) was significantly lower in women with PCOS than in controls (31.8 ± 4.0 vs 35.4 ± 3.9kcal/kgFFM·day, P < 0.001). REE/FFM did not differ between normal-weight, overweight, or obese women with PCOS, and each of these subgroups showed lower REE/FFM values than controls. Reduced REE/FFM values were found in each phenotype of the syndrome. In multiple regression analysis, REE/FFM was independently associated with age and PCOS status, but not with fat mass. In PCOS women, REE/FFM was independently and directly associated with ovarian follicle number. Limitations of the study are the cross-sectional design, which limits the causal inference of the results, and the unavailability of precise information about lifestyle factors, which may be potential confounders. Further prospective studies are needed to establish the importance of this phenomenon in contributing to the weight excess of PCOS. A reduction of REE could potentially favour weight gain in women with PCOS and possibly contribute to the altered metabolic profile typical of this condition, even counteracting the therapeutic strategies aimed to reduce excess body fat in these women. Nevertheless, the presence of this abnormality in both obese/overweight and normal-weight patients suggests that other factors must play a role in this phenomenon. This work was supported by academic grants to PM from the University of Verona (FUR 2010-2022). All authors declare no conflict of interest. N/A.

Evaluating local open-source large language models for data extraction from unstructured reports on mechanical thrombectomy in patients with ischemic stroke

BackgroundA study was undertaken to assess the effectiveness of open-source large language models (LLMs) in extracting clinical data from unstructured mechanical thrombectomy reports in patients with ischemic stroke caused by...

Correlation between Biomarkers and Severity of Clinical Categories in COVID-19 Patients: A Hospital-Based Study in Arunachal Pradesh, India

Background: The COVID-19 pandemic has brought about widespread effects on communities on a global scale, with impacts varying among different demographics. This study focuses on a unique cohort of COVID-19-positive patients from Arunachal Pradesh, a region in northeast India with a substantial indigenous population. This study aims to delve into the features and consequences of COVID-19 in this indigenous population within this distinct demographic region, with a special focus on assessing the effects on tribal communities. Out of a total of 1627 COVID-19 positive cases, 1392 belonged to various tribes of Arunachal Pradesh, categorized as the indigenous population of the region. Our research primarily focuses on examining the biochemical and inflammatory indicators that forecast the clinical results of COVID-19 patients, specifically within both indigenous and non-indigenous groups. Methods: Biochemical markers, including hematological parameters, liver and kidney function biomarkers, D-DIMER, and inflammatory markers, were assessed along with immune-inflammatory ratios: neutrophil-to-lymphocyte ratio (NLR) and lymphocyte-to-monocyte ratio (LMR). Differences in biomarker levels and ratios across disease severities were analyzed, and significant data were observed using descriptive statistics. Results: Elevated levels of Ferritin (CRP, IL-6, D-DIMER, Creatinine, Urea, AST/SGOT, and ALT/SGPT) were associated with increasing disease severity in COVID-19 cases, reflecting increased inflammation, multi-organ dysfunction, and coagulopathy in the severe COVID-19 category amongst the indigenous population. The data showed an aligned report with the non-indigenous population of India when compared with various other studies (using a Spearman rank correlation test). Similarly, an increase in the neutrophil-to-lymphocyte ratio (NLR) and a declining shift in the lymphocyte-to-monocyte ratio (LMR) indicated deregulated immune responses and systemic inflammation in the severe category of COVID-19. Conclusion: This population-based study from northeast India offers important perspectives into the pathophysiology of COVID-19 and its link with disease severity among indigenous and non-indigenous populations.

The extent of interruptions to primary care medical officers' consultations in the Western Cape.

Administrative tasks are an increasing burden for primary care doctors globally and linked to burnout. Many tasks occur during consultations. They cause interruptions with possible effects on patients' and doctors' experiences and care. The burden and typology of interruptions of doctors in primary care consultations have not been studied in South Africa. Given the link between administrative loads and burnout, describing the extent of these interruptions would help. This study's aim was to assess the extent of interruptions on primary care doctors in the Western Cape. This was a descriptive cross-sectional survey. Doctors from rural and urban primary care clinics in the Western Cape answered an online self-administered survey on the types of interruptions experienced during consultations. Interruptions were categorised and their prevalence calculated. Clinical and non-clinical interruption categories were compared. There were 201 consultations from 30 doctors. Most interruptions were from retrieving and recording the current patient's information (93.0%), paperwork for other patients (50.7%), and telephone calls about the current patient (41.8%). Other prevalent interruptions were for emergencies (39.8%) and acquiring consumables (37.3%). The median (interquartile range [IQR]) of four (2-4) interruption types per consultation was higher than global settings. Doctors experienced many interruptions during consultations. Their wide range included interruptions unrelated to the current patient.Contribution:This study adds insights from the global south on clinicians' administrative burden. It elaborates on the types of activities that interrupt consultations in an upper-middle income primary care setting. Exploration of interventions to decrease this burden is suggested.

Sleep and neuroimmunology: a narrative review.

Numerous neuroimmunological disorders present with sleep-related symptoms. The identification of novel autoantibodies introduces new clinical categories in autoimmune diseases of the central nervous system and generates interest in the dynamic interaction between sleep and the immune system. In this review, the complex relationship among sleep, immune regulation, and neuroimmunological disorders was examined with emphasis on the vital role of sleep in modulating immune function and its influence on these conditions, This relationship emphasizes the importance of assessments and management of sleep quality in the treatment approaches for neuroimmunological disorders.

Assessment of Quality of Life in Patients With End-Stage Kidney Disease on Maintenance Hemodialysis Using the Missoula-Vitas Quality of Life Index.

This study aimed to evaluate the quality of life (QoL) in end-stage kidney disease (ESRD) patients on maintenance hemodialysis through the Missoula-Vitas Quality of Life Index-15 (MVQOLI-15) to identify factors affecting their well-being. A cross-sectional study was conducted at the Dialysis Unit of the Nephrology Department, Nishtar Hospital Multan. Over six months, 140 eligible patients were enrolled using non-probability consecutive sampling. Participants aged 18-80 yearson maintenance hemodialysis for at least six monthswere evaluated using the MVQOLI-15questionnaire assessing symptoms, function, interpersonal, well-being, and transcendence dimensions of QoL. Data were analyzed using theIBM SPSS Statistics for Windows, Version 26 (Released 2019; IBM Corp., Armonk, New York). Inferential statistical tests, including the t-test for comparing two groups and analysis of variance (ANOVA) for comparing multiple groups, were utilized to determine the significance of differences in QoL scores among different demographic and clinical categories. P-values less than 0.05 were considered statistically significant. The study analyzed 140 hemodialysis patients, with a mean age of 52.41 ± 16.31 years and an average hemodialysis duration of 4.55 ± 2.46 years. Most participants were aged 61-80 years (35.7%), had secondary education (44.3%), and were married (67.1%). QoLscores, measured using the MVQOLI, indicated mean values for symptoms at 4.51 ± 10.71, function at 5.77 ± 8.04, interpersonal at 7.49 ± 13.67, well-being at -13.60 ± 7.11, transcendence at 8.24 ± 13.12, and a total score of 16.24 ± 2.75. Significant findings include the following: females had higher symptomscores (p=0.001) and lower well-being scores (p=0.000); younger patients (<30 years) had higher function scores (p=0.054); patients on hemodialysis three times per week had higher function scores (p=0.006); patients taking 1 to 3 pills per day had higher transcendence scores (p=0.000); unmarried patients had higher symptoms scores (p=0.064) and lower well-being scores (p=0.004); and illiterate patients had higher symptoms (p=0.005) and transcendence scores (p=0.034). In total score, patients on hemodialysis once per week reported significantly better scores (p=0.011). This study highlights varied QoL experiences among hemodialysis patients, with transcendence scoring the highest and well-being, the lowest. Demographic factors such as age, gender, and education level significantly impact the QoL dimensions. Understanding these findings can guide personalized interventions to improve the well-being of hemodialysis patients.

The Diagnostic Value of Serum Amyloid A and Other Laboratory and Clinical Variables in Cats with Increased Liver Enzyme Activity.

Distinguishing inflammatory from non-inflammatory liver disease in cats may impact management. The study aim was to evaluate if certain diagnostic variables, including Serum Amyloid A (SAA), differ (1) between various clinical disease categories (Primary liver disease, Extrahepatic, Trauma and Inconclusive) and (2) between cytological findings of severe hepatic lipidosis and other cytological findings in cats with increased liver enzymes. Medical records from 5042 cats, where SAA had been measured, were reviewed, and 566 cats fulfilled inclusion criteria consisting of increased liver enzymes and available biochemical panel results. SAA was higher in cats diagnosed with trauma compared to other diseases (p = 0.008). Cytology results were available in 85 cats, and cats with severe lipidosis had lower serum SAA concentration (p < 0.0001) and were younger (p < 0.0002) compared to cats with other cytological findings. The study shows that SAA was higher in cats diagnosed with trauma compared to cats with other causes of increased liver enzymes and that SAA may be useful to distinguish cats with cytologic evidence of hepatic lipidosis from cats with other liver pathologies. Serum Amyloid A may be a valuable complement to liver cytology when investigating cats with increased liver enzymes.

A Comparison of Variable Input Strategies used for Risk-adjustment Models of Antimicrobial Use

Background: External comparisons of antimicrobial use (AU) may be more informative if adjusted for encounter characteristics. Optimal methods to define input variables for encounter-level risk-adjustment models of AU are not established. Methods: This retrospective analysis of electronic health record data included 50 US hospitals in 2020-2021. We used NHSN definitions for all antibacterials days of therapy (DOT), including adult and pediatric encounters with at least 1 day present in inpatient locations. We assessed 4 methods to define input variables: 1) diagnosis-related group (DRG) categories by Yu et al., 2) adjudicated Elixhauser comorbidity categories by Goodman et al., 3) all Clinical Classification Software Refined (CCSR) diagnosis and procedure categories, and 4) adjudicated CCSR categories where codes not appropriate for AU risk-adjustment were excluded by expert consensus, requiring review of 867 codes over 4 months to attain consensus. Data were split randomly, stratified by bed size as follows: 1) training dataset including two-thirds of encounters among two-thirds of hospitals; 2) internal testing set including one-third of encounters within training hospitals, and 3) external testing set including the remaining one-third of hospitals. We used a gradient-boosted machine (GBM) tree-based model and two-staged approach to first identify encounters with zero DOT, then estimate DOT among those with &gt;0.5 probability of receiving antibiotics. Accuracy was assessed using mean absolute error (MAE) in testing datasets. Correlation plots compared model estimates and observed DOT among testing datasets. The top 20 most influential variables were defined using modeled variable importance. Results: Our datasets included 629,445 training, 314,971 internal testing, and 419,109 external testing encounters. Demographic data included 41% male, 59% non-Hispanic White, 25% non-Hispanic Black, 9% Hispanic, and 5% pediatric encounters. DRG was missing in 29% of encounters. MAE was lower in pediatrics as compared to adults, and lowest for models incorporating CCSR inputs (Figure 1). Performance in internal and external testing was similar, though Goodman/Elixhauser variable strategies were less accurate in external testing and underestimated long DOT outliers (Figure 2). Agnostic and adjudicated CCSR model estimates were highly correlated; their influential variables lists were similar (Figure 3). Conclusion: Larger numbers of CCSR diagnosis and procedure inputs improved risk-adjustment model accuracy compared with prior strategies. Variable importance and accuracy were similar for agnostic and adjudicated approaches. However, maintaining adjudications by experts would require significant time and potentially introduce personal bias. If findings are confirmed, the need for expert adjudication of input variables should be reconsidered.Disclosure: Elizabeth Dodds Ashley: Advisor- HealthTrackRx. David J Weber: Consultant on vaccines: Pfizer; DSMB chair: GSK; Consultant on disinfection: BD, GAMA, PDI, Germitec

An analysis of potentially avoidable neurosurgical transfers to a tertiary-care level I trauma center.

Previous studies of neurosurgical transfers indicate that substantial numbers of patients may not need to be transferred, suggesting an opportunity to provide more patient-centered care by treating patients in their communities, while probably saving thousands of dollars in transport and duplicative workup. This study of neurosurgical transfers, the largest to date, aimed to better characterize how often transfers were potentially avoidable and which patient factors might affect whether transfer is needed. This was a retrospective cohort study of neurosurgical transfers to an urban, tertiary-care, level I trauma center between October 1, 2017, and October 1, 2022. Prior to data analysis, the authors devised criteria to differentiate necessary neurosurgical transfers from potentially avoidable ones. A transfer was considered necessary if 1) the patient went to the operating room within 12 hours of arrival at the emergency department (ED); 2) a neurological MRI study was conducted in the ED; 3) the patient was admitted to the ICU from the ED; or 4) the patient was admitted to either neurology or a surgical service (including neurosurgery). Transfers not meeting any of the above criteria were deemed potentially avoidable. Patient and clinical characteristics, including diagnostic groupings from Clinical Classification Software categories, were collected retrospectively via electronic health record data abstraction and stratified by whether the transfer was necessary or potentially avoidable. Statistical differences were assessed with a chi-square test. A total of 5113 neurosurgical transfers were included in the study, of which 1701 (33.3%) were classified as potentially avoidable. Four percent of all transferred patients went to the operating room within 12 hours of reaching the receiving ED, 23.4% were admitted to the ICU from the ED, 26.6% had a neurological MRI study performed in the ED, and 54.4% were admitted to a surgical service or to neurology. Potentially avoidable transfers had a higher proportion of traumatic brain injury, headache, and syncope (p < 0.0001), as well as of spondylopathies/spondyloarthropathies (p = 0.0402), whereas patients needing transfer had a higher proportion of acute hemorrhagic cerebrovascular disease and cerebral infarction (p < 0.0001). This study demonstrates that a large number of neurosurgical transfers can probably be treated in their home hospitals and highlights that the vast majority of patients transferred for neurosurgical conditions do not receive emergency neurosurgery. Further research is needed to better guide transferring and receiving facilities in reducing the burden of excessive transfers.

Borderlines of psychosis - nosological propositions of Polish psychiatrists of the interwar period.

This paper examines nosological categories relating to borderlines between psychosis and other clinical categories, introduced by Polish psychiatrists in the interwar period. In the United States, the discussion about the borderline between neuroses and psychoses was urged by the 1938 article by psychoanalyst Adolph Stern. In Poland, nosological categories regarding the borderline between neuroses and psychoses were proposed by Adam Wizel, Maurycy Bornsztajn, Jan Nelken, and Władysław Matecki. Wizel coined the term 'underdeveloped schizophrenia', Bornsztajn introduced 'schizothymia reactiva' and 'hypochondriac (somatopsychic) schizophrenia', Nelken described 'mild schizophrenia', first introduced by Moscow psychiatric school of Rosenstein, and Matecki presented the category of neurosis-like (pseudo-neurotic) schizophrenia. Additionally, Julian Dretler, after studying the borderline between schizophrenia and manic-depressive psychosis, coined the term 'mixed psychosis' and expressed conviction that it is an independent nosological entity. Like in the United States, the majority of Polish pioneers of the nosological studies of borderline cases were influenced by psychoanalysis. As a consequence of World War II and the new regime, which forced dialectical materialism and Pavlovism as an official ideology of psychiatry and condemned psychoanalysis, the categories presented in the article became forgotten and have not impacted Polish psychiatric nosology.

Congenital variants of the ventral laminae of the sixth and seventh cervical vertebrae are not associated with clinical signs or other radiological abnormalities of the cervicothoracic region in Warmblood horses

AbstractBackgroundThere is controversy about the clinical relevance of congenital variants of the ventral laminae of the sixth (C6) and seventh (C7) cervical vertebrae and their relationship with other radiological abnormalities.ObjectivesTo document the prevalence of congenital variants of C6 and C7 and that of other radiological abnormalities from C6 to the second thoracic vertebra (T2).Study designCross‐sectional.MethodsThe study included Warmblood horses ≥3 years of age undergoing clinical assessment at two referral institutions: 127 control horses and 96 cases (neurologic, neck pain or stiffness, or neck‐related forelimb lameness). All horses underwent a standardised orthopaedic and neurologic examination. Lateral–lateral and lateral 45°–55° ventral–lateral dorsal (left to right and right to left) radiographic views of C5 to T2 were acquired and assessed blinded to the horse's clinical category using a predetermined grading system.ResultsThe ventral profile of C7 was abnormal in 54 horses (24.2%). Cases were less likely to have congenital variants than control horses, p = 0.0002, relative risk (RR): 0.63 (95% confidence intervals [CIs]: 0.4, 1.0). There was no association between the presence of a congenital variant of C7 and the presence of modelling of the articular processes (APs) of C6–C7, C7–T1 or T1–T2. Cases were more likely to have severe modelling of the APs at C6–C7, p = 0.01, RR: 1.94, CI: 1.1, 3.5 and C7–T1, p = 0.04, RR: 1.97, CI: 1.2, 3.2 compared with control horses.Main limitationsRadiographs were read by one assessor independently at each institution.ConclusionsThere was no association between the presence of congenital variants of C7 and any other radiological findings. Congenital variants occurred less frequently in cases compared with control horses. There was no association between the presence or absence of a congenital variant and the type of case.

The burden of readmissions after rib fractures among older adults

BackgroundThe index hospitalization morbidity and mortality of rib fractures among older adults (aged ≥65 years) is well-known, yet the burden and risks for readmissions after rib fractures in this vulnerable population remain understudied. We aimed to characterize the burdens and etiologies associated with 3-month readmissions among older adults who suffer rib fractures. We hypothesized that readmissions would be common and associated with modifiable etiologies. MethodsThis survey-weighted retrospective study using the 2017 and 2019 National Readmissions Database evaluated adults aged ≥65 years hospitalized with multiple rib fractures and without major extrathoracic injuries. The main outcome was the proportion of patients experiencing all-cause 3-month readmissions. We assessed the 5 leading principal readmission diagnoses overall and delineated them by index hospitalization discharge disposition (home or facility). Sensitivity analysis using clinical classification categories characterized readmissions that could reasonably represent rib fracture-related sequelae. ResultsIn 2017, 25,092 patients met the inclusion criteria, with 20% (N = 4,894) experiencing 3-month readmissions. Six percent of patients did not survive their readmission. The 5 leading principal readmission diagnoses were sepsis (many associated with secondary diagnoses of pneumonia [41%] or urinary tract infections [41%]), hypertensive heart/kidney disease, hemothorax, pneumonia, and respiratory failure. In 2019, a comparable 3-month readmission rate of 23% and identical 5 leading diagnoses were found. Principal readmission diagnosis of hemothorax was associated with the shortest time to readmission (median [interquartile range]:9 [5–23] days). Among patients discharged home after index hospitalization, pleural effusion–possibly representing mischaracterized hemothorax–was among the leading principal readmission diagnoses. Some patients readmitted with a principal diagnosis of hemothorax or pleural effusion had these diagnoses at index hospitalization; a lower proportion of these patients underwent pleural fluid intervention during index hospitalization compared with readmission. On sensitivity analysis, 30% of 3-month readmissions were associated with principal diagnoses suggesting rib fracture-related sequelae. ConclusionReadmissions are not infrequent among older adults who suffer rib fractures, even in the absence of major extrathoracic injuries. Future studies should better characterize how specific complications associated with readmissions, such as pneumonia, urinary tract infections, and delayed hemothoraces, could be mitigated.