Large Single-center Cohort Research Articles

Lactate concentration at the end of liver transplant: Early predictor of graft function or just one piece of the puzzle?

The post-operative course after Liver Transplantation (LT) can be complicated by early allograft dysfunction (EAD), primary nonfunction (PNF) and death. A lactate concentration at the end of transplant of ≥5mmol/L was recently proposed as a predictive marker of PNF, EAD, and mortality; this study aimed to validate these previous reports in a large single center cohort. This retrospective cohort study included adult liver transplant recipients who received grafts from deceased donors at our center between June 2012 and May 2021. Receiver operating characteristic (ROC) curves for the lactate concentration at the end of transplantation were computed to determine the AUC for PNF, EAD and mortality at 90 days. In our cohort of 1137 cases, the AUCs for lactate to predict EAD, PNF and mortality were respectively .56 (95% confidence interval [CI]: .53-.60), .69 (95% CI: .52-.85), and .74 (95% CI: .63-.84). The clinical value of lactate concentration at the end of transplantation to predict PNF, EAD and mortality at 90 days was, at best, modest, as shown by the relatively low AUCs. Our findings cannot validate previous reports that the lactate level alone is a good predictor of poor outcomes after liver transplantation.

CMR reclassifies patients with suspected myocardial infarction with non-obstructive coronary arteries (MINOCA)

Abstract Funding Acknowledgements Type of funding sources: None. Objectives This study sought to assess the role of cardiac magnetic resonance (CMR) in investigating patients presenting with suspected acute coronary syndrome (ACS) and non-obstructed coronary arteries. Methods Consecutive patients presenting to a tertiary cardiology centre with suspected ACS and non-obstructed coronary arteries and referred for CMR were retrospectively identified. A comprehensive imaging protocol was performed to include cines, T2-weighted, and late gadolinium enhancement (LGE) sequences. Final CMR diagnosis was based on established patterns of tissue characterisation from myocardial oedema and LGE imaging, with patients grouped into five: myocardial infarction, myocarditis, Takotsubo syndrome, cardiomyopathy, and a normal CMR. Results A total of 888 patients were identified. The mean age across the cohort was 57 years (SD ±15.9 years) with 51% female patients. Median time to CMR from acute presentation was 21 days (Figure 1). Aetiology of presentation was uncertain in more than half of patients referred for CMR (483, 54.1%). Of patients with an initial uncertain aetiology, CMR was able to identify an underlying diagnosis in 74.9%. Diagnosis across the whole cohort was reclassified in 691 patients (77.8%), with overall diagnostic yield (CMR identified underlying aetiology for presentation) of 75.6%. (Figure 2). Conclusions In a large single-centre cohort of patients presenting with suspected ACS and non-obstructed coronary arteries, diagnostic yield with CMR was high at 76%. CMR reclassified nearly 80% of patients. Our results highlight the importance of CMR in the diagnostic pathway of suspected ACS and potential implications on clinical management.

Early-versus-Late Endovascular Stroke Treatment: Similar Frequencies of Nonrevascularization and Postprocedural Cerebrovascular Complications in a Large Single-Center Cohort Study.

Endovascular treatment of acute ischemic stroke is now performed more frequently in the late window in radiologically selected patients. However, little is known about whether the frequency and clinical impact of incomplete recanalization and postprocedural cerebrovascular complications differ between early and late windows in the real world. We retrospectively reviewed all patients with acute ischemic stroke receiving endovascular treatment within 24 hours from 2015 to 2019 and included in the Acute STroke Registry and Analysis of Lausanne. We compared rates of incomplete recanalization and postprocedural cerebrovascular complications (parenchymal hematoma, ischemic mass effect, and 24-hour re-occlusion) in the early (<6 hours) versus late window (6-24 hours, including patients with unknown onset) populations and correlated them with the 3-month clinical outcome. Among 701 patients with acute ischemic stroke receiving endovascular treatment, 29.2% had late endovascular treatment. Overall, incomplete recanalization occurred in 56 patients (8%), and 126 patients (18%) had at least 1 postprocedural cerebrovascular complication. The frequency of incomplete recanalization was similar in early and late endovascular treatment (7.5% versus 9.3%, adjusted P =.66), as was the occurrence of any postprocedural cerebrovascular complication (16.9% versus 20.5%, adjusted P = .36). When analyzing single postprocedural cerebrovascular complications, rates of parenchymal hematoma and ischemic mass effect were similar (adjusted P = .71, adjusted P = .79, respectively), but 24-hour re-occlusion seemed somewhat more frequent in late endovascular treatment (4% versus 8.3%, unadjusted P = .02, adjusted P = .40). The adjusted 3-month clinical outcome in patients with incomplete recanalization or postprocedural cerebrovascular complications was comparable between early and late groups (adjusted P = .67, adjusted P = .23, respectively). The frequency of incomplete recanalization and of cerebrovascular complications occurring after endovascular treatment is similar in early and well-selected late patients receiving endovascular treatment. Our results demonstrate the technical success and safety of endovascular treatment in well-selected late patients with acute ischemic stroke.

Characteristics of ScleroID highlighting musculoskeletal and internal organ implications in patients afflicted with systemic sclerosis

BackgroundSystemic sclerosis (SSc) is a multi-organ disease with impaired health-related quality of life (HRQoL). The EULAR SSc Impact of Disease (ScleroID) is a newly introduced SSc-specific patient-reported outcome to evaluate HRQoL in SSc.ObjectiveTo investigate the correlation between the ScleroID and the involvement of organ systems as well as disease activity/damage in a SSc cohort from a large tertiary care centre.Patients and methodsThe ScleroID and clinical characteristics including internal organ involvement and hand function were investigated in 160 consecutive patients with SSc (median age 46 (43;56) years; diffuse cutaneous SSc 55%).ResultsA strong correlation was found between the ScleroID and articular disease activity scores (DAS28-CRP, DAS28-ESR, CDAI, SDAI), a hand function performance test, the Hand Anatomy Index and muscle strength tests. Additionally, a strong significant correlation was discovered using instruments representing hand function and musculoskeletal disability including the Cochin Hand Function Scale, the Quick Questionnaire of the Disability of the Hands, Arms and the Shoulders and the Health Assessment Questionnaire Disability Index. A significant negative correlation was found between the ScleroID score and the 6-min walking test (6MWT) (rho − 0.444, p < 0.001). Clinically mild lung/heart disease did not show increased ScleroID values. The Mouth Handicap in the Scleroderma Scale and the University of California Los Angeles Scleroderma Clinical Trials Consortium gastrointestinal tract 2.0 also showed significant positive correlations to the ScleroID score (rho: 0.626, p < 0.001; rho: 0.646, p < 0.001, respectively). Patients experiencing oesophageal difficulties bore a significantly higher score compared to individuals with a normal functioning oesophagus (3.2/1.5;4.5/ vs. 2.2/1.0;3.2/, p = 0.011). Moreover, the ScleroID showed a significant positive correlation to the revised EUSTAR disease activity index and modified activity index.ConclusionIn a large single-centre cohort, the previously described ScleroID-related findings were confirmed. Furthermore, several organ involvement-related functional and performance tests showed a good correlation to the ScleroID including the 6MWT and gastrointestinal-related complaints. Many aspects of musculoskeletal damage, overall disease activity, pain and fatigue were also well represented in the ScleroID, which efficiently reflects the impact of organ involvement, disease activity and functional damage.

Predictive factors of acromial fractures following reverse total shoulder arthroplasty: a subgroup analysis of 860 shoulders

Acromion stress fractures (ASF) or scapular spine fractures (SSF) following reverse total shoulder arthroplasty (RTSA) are common complications with impaired clinical outcome. The underlying biomechanical factors remain unclear. The aim of this study was to evaluate basic demographic and radiographic parameters predicting occurrence of different types of ASF/SSF in a large single-center study cohort. A total of 860 RTSA (805 patients) with available minimum follow-up of 2 years were implanted between 2005 and 2018 at a tertiary academic center. All RTSA with subsequent ASF/SSF (n=45 in 43 shoulders [42 patients, 5%]) were identified and classified as Levy I to III. Predictive demographic, surgical, and radiographic factors were evaluated for each subtype and compared to the control group (817 RTSA, 763 patients). The radiographic analysis included critical shoulder angle, lateralization shoulder angle (LSA), distalization shoulder angle (DSA), acromio-humeral distance (ACHD), acromial thickness, deltoid tuberosity index, deltoid length, and center of rotation. Of the 45 ASF/SSF in 42 patients, 8 were classified as Levy I, 21 as Levy II, and 16 as Levy III. Demographic analysis revealed indication as risk factor for Levy I fractures, higher American Society of Anesthesiologists score as risk for Levy type II fractures and higher age as risk factor for Levy type III fractures. None of the measured radiographic parameters were predictive for occurrence of Levy type I and Levy type II ASF. However, analysis of Levy III SSF revealed a higher postoperative LSA (89°±10° vs. 83°±9°, P=.015), a lower postoperative DSA (45°±8° vs. 53°±12°, P=.002), less distalization (ACHD of 33±8 mm vs. 38±10 mm, P=.049), and a more medial center of rotation preoperatively (COR-LA 16±8 mm vs. 12±7 mm, P=.048) as predictive radiographic factors. The present analysis showed a significant association of higher postoperative LSA, lower DSA, a lower ACHD, and higher age as predictive factor only for Levy type III fractures. Some of these factors can be surgically influenced and this knowledge can be of value for preoperative planning and surgical execution to avoid these complications.

Five-year long-term comparison of robotic and laparoscopic gastrectomy for gastric cancer: a large single-center cohort study.

Robotic gastrectomy (RG) has been reported to be technically feasible and safe for patients with gastric cancer. However, 5-year long-term survival and recurrence outcomes for advanced gastric cancer have rarely been reported. This study aimed to compare the long-term oncologic outcomes between RG and laparoscopic gastrectomy (LG) for gastric cancer. The general clinicopathological data of 1905 consecutive patients who underwent RG and LG were retrospectively collected at the Chinese People's Liberation Army General Hospital between November 2011 and October 2017. Propensity score matching (PSM) was used to match groups. The primary endpoints were 5-year disease-free survival (DFS) and overall survival (OS). After PSM, a well-balanced cohort of 283 patients in the RG group and 701 patients in the LG group were included in the analysis. The 5-year cumulative DFS rates were 67.28% in the robotic group and 70.41% in the laparoscopic group. The 5-year OS rate was 69.01% in the robotic group and 69.58% in the laparoscopic group. No significant differences in Kaplan-Meier survival curves for DFS (HR = 1.08, 95% CI 0.83-1.39, Log-rank P = 0.557) and OS (HR = 1.02, 95% CI 0.78-1.34, Log-rank P = 0.850) were observed between the 2 groups. In the subgroup analyses for potential confounding variables, there were no significant differences in 5-year DFS and 5-year OS survival between the 2 groups (P > 0.05), except for patients with pathological stage III and pathological stage N3 (P < 0.05). For patients with early gastric cancer, robotic and laparoscopic approaches have similar long-term survival. For patients with advanced gastric cancer, further studies need to be conducted to assess the long-term survival outcomes of RG.

Vasculitis in the Central Nervous System: Treatment and Outcomes in a Large Single-Center Cohort (P9-5.014)

<h3>Objective:</h3> To describe the demographics, treatment, and outcomes of patients presenting with vasculitis involving the central nervous system (CNS) at a major referral center covering a five-state catchment area in the Intermountain West. <h3>Background:</h3> CNS vasculitis is inflammation of blood vessel walls in the brain or spine that can be life-threatening and/or result in ischemic strokes. Markers suggestive of CNS inflammation include cerebrospinal fluid (CSF) pleocytosis and/or elevated protein level, and on neuroaxis imaging, the presence of parenchymal, leptomeningeal, or vessel wall enhancement. At the time of symptom onset, the diagnostic evaluation focuses on classifying the size of the involved vessels and determining if the vasculitis is a primary angiitis of the CNS or if it is occurring secondary to another process elsewhere in the body, such as a systemic vasculitis, connective tissue disorder, infection, malignancy, or toxic/drug exposure. <h3>Design/Methods:</h3> A retrospective chart review for patients within the University of Utah Health system queried all International Classification of Diseases (ICD) 9 codes for 437.4 (Cerebral arteritis) and ICD10 codes for I67.7 (Cerebral arteritis, not elsewhere classified) with one encounter with a neurologist. Of the 144 total patients identified between January 2012 to October 2022, we further confirmed the diagnosis based on neurologists’ review of each record and categorized patients further to determine if the CNS presentation of vasculitis was primary, secondary, or indeterminate/uncertain. <h3>Results:</h3> We described the demographic characteristics of vasculitis patients with CNS involvement seen at the University of Utah, as well as presenting symptoms, relevant comorbidities, distinct imaging findings (including a focus on imaging modality), CSF abnormalities, treatments, and outcomes. <h3>Conclusions:</h3> This is a comprehensive characterization of patients with vasculitis involving the CNS in a large area of the Intermountain West. Understanding the differences in these patient characteristics, symptoms, and variability in diagnostic and treatment plans will inform better, more efficient approaches. <b>Disclosure:</b> Dr. Hoshina has nothing to disclose. Alen Delic has nothing to disclose. Mr. Wong has nothing to disclose. Dr. Lyden has nothing to disclose. Dr. Kadish has received personal compensation in the range of $500-$4,999 for serving on a Scientific Advisory or Data Safety Monitoring board for Genentech. The institution of Dr. Kadish has received research support from Alexion Pharmaceuticals. Dr. Clardy has received personal compensation for serving as an employee of Veterans Health Administration (VHA). Dr. Clardy has received personal compensation for serving as an employee of University of Utah Health. Dr. Clardy has received personal compensation in the range of $10,000-$49,999 for serving as an Editor, Associate Editor, or Editorial Advisory Board Member for Neurology/AAN Publications. The institution of Dr. Clardy has received research support from Sumaira Foundation for NMO. The institution of Dr. Clardy has received research support from Western Institute for Veteran Research. The institution of Dr. Clardy has received research support from NIH/NINDS. Dr. Clardy has received personal compensation in the range of $500-$4,999 for serving as a AAN Summer Meeting CoDirector Travel and Lodging with AAN. Dr. Clardy has received personal compensation in the range of $500-$4,999 for serving as a Grand Rounds Travel and Lodging with U of Iowa. Dr. Clardy has received personal compensation in the range of $500-$4,999 for serving as a Speaker Honoraria for Grand Rounds with Barrow Neurological Institute. Dr. Clardy has received personal compensation in the range of $500-$4,999 for serving as a Speaker Honoraria for Grand Rounds with Beaumont Health.

P197 Evaluating the safety and factors associated with treatment cessation in Takayasu arteritis

Abstract Background/Aims Immunosuppression in Takayasu arteritis (TA) reduces the risk of arterial disease progression. However, long-term use of glucocorticoids (GC) and other agents carries risk, particularly as patients age. GC tapering practice can vary and there are no guidelines on the safety of treatment cessation due to a lack of data. This study describes the cessation of treatment in a large single-centre cohort and evaluates the baseline, clinical and treatment parameters associated with successful treatment stop. Methods The Imperial College Takayasu Arteritis Cohort (UK) was reviewed retrospectively; 158 patients, median follow-up 8.4 [5-13.6] years. Patients with data available within 1 year of audit (31/03/2021) were analysed. Treatment was defined as &amp;gt; 6 months of GC, csDMARD or biologic medication and cessation as stopping treatment for &amp;gt;1 year. Cessation safety was assessed by serial angiography (whole aorta MRI or CT) and NIH disease activity scoring. Baseline demographic, clinical and treatment parameters as well as initial treatment responses were compared for cessation and non-cessation cases. Data are median [IQR], comparisons are non-parametric for continuous variables. Results Of 129 (82%) cases requiring treatment, 107 (83%) remained in care. 29 (27.1%) cases of cessation were identified, time off-treatment was 3.6 [2.5-8.2] years. For 25 (86%) cessation cases, treatment withdrawal was due to sustained quiescence. Infection, non-adherence and tolerance accelerated cessation in 4 cases. Long-term inactivity was confirmed by disease activity scoring in all cases and by angiography where available (23 cases). No instances of treatment restart were observed. Baseline demographic and disease severity parameters were similar in cessation and non-cessation patients (Table). Cessation cases had lower GC doses after 2 years of treatment and a trend towards lower disease activity, suggesting better responses. Relatedly, biologic administration (reserved for refractory disease) was markedly lower in the cessation group. Finally, cessation cases had earlier treatment start years, were older at audit and had an increased proportion of Numano Type V classification. Conclusion In TA, complete treatment cessation is feasible and safe in a proportion of cases. Initial treatment response, treatment duration and Numano type V arterial involvement are potential predictors of successful treatment cessation and may aid future stratification strategies after validation. Disclosure R.T. Maughan: None. A. Porter: None. C. Dahanayake: None. C. Ianonne: None. R. Alapat: None. C. Pericleous: None. T.A. Youngstein: None. J. Mason: None.

The Effect of Contemporary Brachytherapy Practices on Prognosis in Women with Locally Advanced Cervical Cancer

(1) Background: Over the past two decades use of new imaging modalities and the adaptation of applicators have allowed for advances in volumetric (3D) imaging-based brachytherapy practices for patients with locally advanced cervical cancer. The aim of this study was to compare the oncological outcome and toxicity for three consecutively introduced brachytherapy practices in a large single-center cohort; (2) Methods: Patients treated for cervical cancer with primary radiotherapy and curative intent were consecutively included in this retrospective, single-center cohort study from 2006 to 2019. This cohort was divided into three groups (CT, MRI, and MRI+needles) based on the timing of the introduction of a novel brachytherapy practice; 3D brachytherapy planning using CT- and MRI-guided adaptive brachytherapy and the use of parametrial interstitial needles, respectively. Actuarial estimates were compared between groups. Multivariable Cox regression analyses were performed to correct for other risk factors. Crude rates of severe (≥grade 3) late toxicity were reported; (3) Results: A total of 397 patients were included in this cohort. At a median follow-up of 40 months (interquartile range (IQR) 22-62), actuarial 3-year local control, pelvic control, disease-free survival, and overall survival for the entire cohort were 91% (95% (Confidence Interval (CI)) 88-94), 88% (95% CI 84-91), 69% (95% CI 64-74), and 75% (95% CI 70-79), respectively). Local control, disease-free survival, and overall survival were significantly improved in the MRI+needles group compared to the CT group (p = 0.040, p = 0.004, and p < 0.001, respectively). Independent risk factors for overall survival were treatment in either the CT or MRI group (vs. MRI+needles), older age at diagnosis, adeno (squamous) carcinoma, FIGO stage III/IV, and lymph node metastases. The crude rate of severe late toxicity was 27% in the CT, 26% in the MRI, and 20% in the MRI+needles group; (4) Conclusions: Prognosis in women with locally advanced cervical cancer treated with state-of-the-art MRI-guided adaptive brachytherapy combined with parametrial interstitial needles compares favorably to patients treated with more traditional CT only based brachytherapy.

Therapeutic mammoplasty: a "wise" oncoplastic choice-lessons from the largest single-center cohort from Asia.

The majority of breast cancer patients from India usually present with advanced disease, limiting the scope of breast conservation surgery. Therapeutic mammoplasty (TM), an oncoplastic technique that permits larger excisions, is quite promising in such a scenario and well suited to breast cancer in medium-to-large-sized breasts with ptosis and in some cases of large or multifocal/multicentric tumors. Here, we describe our TM cohort of 205 (194 malignant and 11 benign) patients from 2012 to 2019 treated at a single surgeon center in India, the largest Asian dataset for TM. All patients underwent treatment after careful discussions by a multidisciplinary tumor board and patient counseling. We report the clinicopathological profiles and surgical, oncological, cosmetic, and patient-related outcomes with different TM procedures. The median age of breast cancer patients was 49 years; that of benign disease patients was 41 years. The breast cancer cohort underwent simple (n = 84), complex (n = 71), or extreme (n = 44) TM surgeries. All resection margins were analyzed through intra-operative frozen-section assessment with stringent rad-path analysis protocols. The margin positivity rate was found to be 1.4%. A majority of the cohort was observed to have pT1-pT2 tumors, and the median resection volume was 180 cc. Low post-operative complication rates and good-to-excellent cosmetic scores were observed. The median follow-up was 39 months. We observed 2.07% local and 5.7% distal recurrences, and disease-specific mortality was 3.1%. At median follow-up, the overall survival was observed to be 95.9%, and disease-free survival was found to be 92.2%. The patient-reported outcome measures (PROMs) showed good-to-excellent scores for all types of TMs across BREAST-Q domains. We conclude that in India, a country where women present with large and locally advanced tumors, TM safely expands the indications for breast conservation surgery. Our results show oncological and cosmetic outcomes at acceptable levels. Most importantly, PROM scores suggest improved overall wellbeing and better satisfaction with the quality of life. For patients with macromastia, this technique not only focuses on cancer but also improves self-image and reduces associated physical discomfort often overlooked by women in the Indian setting. The popularization of this procedure will enable Indian patients with breast cancer to receive the benefits of breast conservation.

The Genetic Landscape of Children Born Small for Gestational Age with Persistent Short Stature

Introduction: Among children born small for gestational age, 10–15% fail to catch up and remain short (SGA-SS). The underlying mechanisms are mostly unknown. We aimed to decipher genetic aetiologies of SGA-SS within a large single-centre cohort. Methods: Out of 820 patients treated with growth hormone (GH), 256 were classified as SGA-SS (birth length and/or birth weight <−2 SD for gestational age and life-minimum height <−2.5 SD). Those with the DNA triplet available (child and both parents) were included in the study (176/256). Targeted testing (karyotype/FISH/MLPA/specific Sanger sequencing) was performed if a specific genetic disorder was clinically suggestive. All remaining patients underwent MS-MLPA to identify Silver-Russell syndrome, and those with unknown genetic aetiology were subsequently examined using whole-exome sequencing or targeted panel of 398 growth-related genes. Genetic variants were classified using ACMG guidelines. Results: The genetic aetiology was elucidated in 74/176 (42%) children. Of these, 12/74 (16%) had pathogenic or likely pathogenic (P/LP) gene variants affecting pituitary development (LHX4, OTX2, PROKR2, PTCH1, POU1F1), the GH-IGF-1 or IGF-2 axis (GHSR, IGFALS, IGF1R, STAT3, HMGA2), 2/74 (3%) the thyroid axis (TRHR, THRA), 17/74 (23%) the cartilaginous matrix (ACAN, various collagens, FLNB, MATN3), and 7/74 (9%) the paracrine chondrocyte regulation (FGFR3, FGFR2, NPR2). In 12/74 (16%), we revealed P/LP affecting fundamental intracellular/intranuclear processes (CDC42, KMT2D, LMNA, NSD1, PTPN11, SRCAP, SON, SOS1, SOX9, TLK2). SHOX deficiency was found in 7/74 (9%), Silver-Russell syndrome in 12/74 (16%) (11p15, UPD7), and miscellaneous chromosomal aberrations in 5/74 (7%) children. Conclusions: The high diagnostic yield sheds a new light on the genetic landscape of SGA-SS, with a central role for the growth plate with substantial contributions from the GH-IGF-1 and thyroid axes and intracellular regulation and signalling.

Highly dynamic changes of regional HBV epidemiology over two decades.

HBV epidemiology is highly heterogeneous and rapidly evolving worldwide: we studied its last two-decades dynamics in a large single center cohort. In all consecutive HBsAg-positive subjects firstly admitted (2000-2019) at the Pisa-University-Hospital Hepatology-Referral-Center, demographic, virologic and clinical variables were analyzed by admission decade (2000-2009vs 2010-2019) and origin (Italian vs non-Italian natives). Of 2003, 1878 (93.7%) subjects were eligible: 1798(95.7%) with HBV-chronic [126(7%) HDV, 72(4%) HCV, 11(0.6%) HIV co-infected] and 80(4.3%) HBV-primary infections (93.7% Italians). Among 1589(88.4%) mono-infected, 496(31.2%) were immigrants, younger than Italians [34.0(5.1-77.1)-52.5(10.0-87.2) years], with female prevalence [204/496(41.1%)-340/1093(31.1%); p<0.001] increasing overtime (14.6-45.0%; p<0.001). Italians aged across decades [50.3(11.1-87.2)-56.2(10.0-86.7) years; p<0.001], HBeAg-positivity remained stable (12.3-14.5%) and acute hepatitis increased (4.0-8.0%; p=0.003). CHB declined [439/721(60.9%)-320/868(36.9%); p<0.001] whereas HBeAg-negative infection increased [277/626(44.2%)-538/755(71.3%); p<0.001]. Cirrhosis declined [195/721(27.0%)-125/868(14.4%); p<0.001], except in anti-HDV-patients [93/126(73.8%); 42(45.1%) non-Italians], younger than HBV-mono-infected (47.4-57.6 years; p<0.001). Effective preventive health care policies and immigration flows account for increasing prevalence of HBeAg-negative infection across the last two decades. Antiviral therapy mitigated disease progression in aging Italian CHB but not in CHD patients, mainly young immigrants, emphasizing the unmet need of effective CHD therapies; HBeAg-positive CHB and acute hepatitis B persist in non-vaccinated Italian adults, prompting vaccination in the elderly with risky behaviors.

Clarifying the clinical landscape of pediatric spinal arteriovenous shunts: an institutional experience and individual patient-data meta-analysis

BackgroundPediatric spinal arteriovenous shunts (SAVS) are rare lesions with heterogeneous pathogenesis and clinical manifestations.ObjectiveTo evaluate the clinical characteristics, angioarchitecture, and technical/clinical outcomes in SAVS through a large single-center cohort analysis...

Five-year Clinical Outcomes of Inferior Quadrant Trabectome Surgery for Open Angle Glaucoma.

This retrospective study of 264 eyes having inferior-quadrant trabectome surgery confirms its safety and relatively effectiveness. Most patients however still require IOP-lowering agents and a considerable proportion may need additional glaucoma surgery. To report outcomes from a large single-centre cohort of inferiorly-applied trabectome surgery. Retrospective review of patients undergoing trabectome surgery for chronic open angle glaucoma (COAG) at the University Eye Clinic Bonn, Germany, from 2012 to 2020. Twohundred-sixty-four eyes of 206 patients with COAG were included. Mean review period was 45.43 (range 12-101) months. 105 eyes (39.8%) underwent standalone surgery, of which 74 were pseudophakic and 31 phakic. Mean preoperative IOP was 17.58mmHg (range 12-50mmHg). 105 eyes (39.8%) developed a 'failure event' according to pre-defined criteria at a mean interval of 14.8 months post-op. In absolute terms, 211 patients (79.9%) had a long-term IOP >14mmHg at 7.6 months, 174 patients (65.9%) >16mmHg at 10.6 months, 127 patients (48.1%) >18mmHg at 10.9 months and 77 patients (29.2%) >21mmHg at 11.1 months. Over a five-year period, overall mean IOP remained stable at 13mmHg. The majority of patients were still on glaucoma drops (mean number reduced from 2.9 to 2.7 agents). Sub-group analyses showed that higher pre-operative IOP was a positive predictor for failure whereas combined surgery (with phaco) had better IOP outcomes (16.5mmHg vs. 19.3mmHg respectively). 41 patients (15.5%) developed minor complications: 22 had high postoperative IOP within 3 months, 11 developed a self-resorbing hyphema, 6 had fibrinous uveitis. Trabectome surgery is a safe and relatively effective procedure for lowering IOP but most patients still need IOP-lowering agents and a considerable proportion may need additional glaucoma surgery within a relatively short time. Inferior quadrant treatment may result in inferior IOP outcomes when compared to nasal quadrant surgery.

Early ischemic recurrence in acute spontaneous cervical artery dissection

Background and PurposeEarly ischemic recurrence (EIR) following the diagnosis of acute spontaneous cervical artery dissection (CeAD) has been little investigated. We aimed to determine the prevalence and determinants on admission of EIR in a large single-center retrospective cohort study of patients with CeAD. MethodsEIR was defined as any ipsilateral clinical or radiological cerebral ischemia or intracranial artery occlusion, not present on admission and occurring within 2 weeks. CeAD location, degree of stenosis, circle of Willis support, presence of intraluminal thrombus, intracranial extension, and intracranial embolism were analyzed on initial imaging by 2 independent observers. Uni- and multivariate logistic regression was used to determine their association with EIR. ResultsTwo hundred thirty-three consecutive patients with 286 CeAD were included. EIR was observed in 21 patients (9%,95%CI=5–13%) with a median time from diagnosis of 1.5 days (range:0.1–14.0 days). No EIR was observed in CeAD without ischemic presentation or with less than 70% stenosis. In the remaining cases, poor circle of Willis (OR=8.5, CI95%=2.0–35.4, p = 0.003), CeAD extending to other intracranial arteries than just V4 (OR=6.8, CI95%=1.4–32.6, p = 0.017), cervical artery occlusion (OR=9.5, CI95%=1.2- 39.0, p = 0.031), and cervical intraluminal thrombus (OR=17.5, CI95%=3.0–101.7, p = 0.001) were independently associated with EIR. ConclusionsOur results suggests that EIR is more frequent than previously reported, and that its risk might be stratified on admission with a standard workup. In particular, the presence of a poor circle of Willis, intracranial extension (other than just V4), cervical occlusion, or cervical intraluminal thrombus are associated with high risk of EIR, for which specific management should be further evaluated.

Screening for obstructive sleep apnea: comparing the American Academy of Sleep Medicine proposed criteria with the STOP-Bang, NoSAS, and GOAL instruments.

We evaluated the performance of the 2017 American Academy of Sleep Medicine criteria (AASM2017) in screening obstructive sleep apnea (OSA) and compared them with 3 other validated instruments: NoSAS score, STOP-Bang, and GOAL questionnaires. From July 2019 to December 2021, 4,499 adults undergoing overnight polysomnography were included. The AASM2017 instrument considers an increased high risk for moderate-to-severe OSA in the presence of excessive daytime sleepiness and at least 2 of the following 3 criteria: loud snoring; observed apnea, gasping, or choking; and hypertension. OSA severity was based on polysomnography-derived apnea-hypopnea index cutoffs: 5.0 events/h, 15.0 events/h, and 30.0 events/h. Predictive performance was evaluated by the area under the curve and contingency tables. When screening for any OSA severity, AASM2017 displayed a sensitivity of 31.0-40.6% and a specificity of 80.8-89.6%. For all apnea-hypopnea index thresholds, AASM2017, unlike the GOAL, STOP-Bang, and NoSAS, exhibited superior specificity but markedly lower sensitivity. GOAL, STOP-Bang, and NoSAS, but not AASM2017 criteria, emerged as an adequate screening tool for any OSA severity (all areas under the curve > 0.7) and performed significantly better than AASM2017 in predicting any OSA severity (all P < .001). For all severity OSA levels, GOAL, STOP-Bang, and NoSAS displayed similar performance when compared to each other (all P > .05). GOAL, STOP-Bang, and NoSAS instruments, but not AASM2017 criteria, emerge as useful OSA screening tools in a large referral single-center clinical cohort. Duarte RLM, Magalhães-da-Silveira FJ, Gozal D. Screening for obstructive sleep apnea: comparing the American Academy of Sleep Medicine proposed criteria with the STOP-Bang, NoSAS, and GOAL instruments. J Clin Sleep Med. 2023;19(7):1239-1246.

Late Survival after Hematopoietic Stem Cell Transplantation for Chronic Granulomatous Disease in a Single-Center Cohort

Chronic granulomatous disease (CGD) is an inborn error of immunity associated with significant morbidity and mortality for which hematopoietic stem cell transplant (HSCT) is a definitive treatment. In a large single-center cohort, we examined the late survival (survival at 5 years post-HSCT) of all patients who underwent HSCT for CGD at the Children’s Hospital of Philadelphia (CHOP).

Effective induction immunotherapy minimizes surgical invasiveness for locally advanced lung cancer.

Immunotherapy has been recommended for neoadjuvant therapy in patients with locally advanced non-small cell lung cancer (NSCLC). However, its effect on surgical resection has not yet been examined. This study aimed to examine the effect of induction immunotherapy on surgical resection in terms of the surgical approach, resection extent, and perioperative recovery. We performed a real-world study comprising consecutive patients with clinical stage IB-IIIB NSCLC who received surgical resection after induction immunotherapy from January 2019 to September 2021. The perioperative outcomes were compared in terms of the surgical approach and resection extent. Among 68 patients, 37 (54.4%) achieved a clinical objective response. Standard resection was performed in 37 patients (54.4%), while extended resection was necessary in the other 31 patients (45.6%). Minimally invasive surgery (MIS) was attempted in 37 cases (54.4%), with only 1 (2.7%) conversion. MIS was significantly more commonly accomplished in patients with a clinical objective response than those without (67.6% vs. 35.5%, P=0.008). Patients with a clinical objective response were more likely to have their tumors removed via MIS and/or standard resection (75.7% vs. 51.6%, P=0.04), while those without a clinical objective response more often required extended resection using an open approach. Patients receiving standard resection or MIS had significantly better perioperative outcomes than those who underwent extended resection or thoracotomy (all P<0.05). The results of this large single-center retrospective cohort indicate that in terms of a better clinical response, effective induction immunotherapy could help reduce the resection extent and/or provide more opportunities to perform MIS, resulting in better recovery.

New management of surveillance in patients with baseline serrated polyps: a large single-center retrospective cohort study in China.

Serrate d polyps (SP) is associated with an increased risk of colorectal cancer. Patients with SP history tend to have SP recurrence. However, the risk factors for metachronous polyps (MP) in those patients are not well established. Data of colonoscopy were retrospectively reviewed from October 2012 to October 2021. The pathology database, electronic medical records and telephone follow-up data were also observed. A total of 906 patients were studied including 278 patients with MPs and 628 patients without. The multiplicity of polyps (OR, 13.63; 95% CI, 8.80-21.75), older age (OR, 5.71; 95% CI, 1.87-20.63), abdominal obesity (OR, 2.46; 95% CI, 0.98-6.42), current smoker (OR, 2.93; 95% CI, 1.15-7.83) and sedentary lifestyle (OR, 1.41; 95% CI, 1.22-1.65) are significantly associated with the risk of MPs. Patients with baseline SP < 10 mm were more likely to develop higher or same risk-grade polyps (HSRGP) ( P = 0.0014). Patients with non-clinically significant SPs whether coexisted with adenoma or not were more likely to develop HSRGPs when compared to others ( P < 0.001). Total number of polyps, older age, sedentary behavior, abdominal obesity and smoking status contributed to the risk of MPs at surveillance colonoscopy. Patients with grade 1 SPs might require closer surveillance. SPs coexisting with conventional adenoma did not increase the risk of MPs but may increase the risk of developing HSRGPs.

Lipoprotein(a) predicts recurrent cardiovascular events in patients with prior cardiovascular events post-PCI: five-year findings from a large single center cohort study

BackgroundIt is well established that lipoprotein(a)[Lp(a)] play a vital role in atherosclerosis. Whether Lp(a) can predict recurrence of cardiovascular events (CVEs) in prior CVEs patients is still unclear. We aim to investigate its association with subsequent long-term adverse events in this high-risk population.MethodsA total of 4,469 patients with prior CVEs history after PCI were consecutively enrolled and categorized according Lp(a) values of < 10 (low), 10 to 30 (medium), and ≥ 30 mg/dL (high). The primary endpoint was MACCE, a composite of all-cause death, myocardial infarction, stroke and unplanned revascularization.ResultsDuring an average of 5.0 years of follow-up, 1,078 (24.1%) and 206 (4.6%) patients experienced MACCE and all-cause death with 134 (3.0%) of whom from cardiac death. The incidence of MACCE, all-cause death and cardiac death were significantly higher in the high Lp(a) group (p < 0.05). After adjustment of confounding factors, high Lp(a) level remained an independent risk factor for MACCE (adjusted HR 1.240, 95%CI 1.065–1.443, p = 0.006), all-cause death (adjusted HR 1.445, 95%CI 1.023–2.042, p = 0.037) and cardiac death (adjusted HR 1.724, 95%CI 1.108–2.681, p = 0.016). This correlation remained significant when treated as a natural logarithm-transformed continuous variable. This finding is relatively consistent across subgroups and confirmed again in two sensitivity analyses.ConclusionsOur present study confirmed that Lp(a) was an independent predictor for recurrent CVEs in patients with established CVEs, illustrating that Lp(a) level might be a valuable biomarker for risk stratification and prognostic assessment in this high-risk population.