Late Cohort Research Articles

Stringent screening strategy significantly reduces reactivation rates of tuberculosis in patients with inflammatory bowel disease on anti-TNF therapy in tuberculosis endemic region.

Anti-tumor necrosis factor (anti-TNF) therapy use in patients with inflammatory bowel disease (IBD) leads to an increased risk of tuberculosis (TB) reactivation despite latent tuberculosis (LTB) screening, especially in TB endemic regions. We evaluated the effect of stringent screening strategy and LTB prophylaxis on TB reactivation. We performed an ambispective comparison between patients who received anti-TNF therapy after January 2019 (late cohort) and between Jan 2005 and Jan 2019 (early cohort). Late cohort patients were subjected to stringent screening criteria which included all: history of past TB/recent contact with active TB, chest X-ray, CT (computed tomography) chest, IGRA (interferon-gamma release assay), TST (tuberculin skin test), and if any positive were given chemoprophylaxis. A cohort comparison was done to evaluate for risk reduction of TB following the stringent screening strategy. One hundred seventy-one patients (63: ulcerative colitis/108: Crohn's disease, mean age diagnosis: 28.5±13.4years, 60% males, median follow-up duration after anti-TNF: 33months [interquartile range: 23-57months]) were included. Among the 112 in the early cohort, 29 (26%) underwent complete TB screening, 22 (19.6%) had LTB, 10 (9%) received chemoprophylaxis, and 19 (17%) developed TB. In comparison, in the late cohort, 100% of patients underwent complete TB screening, 26 (44%) had LTB, 23 (39%) received chemoprophylaxis, and only 1(1.7%) developed TB (p<0.01). On survival analysis, patients in early cohort had a higher probability of TB reactivation compared with the late cohort (HR: 14.52 (95% CI: 1.90-110.61 [p=0.01]) after adjusting for gender, age at anti-TNF initiation, concomitant immunosuppression, anti-TNF doses, and therapy escalation. The high risk of TB reactivation with anti-TNF therapy in TB endemic regions can be significantly mitigated with stringent LTB screening and chemoprophylaxis.

Temporal Trends in Outcomes in Patients With Adrenocortical Carcinoma: A Multidisciplinary Referral-center Experience.

Reporting temporal trends in adrenocortical carcinoma (ACC) helps guide management strategies. This work aimed to report the trends in disease burden and clinical outcomes over time that cannot be adequately captured from individual clinical trials. A retrospective study was held of ACC patients seen at a referral cancer center between February 1998 and August 2019. Clinical outcomes were compared between an early cohort (February 1998-June 2007) and a late cohort (July 2007-August 2019). A total of 621 patients included with a median age at diagnosis of 49.3 years (range, 0.5-86.6 years). There were 285 (45.9%) patients with hormonal overproduction. More patients in the late cohort had stage IV disease compared to the early cohort (36.8% vs 23.1%; P < .0001). Resection of the primary tumor was performed in 502 patients (80.8%). Complete resection (R0) was more common in the late cohort (165 [60.2%]) than in the early cohort (100 [44.6%]; P = .0005). Of 475 patients with metastatic disease (stage IV or recurrent metastatic disease), 352 (74.1%) received mitotane, 320 (67.4%) received chemotherapy, and 53 (11.2%) received immunotherapy. In the early cohort, 70 (33%) received 2 or more lines of therapy, whereas in the late cohort, 127 (48%) received 2 or more lines of therapy. The 5-year overall survival (OS) rates were 65%, 58%, 45%, and 10% for stage I, II, III, and IV disease, respectively, whereas the 2-year OS rates in patients with stage IV disease was 24% in the early cohort and 46% in the late cohort (P = .01). ACC clinical outcomes improved over the past 2 decades as more patients had complete resection or received more lines of systemic therapy.

Early Postoperative Extubation is Associated with Shorter Hospitalization and Improved Short-Term Survival in Patients Undergoing Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy.

Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) is associated with significant operative time, hospital resources, and morbidity. We examine factors associated with hospital length of stay (LOS) and early overall survival (OS) after CRS/HIPEC. Patients who underwent CRS/HIPEC were evaluated for factors associated with LOS. Institutional learning curve influence was addressed by comparing early vs late cohorts. Variables with P < .200 after univariate analysis were considered for inclusion in multivariate linear regression modeling. Independent factors associated with OS were evaluated using the Kaplan-Meier method. Seventy patients underwent CRS/HIPEC (mean age 52.3years, 64.3% female, and 68.6% Caucasian). Presence of any surgical complication was found in 26 (37.1%), 28 (40%) remained intubated postoperatively, and the mean Peritoneal Carcinomatosis Index (PCI) score was 14.4 (10.4). Mean intensive care unit and hospital LOS were 2.9days (2.3) and 9.6days (3.6), respectively. After adjusting for covariates, only shorter time to postoperative ambulation (regression coefficient .92, P = .001) and early extubation (regression coefficient -1.90, P = .018) were associated with decreased hospital LOS on multivariate analysis. Immediate postoperative extubation conferred an independent early survival benefit on Kaplan-Meier analysis (mean OS 714.8 vs 473.4days, P = .010). There was no difference in hospital LOS or OS between early and late cohorts. Early postoperative extubation and shorter time to ambulation are associated with decreased hospital LOS. Moreover, CRS/HIPEC patients extubated immediately postoperatively have an early survival benefit. Every effort should be made to achieve early postoperative extubation and mobilization in CRS/HIPEC patients.

Era of endovascular aortic aneurysm repair is linked to preoperative anatomic severity and perioperative patient outcomes

Varying opinions on optimal elective and emergent surgical management of infrarenal abdominal aortic aneurysms are expressed by the most recent Society for Vascular Surgery (SVS), European Society for Vascular Surgery, vs UK National Institutes for Health and Care Excellence guidelines. The UK National Institutes for Health and Care Excellence guidelines propose that open surgical repair serve as the default treatment for infrarenal abdominal aortic aneurysm. The rationale for this approach relied on data from the early era of endovascular aneurysm repair (EVAR) and are in contrast to the more balanced approaches of the SVS and European Society for Vascular Surgery. We hypothesize that significant differences in patient selection, management, and postoperative outcome are related to the era in which treatment was undertaken, contextualizing the outcomes reported in early-era EVAR randomized controlled trials. Retrospectively, two cohorts representing all EVAR patients from "early" (n= 167; 2008-2010) and "late" (n= 129; 2015-2017) periods at a single treating institution were assembled. Primary outcomes of era-related changes in preoperative demographics, anatomy, and intraoperative events were assessed; anatomy was compared using the SVS anatomic severity grading system. These era-related differences were then placed in the context of early perioperative outcomes and at follow-up to 1year. Choice of surgical strategy differed by era, despite the same patient preoperative comorbidities between EVAR groups. Preoperative anatomic severity was significantly worse in the early cohort (P< .001), with adverse proximal and distal seal zone features (P< .001). Technical success was 16.2% higher in the late cohort, with significantly fewer type 1A/B endoleaks perioperatively (P< .001). In-hospital complications, driven by higher acute kidney injury and surgical site complications in the early cohort, resulted in a 16.5% difference between cohorts (P< .05). At 1year of follow-up, outcome differences persisted; late-era patients had fewer 1A endoleaks, fewer graft complications, and better reintervention-free survival. From a granular dataset of EVAR patients, we found an impact of EVAR repair era on early clinical outcomes; late cohort infrarenal EVAR patients had less severe preoperative anatomy and improved perioperative and follow-up outcomes to 1year, suggesting that the results of early EVAR randomized controlled trials may no longer be generalizable to modern practice.

The Incidence Trend of Papillary Thyroid Carcinoma in the United States During 2003-2017.

BackgroundThe rapid increase in the detection rate of thyroid cancer over the past few decades has caused some unexpected economic burdens. However, that of papillary thyroid carcinoma (PTC) seems to have had the opposite trend, which is worthy of further comprehensive exploration.MethodsThe Surveillance, Epidemiology, and End Results 18 database was used to identify patients with PTC diagnosed during 2003-2017. The incidence trends were analyzed using joinpoint analysis and an age-period-cohort model.ResultsThe overall PTC incidence rate increased from 9.9 to 16.1 per 100 000 between 2003 and 2017. The joinpoint analysis indicated that the incidence growth rate began to slow down in 2009 (annual percentage change [APC] = 3.1%, 95% confidence interval [CI] = 1.9%–4.4%). After reaching its peak in 2015, it began to decrease by 2.8% (95% CI = −4.6% to −1.0%) per year. The stratified analysis indicated that the incidence patterns of different sexes, age groups, races, and tumor stages and sizes had similar downward trends, including for the localized (APC = −4.5%, 95% CI = −7% to −1.9%) and distant (APC = −1.3%, 95% CI = −2.7% to −.1%) stages, and larger tumors (APC = −4%, 95% CI = −12% to 4.7%). The age-period-cohort model indicated a significant period effect on PTC, which gradually weakened after 2008-2012. The cohort effect indicates that the risk of late birth cohorts is gradually stabilizing and lower than that of early birth cohorts.ConclusionThe analysis results of the recent downward trend and period effect for the incidence of each subgroup further support the important role of correcting overdiagnosis in reducing the prevalence of PTC. Future research needs to analyze more-recent data to verify these downward trends.

A Project ECHO and Community Health Worker Intervention for Patients with Diabetes

BackgroundBoth community health workers and the Project ECHO model of specialist telementoring are innovative approaches to support primary care providers in the care of complex patients with diabetes. We studied the effect of an intervention that combined these 2 approaches on glycemic control. MethodsPatients with diabetes were recruited from 10 federally qualified health centers in New Mexico. We used electronic health record (EHR) data to compare HbA1c levels prior to intervention enrollment with HbA1c levels after 3 months (early follow-up) and 12 months (late follow-up) following enrollment. We propensity matched intervention patients to comparison patients from other sites within the same electronic health records databases to estimate the average treatment effect. ResultsAmong 557 intervention patients with HbA1c data, mean HbA1c decreased from 10.5% to 9.3% in the pre- versus postintervention periods (P < .001). As compared to the comparison group, the intervention was associated with a change in HbA1c of −0.2% (95% confidence interval [CI] −0.4%-0.5%) and −0.3 (95% CI −0.5–0.0) in the early and late follow-up cohorts, respectively. The intervention was associated with a significant increase in percentage of patients with HbA1c <8% in the late follow-up cohort (8.1%, 95% CI 2.2%−13.9%) but not the early follow-up cohort (3.6%, 95% CI −1.5% to 8.7%) DiscussionThe intervention was associated with a substantial decrease in HbA1c in intervention patients, although this improvement was not different from matched comparison patients in early follow-up. Although combining community health workers with Project ECHO may hold promise for improving glycemic control, particularly in the longer term, further evaluations are needed.

Ileal microbial shifts after Roux-en-Y gastric bypass orchestrate changes in glucose metabolism through modulation of bile acids and L-cell adaptation

Roux-en-Y gastric bypass (RYGB)-induced glycemic improvement is associated with increases in glucagon-like-peptide-1 (GLP-1) secreted from ileal L-cells. We analyzed changes in ileal bile acids and ileal microbial composition in diet-induced-obesity rats after RYGB or sham surgery to elucidate the early and late effects on L-cells and glucose homeostasis. In early cohorts, there were no significant changes in L-cell density, GLP-1 or glucose tolerance. In late cohorts, RYGB demonstrated less weight regain, improved glucose tolerance, increased L-cell density, and increased villi height. No difference in the expression of GLP-1 genes was observed. There were lower concentrations of ileal bile acids in the late RYGB cohort. Microbial analysis demonstrated decreased alpha diversity in early RYGB cohorts which normalized in the late group. The early RYGB cohorts had higher abundances of Escherichia–Shigella but lower abundances of Lactobacillus, Adlercreutzia, and Proteus while the late cohorts demonstrated higher abundances of Escherichia–Shigella and lower abundances of Lactobacillus. Shifts in Lactobacillus and Escherichia–Shigella correlated with decreases in multiple conjugated bile acids. In conclusion, RYGB caused a late and substantial increase in L-cell quantity with associated changes in bile acids which correlated to shifts in Escherichia–Shigella and Lactobacillus. This proliferation of L-cells contributed to improved glucose homeostasis.

Long-term outcomes after fenestrated endovascular aortic repair for juxtarenal aortic aneurysms

ObjectiveFenestrated endovascular aortic aneurysm repair (FEVAR) for juxtarenal aortic aneurysm (jAAA) disease is safe and effective with good short- and mid-term outcomes. The durability issues have mainly focused on the proximal and distal seal and target vessel (TV) instability, and long-term data are scarce. In previous studies, we have reported the short-term outcomes after FEVAR and compared our early and late experience and the long-term results for the early cohort. In the present report, we have provided the long-term outcomes for our late experience cohort who had undergone FEVAR at the Vascular Center (Skåne University Hospital, Malmö, Sweden). MethodsConsecutive patients who had undergone FEVAR for jAAAs from 2007 to 2011 were included in the present study. Data were collected retrospectively from the medical and imaging records. The follow-up protocol consisted of a clinical examination 1 month postoperatively and computed tomography angiography combined with plain abdominal radiography at 1 and 12 months and annually thereafter. The primary endpoints were TV instability, reinterventions, and survival. Changes in the aneurysm diameter and renal function and the incidence and type of endoleaks were also analyzed. ResultsA total of 94 patients were included in the present study. The median follow-up time was 89 months (range, 0-152 months). A total of 280 fenestrations or scallops were used, of which 205 were stented. Technical success was 89.4%. Primary TV patency was 94% ± 1% at 1 year, 90% ± 2% at 3 years, and 89% ± 2% at 5 years. Of the 94 patients, 37 (39.4%) had required a total of 70 reinterventions. The mean time to the first reintervention was 21 ± 3.97 months. Five patients (5.3%) had died of aneurysm-related causes. Overall survival was 95.7% ± 2.1% at 1 year, 87.1% ± 3.5% at 3 years, and 71.0% ± 4.7% at 5 years. A stable or decreasing aortic diameter after treatment was seen in 91% of the cases. The mean glomerular filtration rate had decreased from 59.2 ± 14.9 mL/min/1.73 m2 preoperatively to 50.0 ± 18.6 mL/min/1.73 m2 at the end of follow-up. ConclusionsThe results of the present study have shown that the long-term results after treatment of jAAAs with FEVAR remain good and the treatment is safe and effective. Although the need for reintervention remained high, long-term renal function and survival support the use of FEVAR as a valid treatment option for jAAA disease.

Trends in outpatient versus inpatient total shoulder arthroplasty over time.

BackgroundThe purpose of this study was to investigate the safety of outpatient and inpatient total shoulder arthroplasty (TSA) and to investigate changes over time.MethodsPatients undergoing primary TSA during 2006-2019 as part of the American College of Surgeons National Surgical Quality Improvement Program were identified. Patients were divided into an early cohort (2006-2016, 12,401 patients) and a late cohort (2017-2019, 12,845 patients). Outpatient procedures were defined as those discharged on the day of surgery. Patient comorbidities and rate of adverse events within 30 days postoperatively were compared with adjustment for baseline characteristics using standard multivariate regression.ResultsThere was a significant reduction in complications over time when considering all cases (5.69% in the early cohort vs. 3.67% in the late cohort, adjusted relative risk [RR] = 0.65, 95% confidence interval [CI] = 0.58-0.73, P < .001). The rate of complications decreased over time among inpatients (5.80% vs. 3.90%, adjusted RR = 0.68, 95% CI = 0.60-0.76, P < .001). However, there was no difference in the rate of complications among outpatients over time (1.98% vs. 1.38%, adjusted RR = 0.64, 95% CI = 0.28-1.47, P = .293). There were significantly more complications among inpatients vs. outpatients in both the early and late cohorts (early: 5.80% vs. 1.98%, adjusted RR = 2.57, 95% CI = 1.24-5.34, P = .011, late: 3.90% vs. 1.38%, adjusted RR = 2.28, 95% CI = 1.39-3.74, P = .001). TSA became more common in elderly patients over 70 years of age over time in both the inpatient and outpatient cohorts, whereas fewer young patients (aged 18-59 years) underwent TSA in the late cohorts than in the early cohorts for both the inpatient and outpatient samples (P < .001).ConclusionThe overall complication rate of TSA has decreased over time as outpatient TSA has become increasingly common. When contemporary data are examined, the complication rate of outpatient procedures has remained constant over time while that of inpatient procedures decreased, despite the changing demographics of patients undergoing TSA. This indicates that outpatient TSA remains a safe procedure as patient selection criteria have evolved, while the safety of inpatient TSA continues to improve.

Outcomes of Patients with COVID-19 from a Specialized Cancer Care Emergency Room

Purpose Our goal was to identify discrete clinical characteristics associated with safe discharge from an emergency department/urgent care for patients with a history of cancer and concurrent COVID-19 infection during the SARS-CoV-2 pandemic and prior to widespread vaccination. Patients and Methods We retrospectively analyzed 255 adult patients with a history of cancer who presented to Memorial Sloan Kettering Cancer Center (MSKCC) urgent care center (UCC) from March 1, 2020 to May 31, 2020 with concurrent COVID-19 infection. We evaluated associations between patient characteristics and 30-day mortality from initial emergency department (ED) or urgent care center (UCC) visit and the absence of a severe event within 30 days. External validation was performed on a retrospective data from 29 patients followed at Fred Hutchinson Cancer Research Center that presented to the local emergency department. A late cohort of 108 additional patients at MSKCC from June 1, 2020 to January 31, 2021 was utilized for further validation. Results In the MSKCC cohort, 30-day mortality and severe event rate was 15% and 32% respectively. Using stepwise regression analysis, elevated BUN and glucose, anemia, and tachypnea were selected as the main predictors of 30-day mortality. Conversely, normal albumin, BUN, calcium, and glucose, neutrophil–lymphocyte ratio <3, lack of (severe) hypoxia, lack of bradycardia or tachypnea, and negative imaging were selected as the main predictors of an uneventful course as defined as a Lack Of a Severe Event within Thirty Days (LOSETD). Utilizing this information, we devised a tool to predict 30-day mortality and LOSETD which achieved an area under the operating curve (AUC) of 79% and 74% respectively. Similar estimates of AUC were obtained in an external validation cohort. A late cohort at MSKCC was consistent with the prior, albeit with a lower AUC Conclusion We identified easily obtainable variables that predict 30-day mortality and the absence of a severe event for patients with a history of cancer and concurrent COVID-19. This has been translated into a bedside tool that the clinician may utilize to assist disposition of this group of patients from the emergency department or urgent care setting.

The Cost Effectiveness of Delaying Filgrastim Administration after Autologous Stem Cell Transplant in Patients with Multiple Myeloma - a Single Institution Experience

BackgroundASCO clinical guidelines recommends administration of WBC growth factors after autologous stem cell transplant (ASCT) to reduce the duration of severe neutropenia (Smith TJ et al., Recommendations for the use of WBC growth factors: American society of clinical oncology clinical practice guideline update. J Clin Oncol, 33(28):3199-3212, 2015). But there is conflicting data regarding the optimal timing of granulocyte colony stimulating factor (G-CSF) initiation post-transplantation and a lack of recent cost effectiveness analysis. Based on single center studies showing similar results between an early approach and a delayed one, we changed our institutional standard to a delayed strategy since June 2020.MethodsWe retrospectively compared the outcomes of adult multiple myeloma ASCT patients who received G-CSF either on day 2 (early) or day 5 (late) at Roger Williams Medical Center. Sixteen consecutive patients received day 2 G-CSF between July 2018 and June 2020 (D+2 cohort) while seven received day 5 since implementing the change in June 2020 (D+5 cohort). The doses of G-CSF given were 300 mcg, 480 mcg, 600 mcg or 960 mcg. One-way factorial ANOVA and Fit Y by X was used for comparison of variables. Descriptive statistics were used where appropriate.ResultsBaseline characteristics were comparable between the D+2 and D+5 cohorts (median age 62 vs 63 years, median CD34+cells 4.01 vs 4.54 x10 6/kg respectively). The median number of prior treatments, conditioning intensity, disease status at transplant and G-CSF doses were similar in both cohorts. Median ANC at G-CSF initiation was different (3300 in D+2 vs 100 in D+5). The median follow-up for survivors was 215 days for D+5 cohort (range: 135-404 days) and 699 days for D+2 cohort (range: 418-923 days). The results are summarized in table 1. For the primary outcome, median time to neutrophil engraftment was 13 days versus 10 days in the early and late cohorts, respectively (p=0.07). Median days from administration of GCSF to hospital discharge was noted to be shorter in the late cohort (13 vs 17.5 days, p=0.05). There was no statistically significant difference in the incidence of febrile neutropenia or transfusion requirements with late initiation of G-CSF. While engraftment syndrome and duration of antibiotics were noted to be more in the early cohort, these were not statistically significant. Median length of hospital stay was a day and half shorter in the late cohort. 6-month OS favored the D+5 cohort (p=0.03); this was likely due to transplant related deaths in early cohort. The average cost saving per patient by implementing the late strategy was 887.4 $.ConclusionsLate initiation of G-CSF following autologous ASCT in patients with multiple myeloma was associated with a shorter time to neutrophil engraftment and length of stay post transplantation with no difference in overall outcomes. Cost benefit analysis favors delaying initiation of GCSF for autologous SCT at our center. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Grow fast, die young: Does compensatory growth reduce survival of juvenile blacktip sharks (Carcharhinus limbatus) in the western Gulf of Mexico?

Effective conservation and management necessitate an understanding of the ecological mechanisms that shape species life histories in order to predict how variability in natural and anthropogenic impacts will alter growth rates, recruitment, and survival. Among these mechanisms, the interaction between parturition timing and prey availability frequently influences offspring success, particularly when postnatal care is absent. Here, we assess how parturition timing and nursery conditions, including prey abundance and environmental conditions, influence the growth and potential survival of blacktip sharks (Carcharhinus limbatus) in western Gulf of Mexico (GOM) estuaries over their first year. Catch data from long‐term gillnet monitoring allowed for clear delineation of cohorts based on size frequency distribution plots, and showed that late parturition cohorts born in estuaries with fewer prey resources exhibited more rapid growth than early parturition cohorts that experienced more abundant prey. Compensatory behaviors that promoted accelerated growth led to reduced second year residency, likely due to reduced survival resultant from greater risk taking and potentially due to reduced site fidelity attributed to larger body size. Water temperatures influenced blacktip growth rates through physiological increases in metabolism and potential premigratory foraging cues associated with cooling temperatures. Gradual warming of the GOM (0.03°C year−1) was also correlated with earlier parturition across the study period (1982–2017), similar to other migratory species. Considering current trends in climate and associated phenological shifts in many animals, testing hypotheses assessing compensatory growth‐risk trade‐offs is important moving forward to predict changes in life histories and associated recruitment in concert with current and future conservation actions, like wildlife management.

Early administration of remdesivir to COVID-19 patients associates with higher recovery rate and lower need for ICU admission: A retrospective cohort study.

ObjectivesRemdesivir is one of the most widely recommended and used medications for COVID-19 treatment. However, different outcomes have been reported for hospitalized patients with COVID-19 treated with remdesivir. Specifically, the effect of the timing of remdesivir initiation (from patient’s symptom onset) on clinical outcomes in COVID-19 patients has not been investigated.MethodsThis is a retrospective cohort study of patients hospitalized with COVID-19 and treated with or without remdisivir. The primary outcome was patient’s recovery rate, defined as clinical improvement and patient’s discharge by day 14 of symptom onset. The secondary outcome was the need for intensive care unit (ICU) admission, mechanical ventilation, and mortality within 28 days of patient’s symptom onset.ResultsOut of 323 hospitalized adults with COVID-19, 107 (33.1%) received no remdesivir during their hospital stay, 107 (33.1%) received remdesivir early within 7 days of the symptom onset, and 109 (33.7%) received it at 8 days or later of symptom onset. At day 14 following symptom onset, higher proportion of patients recovered in the early remdesivir compared to the late remdesivir cohort, or patients who did not receive remdesivir (adjusted odds ratio, aOR, 2.65; 95% confidence interval [CI], 1.31 to 5.35). Moreover, early administration of remdesivir was associated with lower admission to intensive care unit (adjusted hazard ratio [aHR], 0.31; 95% CI, 0.15 to 0.64), less need for mechanical ventilation (aHR, 0.22; 95% CI, 0.10 to 0.51), and lower mortality at 28 days (aHR, 0.15; 95% CI, 0.04 to 0.53), as compared to the late remdesivir cohort or patients who did not receive remdesivir.ConclusionEarly administration of remdesivir within 7 days of symptom onset is associated with less need for mechanical ventilation and lower 28-days mortality.

Assessing the role for nailfold videocapillaroscopy in interstitial lung disease classfication: a systematic review and meta-analysis.

The nailfold videocapillaroscopy (NVC) has been known to assist with interstitial lung disease (ILD) classification. However, evidence on its diagnostic efficacy is limited, particularly in some connective tissue disease-related interstitial lung diseases (CTD-ILD), and in interstitial pneumonia with autoimmune features (IPAF). This study aimed to address this limitation by conducting a meta-analysis on the efficacy of the NVC in ILD subgroups of CTD-ILD, IPAF and idiopathic pulmonary fibrosis (IPF). MEDLINE, EMBASE, CENTRAL were screened from inception to December 2020 according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies that report prevalence of nailfold abnormalities (NVC+) in CTD-ILD, IPAF and IPF cohorts were included. Data were presented as prevalence ratio (PR) with 95% CI using a random-effects model. Quality of evidence was assessed using GRADE criteria. Twenty-one studies were eligible. Prevalence of NVC+ was highest in CTD-ILD; PR (95 CI%) 80.4% (74.3%, 85.3%), followed by IPAF; 27.4% (10.9%, 53.7%), and IPF; 13.8% (5.7%, 29.9%). Late scleroderma pattern was the most prevalent nailfold pattern; 40.4% (28.1%, 54.1%) in our CTD-ILD cohort. Quality of evidence was low for CTD-ILD, IPAF and IPF cohorts, moderate for the late scleroderma pattern cohort. NVC can increase the diagnostic accuracy of ILD when used in a multi-disciplinary setting, and appears to have greatest utility in CTD-ILD, followed by IPAF and IPF. The Late Scleroderma Pattern was the most frequent nailfold capillary pattern in SSc-ILD. Future research will allow for greater understanding of the prognostic value of the NVC in ILD.

EARLY DISCHARGE OF PRIMARY PCI PATIENTS

BACKGROUND There is increasing evidence that low-risk patients with ST Elevation Myocardial Infarction (STEMI) can be safely discharged at ≤72hours from admission. Assessment of patients as low-risk is based on clinical judgement and no consistent criteria are used in practice. At this time, assumption is made that low-risk patients are predominantly undergoing early discharge, but no definitive data exists that categorizes these patients in our institution (Tertiary Care Center). The objective of the study is to describe the patients undergoing early discharge and to determine if they meet the early discharge criteria that is recommended in guidelines. METHODS AND RESULTS The Zwolle score was retrospectively applied to all ST elevation myocardial infarction patients treated with primary PCI between January 2019 and January 2021 at a large Canadian teaching hospital. The Zwolle index is an externally validated risk score that has been used to identify low-risk primary PCI patients who can safely be discharged from the hospital within 48 h to 72 h. The length of stay was defined as the time (in days) from first balloon inflation to the date and time of discharge. Data were collected on 1255 patients. 622 of these patients were repatriated to other hospitals and 570 patients were directly discharged from our institution. Of the patients discharged directly, 426 (75%) underwent early discharge and 144 (25%) were late discharge. Early discharge patients tended to be younger (63±11.4, p < 0.01), with higher EF (43±5.7, p < 0.01), lower Killip score (1.37±0.59, p < 0.01) and lower creatinine (84±22, p < 0.01) than the late discharge cohort (table 1). No significant difference between the early discharge and cohort undergoing repatriation. In the early discharge group, 64% of the patients had Zwolle score of 3 or lower, identifying them as low risk. The average Zwolle score was 6 in the high-risk patients that underwent early discharge. 30-day hospital visit and readmission was 13% in the high risk group and 20% at 1 year. CONCLUSION This study provided significant insight into the characteristics of patients currently being discharged from a tertiary cardiac care unit. Some high-risk patients are undergoing early discharge for which the early discharge criteria was not validated. More data is needed to determine if there is a signal of potential adverse outcome in this high-risk population. There is increasing evidence that low-risk patients with ST Elevation Myocardial Infarction (STEMI) can be safely discharged at ≤72hours from admission. Assessment of patients as low-risk is based on clinical judgement and no consistent criteria are used in practice. At this time, assumption is made that low-risk patients are predominantly undergoing early discharge, but no definitive data exists that categorizes these patients in our institution (Tertiary Care Center). The objective of the study is to describe the patients undergoing early discharge and to determine if they meet the early discharge criteria that is recommended in guidelines. The Zwolle score was retrospectively applied to all ST elevation myocardial infarction patients treated with primary PCI between January 2019 and January 2021 at a large Canadian teaching hospital. The Zwolle index is an externally validated risk score that has been used to identify low-risk primary PCI patients who can safely be discharged from the hospital within 48 h to 72 h. The length of stay was defined as the time (in days) from first balloon inflation to the date and time of discharge. Data were collected on 1255 patients. 622 of these patients were repatriated to other hospitals and 570 patients were directly discharged from our institution. Of the patients discharged directly, 426 (75%) underwent early discharge and 144 (25%) were late discharge. Early discharge patients tended to be younger (63±11.4, p < 0.01), with higher EF (43±5.7, p < 0.01), lower Killip score (1.37±0.59, p < 0.01) and lower creatinine (84±22, p < 0.01) than the late discharge cohort (table 1). No significant difference between the early discharge and cohort undergoing repatriation. In the early discharge group, 64% of the patients had Zwolle score of 3 or lower, identifying them as low risk. The average Zwolle score was 6 in the high-risk patients that underwent early discharge. 30-day hospital visit and readmission was 13% in the high risk group and 20% at 1 year. This study provided significant insight into the characteristics of patients currently being discharged from a tertiary cardiac care unit. Some high-risk patients are undergoing early discharge for which the early discharge criteria was not validated. More data is needed to determine if there is a signal of potential adverse outcome in this high-risk population.

Survival and durability after endovascular aneurysm repair reflect era-related surgical judgement

ObjectiveAbdominal aortic aneurysm management guidelines from the National Institute for Clinical Excellence in 2020, based heavily on randomized controlled trials in an early era of infrarenal endovascular aneurysm repair (EVAR), suggested that the long-term outcomes after EVAR jeopardize its use in elective abdominal aortic aneurysm repair. We hypothesized that, in a rapidly evolving surgical field, the era of aneurysm repair may have a significant influence on long-term patient outcomes. MethodsUsing a single-center retrospective cohort design, we identified two EVAR cohorts, the early cohort (n = 166) who underwent EVAR from 2008 to 2010, and a contemporary late cohort (n = 129) from 2015 to 2017. We assessed patient preoperative demographics and era of repair against the primary outcomes of reinterventions, reintervention-free survival, and mortality, addressing their relationships to anatomic selection criteria, graft durability, endoleak, and aneurysm diameter to 5 years after the procedure. ResultsEarly cohort patients had decreased reintervention-free survival (early 80.1% vs late 93.3%) and decreased overall survival (early 71.3% vs late 81%) at 3 years and throughout follow-up. The preoperative anatomy judged suitable for EVAR in early cohort patients was more variable than for late cohort patients, including 104% larger proximal and 106% larger distal landing zone diameters, with a mean 11.6-mm shorter length infrarenal aortic and 13.3-mm shorter length iliac sealing zones in the early group. Early cohort patients had more complications during follow-up, including graft kinking and endoleaks, and 24.4% of early vs 8.5% of late patients underwent one or more reinterventions. ConclusionsAlthough technical skill in EVAR implantation may not evolve significantly after a threshold of cases, surgical judgement, relating to anatomic selection and device sizing, requires feedback from long-term sequalae and significantly impacted EVAR outcomes by era. EVAR patients from an early repair era had significantly worse outcomes, with more complications, reinterventions, and a decrease in survival.

Comprehensive Search for Novel Circulating miRNAs and Axon Guidance Pathway Proteins Associated with Risk of ESKD in Diabetes.

Mechanisms underlying the pro gression of diabetic kidney disease to ESKD are not fully understood. We performed global microRNA (miRNA) analysis on plasma from two cohorts consisting of 375 individuals with type 1 and type 2 diabetes with late diabetic kidney disease, and targeted proteomics analysis on plasma from four cohorts consisting of 746 individuals with late and early diabetic kidney disease. We examined structural lesions in kidney biopsy specimens from the 105 individuals with early diabetic kidney disease. Human umbilical vein endothelial cells were used to assess the effects of miRNA mimics or inhibitors on regulation of candidate proteins. In the late diabetic kidney disease cohorts, we identified 17 circulating miRNAs, represented by four exemplars (miR-1287-5p, miR-197-5p, miR-339-5p, and miR-328-3p), that were strongly associated with 10-year risk of ESKD. These miRNAs targeted proteins in the axon guidance pathway. Circulating levels of six of these proteins-most notably, EFNA4 and EPHA2-were strongly associated with 10-year risk of ESKD in all cohorts. Furthermore, circulating levels of these proteins correlated with severity of structural lesions in kidney biopsy specimens. In contrast, expression levels of genes encoding these proteins had no apparent effects on the lesions. In in vitro experiments, mimics of miR-1287-5p and miR-197-5p and inhibitors of miR-339-5p and miR-328-3p upregulated concentrations of EPHA2 in either cell lysate, supernatant, or both. This study reveals novel mechanisms involved in progression to ESKD and points to the importance of systemic factors in the development of diabetic kidney disease. Some circulating miRNAs and axon guidance pathway proteins represent potential targets for new therapies to prevent and treat this condition.

COVID-19 severity and outcome in multiple sclerosis: Results of a national, registry-based, matched cohort study

BackgroundRisk factors associated with coronavirus disease 2019 (COVID-19) severity in patients with multiple sclerosis (MS) have been described. Recent improvements in supportive care measures and increased testing capacity may modify the risk of severe COVID-19 outcome in MS patients. This retrospective study evaluates the severity and outcome of COVID-19 in MS and characterizes temporal trends over the course of the pandemic in the United States. MethodsWe conducted a comparative cohort study using de-identified electronic health record (EHR) claims-based data. MS patients diagnosed with COVID-19 between February 2, 2020 and October 13, 2020 were matched (1:2) to a control group using propensity score analysis. The primary outcome was a composite of intensive care unit (ICU) admission, mechanical ventilation, and/or death. ResultsA total of 2,529 patients (843 MS and 1,686 matched controls) were included. Non-ambulatory and pre-existing comorbidities were independent risk factors for COVID-19 severity. The risk for the severe composite outcome was lower in the late cohorts compared with the early cohorts. ConclusionsThe majority of MS patients actively treated with a disease-modifying therapy (DMT) had mild disease. The observed trend toward a reduction in severity risk in recent months suggests an improvement in COVID-19 outcome.

180. Do robotic procedures have improved perioperative outcomes after a learning curve period?

<h3>BACKGROUND CONTEXT</h3> Robot-assisted surgical techniques are increasingly implemented to increase surgeon accuracy and stamina; however, the effects of surgeon learning curve on outcomes have not been well studied. <h3>PURPOSE</h3> Identify differences in outcomes and complication rates between robot-assisted and unassisted lumbar interbody fusions, and determine the presence of a learning curve with regard to surgeon case load. <h3>STUDY DESIGN/SETTING</h3> Retrospective review of a single-center stereographic database. <h3>PATIENT SAMPLE</h3> This study included 581 robotic assisted surgical patients. <h3>OUTCOME MEASURES</h3> Perioperative outcomes (estimated blood loss [EBL], length of stay [LOS]), postoperative complication rates, return to OR (30 days). <h3>METHODS</h3> Robotic cases were isolated from a single center multisurgeon database. Surgeons' cases were ranked by date of surgery into 3 quartiles: 1st quartile 2018 (Early) was analyzed against the 3rd quartile 2020 (Late). Univariate analysis was used to assess differences between quartiles. A propensity score matched (PSM) cohort of patients undergoing identical surgical procedures without robotic assistance was included as a control group and compared to both Early and Late groups. <h3>RESULTS</h3> A total of 281 patients undergoing robotic surgery met inclusion criteria (age: 56±12.5, BMI: 30±6, 42% female) with an average of 1.6 levels fused. Early group had 95 patients and Late group had 94. Late group had a lower EBL (314 vs 492, p<0.05), shorter LOS (3.8 vs 4.7, p=.1), greater amount of levels fused (2 vs 1.4, p=.021), greater amount of decompressions (2.5 vs 1, p=.003), with less return to the OR within 30 days (7% vs 14%, p=.2), and a lower rate of overall postoperative complications (34% vs 54%, p=.04). In the control group, the mean EBL was 390±790, LOS 3.7±2.7, overall postoperative complication rate 58%, and rate to return to OR within 30 days was 8%. When the control cohort was compared to the Early robotic cohort, the robotic cohort had a higher EBL (492ml vs 390ml, p<0.05), greater LOS (4.7 vs 3.7 days, p<0.05), greater return to OR within 30 days (14% vs 8%, p=.1), and a comparable overall rate of complications (54% vs 58%, p>0.05). When the control cohort was compared to the Late robotic cohort, the robotic cohort had a lower EBL (314ml vs 390ml, p=.1), comparable LOS (3.7 vs 3.8 days, p>0.05), similar return to OR within 30 days (7% vs 8%, p>0.05), and a lower overall rate of complications (34% vs 58%, p=.02). <h3>CONCLUSIONS</h3> In this study, perioperative outcomes improved drastically in the later cohort. When compared to an identical control cohort, early robotic cases had worse perioperative outcomes. However, when the later robotics cases were compared to the control cohort, robotic-assisted procedures demonstrate superior clinical outcomes. These findings suggest despite the initial worse outcomes of robotic surgery it proves to be an increasingly viable option for adult spinal deformity surgery. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.

Not Just Later, but Fewer: Novel Trends in Cohort Fertility in the Nordic Countries.

With historically similar patterns of high and stable cohort fertility and high levels of gender equality, the Nordic countries of Sweden, Finland, Norway, Denmark, and Iceland are seen as forerunners in demographic behavior. Furthermore, Nordic fertility trends have strongly influenced fertility theories. However, the period fertility decline that started around 2010 in many countries with relatively high fertility is particularly pronounced in the Nordic countries, raising the question of whether Nordic cohort fertility will also decline and deviate from its historically stable pattern. Using harmonized data across the Nordic countries, we comprehensively describe this period decline and analyze the extent to which it is attributable to tempo or quantum effects. Two key results stand out. First, the decline is mostly attributable to first births but can be observed across all ages from 15 to the mid-30s. This is a reversal from the previous trend in which fertility rates in the early 30s increased relatively steadily in those countries in the period 1980-2010. Second, tempo explains only part of the decline. Forecasts indicate that the average Nordic cohort fertility will decline from 2 children for the 1970 cohort to around 1.8 children for the late 1980s cohorts. Finland diverges from the other countries in terms of its lower expected cohort fertility (below 1.6), and Denmark and Sweden diverge from Finland, Iceland, and Norway in terms of their slower cohort fertility decline. These findings suggest that the conceptualization of the Nordic model of high and stable fertility may need to be revised.