Long-term Morbidity Research Articles

Acute Kidney Injury after Isolated Coronary Bypass Surgery

AbstractAcute kidney injury (AKI) is among the most serious of the common postoperative complications of cardiac surgeries, which can increase the short- and long-term morbidity and mortality of patients. This study aimed to examine possible risk factors that lead to AKI. We sought to compare our AKI rates to national averages in coronary artery bypass grafting (CABG) reported by the Society of Thoracic Surgeons (STS). We reviewed our institution's data for renal failure in CABG procedures performed between January 1, 2020, and June 30, 2023. From the database, we identified 1,068 CABG patients and reviewed demographics, nonmodifiable conditions, and modifiable risk factors. The STS database uses the Risk, Injury, Failure, Loss, and End-stage renal disease definition for renal failure. Of our patient sample, 14 (1.3%) experienced renal failure. The national rate for AKI after isolated CABG was 1.9% in 2023. Chronic lung disease was a risk factor for AKI development. The mean perfusion, cross-clamp, ventilator times, and hospital stay increased in AKI patients. All patients who suffered from AKI had undergone perioperative blood transfusion. Our single-center experience with renal failure is slightly better than the national average. In our population, chronic lung disease and lower preoperative ejection fractions were associated with increased rates of AKI. Modifiable risk factors in our population included perioperative blood transfusion and increased perfusion/cross-clamp times. Lastly, AKI patients spent longer time on ventilators, increased lengths of stay, and increased postoperative mortality.

Insulin Resistance after Fontan Palliation.

Patients with a single ventricle heart who had Fontan palliation (S/P Fontan) are at increased risk for acquired morbidity. Insulin resistance (IR) is a predictor of cardiac morbidity and mortality. A single-center, cross-sectional study using S/P Fontan and controls was designed to assess IR S/P Fontan. Group comparisons were made in IR via the Quantitative Insulin Index (QUICKI) and the natural log-transformed homeostasis model assessment, ln (HOMA-IR), without/with adjusting for age. A total of 89 patients (59 Fontan and 30 controls) were included. Fontan patients showed a significant decrease in QUICKI (0.34 ± 0.03 vs 0.37 ± 0.02) and an elevation of ln (HOMA-IR) (0.82 ± 0.62 vs 0.24 ± 0.44) compared to controls (both p < 0.0001); this remained significant even adjusting for age. With older age, there was a significant, progressive decrease in QUICKI (p = 0.01) and an increase in ln (HOMA-IR) (p = 0.02) S/P Fontan. Analysis excluding Fontan patients with obesity still showed a significant reduction of QUICKI and an elevation of ln (HOMA-IR) in Fontan patients compared to controls when adjusting for age (both p < 0.05). Using QUICKI, IR was present in 41 (69.5%) Fontan patients vs. 3 (10%) controls (p < 0.0001) and using HOMA-IR, IR was present in 32 (54.2%) vs 5 (16.7%) controls (p = 0.001). Fontan patients had significantly more IR compared to controls and the prevalence of IR increases with age. Since IR is known to correlate with long-term morbidity and mortality and can be ameliorated by therapies, we believe it is critical that IR be identified as early as possible in Fontan patients.

7147 A Retrospective Evaluation of Biochemical and Clinical Criteria of Permanent Hypoparathyroidism After Total Thyroidectomy and Their Associated Outcomes

Abstract Disclosure: D.G. Su: None. S. Tsou: None. W. Shen: None. Q. Duh: None. C. Graves: None. I. Suh: None. Background: Postoperative hypoparathyroidism (hypoPT) is the most common complication of total thyroidectomy and carries long-term morbidity. However, reported incidences vary widely due to nonstandardized measurement practices and absence of a universally accepted definition. This study aims to evaluate various definitions of hypoPT and to identify influencing factors such as diagnosis and operative duration. Methods: We performed a retrospective analysis of patients with a diagnosis of hypoPT (ICD-9: E20, E20.0, E20.8, E20.9, E89.2) between January 2012 and January 2019 at a single large academic institution, and only included those who had underwent a total thyroidectomy six months prior. Definitions based on low parathyroid hormone (PTH) values (PTH &amp;lt; 10 pg/mL), low calcium levels (corrected calcium [Ca] &amp;lt; 8.5 mg/dL or ionized Ca [iCa] &amp;lt; 1.1 mmol/L), and postoperative supplementation (elemental calcium or vitamin D) were evaluated at 6 and 12 months postoperatively. Postoperative hypocalcemic symptoms were graded by disease severity (based on the presence of numbness/paresthesia, muscle spasms/aches, and Chvostek/Trousseau signs). Patient demographics, operative and pathological characteristics, and use of parathyroid autotransplantation were recorded. Results: Of 879 patients with hypoPT ICD-9 diagnoses, 124 (14%) underwent a total thyroidectomy and were included. Our cohort was 64% female with a median age of 52.9 years. Fifty-one patients (41%) had low PTH levels, 49 (39%) had low calcium levels, and only 26 (21%) had both low PTH and calcium. Of 94 patients (76%) with hypocalcemic symptoms, 68 (73%) required long-term calcium or vitamin D supplementation. Twenty-eight (22.6%) patients had either an ED visit or readmission for hypocalcemia postoperatively. One hundred seven patients (86%) had a pathologic diagnosis of malignancy, of which 37% had extrathyroidal extension, 25% vascular invasion, and 36% positive margins. Those who underwent parathyroid autotransplantation (33%) were less likely to meet biochemical definition of hypoPT (p = 0.0312). Dosage of calcium/vitamin D supplementation did not correlate with symptom grade. Conclusions: Postoperative hypocalcemic symptoms and long-term calcium/vitamin D supplementation were the most common characteristics found in our permanent hypoPT cohort. However, substantial heterogeneity in defining postoperative hypoPT exists, with no definition capturing the full spectrum of affected patients. Further research is necessary to develop reliable diagnostic criteria or biomarkers for hypoPT prediction and management. Presentation: 6/2/2024

Nonfatal Firearm Injury & Subsequent Emergency Department Utilization Among Non-Elderly Adults

IntroductionThe mortality, long-term morbidity, and exacerbated healthcare needs due to firearm injury in the US are significant and growing. However, the relationship between exposure to a nonfatal firearm injury and long-term ED utilization is poorly understood. This study estimates the association between exposure to a nonfatal firearm injury and ED utilization in the subsequent year. MethodsUsing all-payer ED data among non-elderly adults in Georgia and New York, all ED visits for nonfatal firearm injuries from 2017-2018 were identified. Sociodemographic, clinical, and contextual characteristics between nonfatal firearm injury ED patients and the broader population of ED users were compared. ED utilization in the year following a nonfatal firearm injury relative to ED use in the year before, and compared to ED use by a propensity score matched control group was examined, using Poisson and negative binomial multivariable regressions. Analyses were performed in 2024. ResultsNonfatal firearm injury ED patients were disproportionately male, younger, non-Hispanic Black, uninsured, and residents of areas with low median income and high firearm ownership. Compared to a matched control group, multivariable analyses indicated that nonfatal firearm injury ED patients had significantly higher risks of having hospital admissions through the ED (aRR: 1.42), all-cause injury-related ED visits (aRR: 1.47), non-firearm injury-related ED visits (aRR: 1.26), and additional nonfatal firearm injury-related ED visits (aRR: 325.45) in the subsequent year (p<0.001 for all). About one in every eight ED users with a firearm-related injury at index also sought ED care for another nonfatal firearm injury within one year. ConclusionsNonfatal firearm-related injuries contribute to preventable harm, health inequity and increased ED utilization.

Pulmonary complications of bone marrow transplantation.

Bone marrow transplantation, now often known as haematopoietic stem cell transplantation (HSCT), is a complex choreographed procedure used to treat both acquired and inherited disorders of the bone marrow. It has proven invaluable as therapy for haematological and immunological disorders, and more recently in the treatment of metabolic and enzyme disorders. As the number of performed transplants grows annually, and with patients enjoying improved survival, a knowledge of both early and late complications of HSCT is essential for respiratory trainees and physicians in practice. This article highlights the spectrum of respiratory complications, both infectious and non-infectious, the timeline of their likely occurrence, and the approaches used for diagnosis and treatment, keeping in mind that more than one entity may occur simultaneously. As respiratory issues are often a leading cause of short- and long-term morbidity, consideration of a combined haematology/respiratory clinic may prove useful in this patient population.

Thrombosis and anticoagulation after portal vein reconstruction during pancreatic surgery – A systematic review

ObjectiveTo comprehensively assess thrombotic events and their clinical impact in patients receiving pancreatic surgery with venous resection and reconstruction. BackgroundPortal vein (PV, including the portal vein and superior mesenteric vein) resection and reconstruction enables surgical removal of borderline-resectable and locally advanced pancreatic cancer. Thrombosis of the reconstructed PV represents a major source of early postoperative and long-term morbidity and mortality. No universally accepted standard for anticoagulation exists. Here, we aimed to assess early and late thrombosis rates after PV reconstruction with special regard to type of PV reconstruction as well as anticoagulation regimen. MethodsPRISMA guidelines were followed. Studies reporting on PV resection and reconstruction providing data on thrombosis rates were included. The following parameters were assessed: Study type, year of publication, number of patients, type/number of PV reconstruction, follow-up period, postoperative mortality, rate of thrombosis of reconstructed PV axis, intraoperative blood loss, and anticoagulation. Results23 studies with 2751 patients were included in the final analysis. 670 patients received tangential resection of the PV with venorrhaphy or patch repair, 1505 patients had segmental resection with end-to-end reconstruction, and 576 patients received reconstruction with an interposition graft/conduit. The pooled overall thrombosis rate was 15%. Reconstruction of tangential defects with either venorrhaphy or patch repair as well as end-to-end repair of segmental defects resulted in a thrombosis rate of 12%. Subgroup analysis according to the type of graft reconstruction revealed the highest occlusion rates of 55% in patients with allogeneic grafts, followed by up to 27% in patients with synthetic PV conduits. Autologous conduits had a thrombosis rate of 10%. Early thrombotic events were detected in 5% of patients after venorrhaphy/patch reconstruction and end-to-end reconstruction. Early events were most common in the allogeneic graft subgroup (22%), followed by synthetic conduits (15%). There were fewer early events in the autologous graft group (7%). Early PV thrombosis was associated with relevant mortality of up to 26%. Anticoagulation regimens varied between studies. ConclusionThe overall rate of thrombosis after portal vein resection is low. However, among different reconstruction techniques, allogeneic interposition grafts/conduits had the highest thrombosis rates among the different types of reconstruction after PV resection. No specific anticoagulation strategy can be considered beneficial on the basis of the existing literature. Mini-AbstractThrombosis of the reconstructed portal vein (PV) after PV resection in pancreatic surgery represents a relevant source of major morbidity and mortality. In this systematic review, while we observed an overall low thrombosis rate following PV resection, reconstruction with allogeneic grafts harbors the highest risk of postoperative thrombosis. Early thrombosis was most common after reconstruction with allogeneic grafts and associated with postoperative mortality. Anticoagulation strategies vary greatly among different studies.

Foramen Ovale Pulsatility Index as an Early Affected Doppler Study among Abnormal Growth Fetuses: A Recent Insight for Practice Based on a Prospective Study.

Routine Doppler study is a common tool for early diagnosis of Fetal Growth Restriction (FGR) and Small for Gestational Age (SGA) patients. It aimed to determine the role of the Foramen Ovale Pulsatility Index (FOPI) study beside routine Doppler study among patients with FGR and SGA fetuses. This prospective study was conducted on 35 FGR, 32 SGA, and 33 Appropriate for Gestational Age (AGA) fetuses. Demographic data, amniotic fluid index, neonatal outcome, and Doppler velocimetry, including Umbilical Artery Pulsatility Index (UMAPI), Uterine Artery Pulsatility Index (UTAPI), Middle Cerebral Artery Pulsatility Index (MCAPI), Ductus Venosus Pulsatility Index (DVPI), and FOPI were documented. Kolmogorov-Smirnov normality test, one-way ANOVA, Mann-Whitney U, Kruskal-Wallis, non-parametric pairwise comparisons adjusted for Bonferroni correction, Pearson correlation test, Chi square, Fisher's exact test, and Receiver Operating Characteristic Curve (ROC) analysis with Youden's Index (sensitivity+specificity-1) to estimate cut-off point were used to analyze the data at significance level <0.05 for all tests. FOPI cut-off points were 2.24 (sensitivity=77%, specificity=94%) and 1.15 (sensitivity=90%, specificity=20%) to predict FGR and SGA, respectively. FOPI showed a positive correlation with UMAPI and UTAPI (r=0.52 and r=0.30, P<0.001 and P=0.006, respectively), but not with MCAPI and DVPI (r=0.08 and r=0.12, P=0.50 and P=0.30, respectively). Besides, UMAPI, UTAPI, and FOPI were altered among patients with stages I and II FGR. Umbilical cord potential hydrogen (umbilical cord pH), 1- and 5-min Apgar score significantly increased by Birth weight centile; however, UMAPI, FOPI, and UTAPI significantly decreased. UMAPI is recommended to predict short-term neonatal morbidities and demonstrate the early or late onset FGR. Besides, FOPI is suggested as the first-line Doppler study to detect abnormal growth velocity. More studies are warranted, especially considering long-term neonatal morbidities.

Impact of a remote second opinion program on changes in recommended treatment plans for patients with cancer across the U.S.

386 Background: Second opinion consultations are a promising strategy to identify errors in diagnosis and recommend the optimal course of treatment for the patient. Yet, there are several barriers to patients accessing second opinions, including geographic barriers. By bringing high-level care to patients where they live, remote second opinion programs might benefit populations without access to subspecialty cancer centers, including those from underserved communities. While meaningful changes from in-person second opinions have been observed at several institutions, little is known about how often remote second opinions lead to similar improvements in treatment plans. Thus, our objective was to examine the extent to which the Memorial Sloan Kettering Cancer Center (MSK) remote second opinion program led to changes in treatment plans for cancer patients residing across the U.S. Methods: MSK is a high-volume cancer center based in NYC. MSK’s remote second opinion program was developed and rolled out as part of a national cancer benefits solution in 2016. Each second opinion review process is conducted by an MSK subspecialist and enabled by a customized digital platform. The process is asynchronous. To capture subspecialists’ perceptions of the importance of any changes to diagnosis or treatment recommended, we designed and administered a questionnaire starting in December 2023 that subspecialists completed after each case. Here, we report summary findings from the first 100 second opinion cases with complete information from this questionnaire. Results: These 100 case reviews were completed between December 2023 and April 2024. Spanning cancer types, the cases were reviewed by 49 unique subspecialists. There were 17 patients with breast cancer, 9 with colon cancer, 9 with lymphoma, 9 with prostate cancer, 7 with endometrial cancer, 7 with squamous cell carcinoma, 6 with myeloma, 5 with ovarian cancer, and 31 with one of 18 other cancer types. Patients had a mean age of 57 years (median 58) and 61% were female. Patients were from 27 different U.S. states. Of the 100 cases reviewed, subspecialists made a “meaningful change” (expected to affect patient outcomes) in recommended treatment, in 39 cases (39%). These meaningful changes included better prognosis / survival (n=26, 67%), reduced short-term morbidity / quality of life / toxicity (n=17, 44%), or improved long-term morbidity / quality of life / toxicity (n=29, 74%). There was a higher percent of recommended changes for liquid tumor cases compared to solid tumor cases (11/17, 65% for liquid; 28/83, 34% for solid). Conclusions: Findings are crucial for understanding potential opportunities to grow remote second opinion programs to benefit patients. This information is also essential for identifying the most effective strategies to reach underserved communities with geographic access barriers to high-quality subspecialty cancer care.

Paediatric Knee Injuries: A Narrative Review.

The prevalence of paediatric knee injuries is increasing due to higher participation in competitive sports, larger build and more use of imaging in diagnosis. A thorough history of injury (including mechanism and symptoms of pain and instability), together with a comprehensive examination (presence of an effusion, tender areas, range of movement and joint laxity) will dictate the need for radiological investigations. Magnetic Resonance Imaging (MRI) is indicated in most paediatric patients with a history of injury and an acute knee effusion, which indicates damage to an intra-articular structure. Red flags requiring onward referral to a specialist include diagnosed fractures, traumatic knee effusion, instability, or persistent unexplained nocturnal pain or lump. Correct identification and management of injuries will help reduce long-term morbidity. The aim of this review is to provide the reader with an understanding of the management of paediatric knee injuries at primary presentation in the community setting or emergency department.

INTEGRATED CARE FOR URETEROCELE PROLAPSE

Ureteroceles are rare congenital anomalies, occurring in about 1 in 4000 individuals, with a higher incidence in females, particularly those with a duplex renal system. The etiology and clinical presentation of ureteroceles vary, often complicating diagnosis and management. Common symptoms include antenatal hydronephrosis, vesicoureteral reflux (VUR), and recurrent urinary tract infections (UTIs). In cases of ectopic ureteroceles, there is a risk of significant complications, such as hypertension and renal failure, requiring timely and precise intervention. Diagnostic methods include sonography and voiding cystourethrography (VCUG), while management approaches range from minimally invasive endoscopic incisions to more complex excision and reimplantation procedures, depending on the severity. We report the case of a 1.5-month-old female infant, born via LSCS, presenting with fever and a rapidly enlarging reddish mass descending from the urethra. Initially the size of a peanut, it grew to the size of a lemon, accompanied by symptoms of straining during urination and defecation. While prenatal scans showed hydro-ureteronephrosis, postnatal imaging appeared normal until the mass emerged. Clinical suspicion of a ureterocele was confirmed through imaging studies. This case highlights the unpredictable nature of ureteroceles, emphasizing the importance of prenatal and postnatal screening. Treatment strategies must be individualized, considering the rapid progression of the condition. While endoscopic incision is favored for its minimally invasive approach, reconstructive surgery may be necessary if complications such as reflux or a duplex renal system are present. Early detection remains key to preventing long-term morbidity and improving outcomes in infants with ureteroceles.

Metachronous Second Primary in the Form of Nasopharyngeal Carcinoma Following Treatment of Small Cell Neuroendocrine Carcinoma of the Head and Neck: Dual Tracer PET/CT Findings Highlighting SSTR2 Expression and Its Theranostic Implications

AbstractPatients of head and neck squamous cell carcinoma (HNSCC) experience increased risk of developing second primary cancer (SPC) necessitating active surveillance during their disease course. SPCs are associated with poor prognosis and are the leading cause of long-term morbidity and mortality impacting survival of patients with HNSCC. Small cell neuroendocrine carcinoma (SmNEC) is a rare but aggressive neoplasm with poor prognosis and high risk of local recurrence and distant metastasis. We report an exceedingly rare case of nasopharyngeal carcinoma (NPC) presenting as a recurrence in the form of metachronous second primary to primary SmNEC 9 years after chemotherapy. The dual tracer positron emission tomography and computed tomography (PET/CT) imaging approach ([68Ga]Ga-DOTATATE-PET/CT with 18F-FDG-PET/CT) was explored in such metachronous NPCs, and the findings are illustrated with its potential for theranostic applications. NPC is a rare malignancy with significant geographical variations in incidence rates. Somatostatin receptor 2 (SSTR2) expression in NPC is well documented and can serve as a potential theragnostic marker in advanced NPC where the successful outcome is minimal with currently available treatment modalities.

A lifetime economic model of mortality and secondary care use for patients discharged from hospital following acute stroke.

The long-term health-economic consequences of acute stroke are typically extrapolated from short-term outcomes observed in different studies, using models based on assumptions about longer-term morbidity and mortality. Inconsistency in these assumptions and the methods of extrapolation can create difficulties when comparing estimates of life-time cost-effectiveness of stroke care interventions. To develop a long-term model consisting of a set of equations to estimate the life-time effects of stroke care interventions to promote consistency in extrapolation of short-term outcomes. Data about further admissions and mortality was provided for acute stroke patients discharged between 2013 and 2014 from a large English service. This was combined with data from UK life tables to create a set of parametric equations in a model that use age, sex, and modified Rankin Scores to predict the life-time risk of mortality and secondary care resource utilisation including ED attendances, non-elective admissions, and elective admissions. A cohort of 1,509 (male 51%; mean age 74) stroke patients had median follow-up of seven years and represented 7,111 post-discharge patient years. A logistic model estimated mortality within twelve months of discharge and a Gompertz model was used over the remainder of the lifetime. Hospital attendances were modelled using a Weibull distribution. Non-elective and elective bed days were both modelled using a log-logistic distribution. Mortality risk increased with age, dependency, and male sex. Although the overall pattern was similar for resource utilisation, there were different variations according to dependency and gender for ED attendances and non-elective/elective admissions. For example, 65-year-old women with a discharge mRS of 1 would gain an extra 6.75 life years compared to 65-year-old women with a discharge mRS of 3. Over their lifetime, 65-year-old women with a discharge mRS of 1 would experience 0.09 less ED attendances, 2.12 less non-elective bed days and 1.28 additional elective bed days than 65-year-old women with a discharge mRS of 3. Using long-term follow-up publicly available data from a large clinical cohort, this new model promotes standardised extrapolation of key outcomes over the life course, and potentially can improve the real-world accuracy and comparison of long-term cost-effectiveness estimates for stroke care interventions. Data is available upon reasonable request from third parties.

Comparing NEWS2, TRISS, RTS, SI, GAP, and MGAP in predicting early and total mortality rates in trauma patients based on emergency department data set: A diagnostic study

IntroductionIn the global context, trauma remains a significant cause of mortality, particularly among individuals under 50 years old with mortality and morbidity. Timely assessment, efficient triage, and appropriate post-trauma care can help mitigate long-term mortality and morbidity risks. While the trauma and injury severity score (TRISS) is considered accurate, its complexity limits clinical utility, prompting the development of new tools like the National Early Warning Score 2 (NEWS2) and others. Thus, this study aims to evaluate the predictive abilities of NEWS2, RTS (revised trauma score), TRISS, SI (shock index), GAP (Glasgow coma score, age, and systolic blood pressure), and MGAP (mechanism of injury, Glasgow coma score, age, and systolic blood pressure) scoring systems in trauma patient care to enhance outcomes and reduce mortality and morbidity rates. MethodsThis retrospective diagnostic study included a total of 6894 trauma patients with data collected from the emergency department. Patient information, including vital signs and demographic data, was recorded on datasheets completed by ED staff. Ethical guidelines were followed, and patient consent forms were not required due to the study's retrospective nature. Scoring systems such as NEWS2, RTS, TRISS, SI, GAP, and MGAP were calculated and interpreted based on specific formulas and scoring charts. ResultsOf 6894 patients, 2.83% died during hospitalization, and 0.72% within the first 24 hours. Factors associated with mortality included age, cause of injury, duration of hospitalization, and various physiological parameters. The majority of scoring systems are reliable in predicting mortality, except for the sock index (SI), with NEWS2 demonstrating the highest sensitivity and accuracy for predicting mortality rates, while TRISS and RTS were the most specific. GAP was also the most competent predictor of overall mortality. ConclusionMost scoring systems effectively predict mortality, with TRISS and NEWS2 demonstrating high sensitivity and specificity together in forecasting in-hospital mortality. NEWS2 stands out as a precise tool for mortality prediction in the emergency department due to its simplicity and quick application. However, further research is needed to identify the most effective predictive system in trauma patients.

Risk factors for incisional hernia after open abdominal aortic aneurysm repair: a systematic review and meta-analysis.

The incidence of incisional hernia (IH) after an open abdominal aortic aneurysm (AAA) repair can reach up to 35%, contributing to long-term morbidity. Individual studies have been limited in identifying modifiable risk factors for IH after an open AAA repair. This meta-analysis aims to review all the risk factors for IH after an open AAA repair. We searched Cochrane Central, Embase, PubMed, MEDLINE, and Web of Science databases for original studies. Risk factors assessed were age, sex, comorbidities, surgical incision, blood loss, and surgical site infection (SSI). Data analysis was done using RStudio 4.1.2. We computed Relative Risk (RR) for dichotomous outcomes and Mean differences (MD) with 95% Confidence Interval (CI) for continuous outcomes. P-values less than 0.05 were considered statistically significant. Ten studies met the inclusion criteria among 1,795 screened articles. Among those ten studies, there were a total of 1,806 patients of which 341 patients developed IH. Older age (Mean 69.6-70.7 years, MD 1.39 years, CI [1.12-1.66], P < 0.01), midline vertical incision (RR 1.55, CI [1.06-2.25], P = 0.02) and increased intraoperative blood loss (MD 429.8ml, CI [234.8- 624.8], P < 0.01) were associated with an increased incidence of IH. Surgical site infection (SSI) was noted as a risk factor for IH after open AAA repair (RR 2.36, CI [1.31-4.24], P = 0.004). No statistically significant association was found between the incidence of IH and sex (RR 1.0, CI [0.8-1.14], P = 0.98), smoking (RR 1.01, CI [0.93-1.09], P = 0.88), diabetes (RR 1.38, CI [0.85-2.25], P = 0.19), and chronic kidney disease (RR 1.55, CI [0.47-5.09], P = 0.46). This meta-analysis shows that age, midline vertical incision, intraoperative blood loss, and SSI are risk factors for IH after open AAA repair.

Sex-dependent temporal changes in astrocyte-vessel interactions following diffuse traumatic brain injury in rats.

Traumatic brain injury (TBI) is associated with diffuse axonal injury (DAI), a primary pathology linked to progressive neurodegeneration and neuroinflammation, including chronic astrogliosis, which influences long-term post-TBI recovery and morbidity. Sex-based differences in blood-brain barrier (BBB) permeability increases the risk of accelerated brain aging and early-onset neurodegeneration. However, few studies have evaluated chronic time course of astrocytic responses around cerebrovascular in the context of aging after TBI and sex dependence. We observed increased glial fibrillary acidic protein (GFAP)-labeled accessory processes branching near and connecting with GFAP-ensheathed cortical vessels, suggesting a critical nuance in astrocyte-vessel interactions after TBI. To quantify this observation, male and female Sprague Dawley rats (∼3months old, n = 5-6/group) underwent either sham surgery or midline fluid percussion injury. Using immunohistochemical analysis, we quantified GFAP-labeled astrocyte primary and accessory processes that contacted GFAP-ensheathed vessels in the somatosensory barrel cortex at 7, 56, and 168days post-injury (DPI). TBI significantly increased GFAP-positive primary processes at 7 DPI (P < 0.01) in both sexes. At 56 DPI, these vessel-process interactions remained significantly increased exclusively in males (P < 0.05). At 168 DPI, both sexes showed a significant reduction in vessel-process interactions compared to 7 DPI (P < 0.05); however, a modest but significant injury effect reemerged in females (P < 0.05). A similar sex-dependent pattern in the number of accessory processes provides novel evidence of long-term temporal changes in astrocyte-vessel interactions. TBI-induced changes in astrocyte-vessel interactions may indicate chronic BBB vulnerability and processes responsible for early onset vascular and neurodegenerative pathology.

The Effect of Cardiac Rehabilitation in Paediatric Fontan Circulation Patients: A Prospective Intervention Study.

Background and Objectives: The Fontan procedure, a palliative surgery for univentricular heart physiology, often reduces exercise capacity and quality of life. This study aimed to evaluate the impact of cardiac rehabilitation (CR) on improving outcomes in Fontan patients to inform evidence-based care. Materials and Methods: Fontan patients aged 8-30 participated in a structured CR program for at least three months. The program included weekly aerobic and resistance training sessions with educational and nutritional guidance. Baseline and post-CR assessments included cardiac function, fitness, daily activity, and health-related quality of life (HRQOL). Results: The cohort included ten Fontan patients, of whom six had a right systemic ventricle. CR significantly improved cardiorespiratory fitness, as seen in VO2 max (from 27.92 ± 5.15 to 34.69 ± 1.14 mL/kg/min, p = 0.0089) and percent predicted VO2 (from 0.67 ± 0.18 to 0.90 ± 0.02, p = 0.005). VCO2 increased by +8.68 ± 8.59 mL/kg/min but did not reach statistical significance (p = 0.05). Most haemodynamic and ventilatory parameters showed no significant improvement. All the SF-36 questionnaire domains showed significant HRQOL gains (p < 0.001). High adherence (85-93%), no adverse events, and reduced NT-proBNP levels supported the program's safety. Conclusions: This study's findings have important implications for the care of Fontan patients. CR significantly improved exercise capacity and HRQOL in Fontan patients across various anatomies, particularly in the right systemic ventricle. Integrating physical conditioning into standard care could reduce long-term morbidity and mortality; however, further research is needed to refine the protocols and confirm sustained benefits.

Schistosomiasis in the Military-A Narrative Review.

Schistosomiasis is a parasitosis caused by trematodes of the genus Schistosoma. Humans are infected when coming into contact with freshwater containing the parasites' infective stages, which are amplified through freshwater-dwelling snails acting as intermediate hosts. Schistosomiasis has posed significant problems for troops exposed to freshwater in endemic regions ever since the Napoleonic wars. Schistosomiasis has substantial differences in clinical presentation, depending on the type of parasite, intensity of infection and reinfection, clinical form, and disease stage. It can remain undiagnosed for long periods of time, with well-known long-term morbidity and mortality risks. The diagnosis of schistosomiasis depends on its stage and relays on several tests, all with limitations in sensitivity and specificity. The diagnostic gold standard is the detection of eggs in urine, feces, or tissue biopsies, but this can raise problems in patients such as military personnel, in which the worm burden is usually low. Praziquantel is the drug of choice for schistosomiasis. Currently, there is no available commercial vaccine against any Schistosoma parasite. Avoiding freshwater exposure is the best prevention. Herein, we review the clinical presentation, diagnosis, treatment, and prevention of schistosomiasis in the military. This information may decrease the impact of schistosomiasis on this particular professional group.

Secondary solid malignancies in long-term survivors after total body irradiation

BackgroundTotal body irradiation (TBI)-based allogeneic hematopoietic stem cell transplantation (allo-HSCT) is a curative treatment for selected patients with acute myeloid leukemia (AML). Yet, secondary malignancies contribute to long-term morbidity and mortality with TBI potentially influencing these risks.MethodsThis retrospective study analyzed the cumulative incidences of secondary solid malignancies and precancerous lesions of 89 consecutive AML patients after TBI-based conditioning before 1st allo-HSCT between 2000 and 2016. TBI was performed with an average dose rate of 4 cGy/min and a twice-daily fractionation. Cause-specific hazard models analyzed risk factors for secondary malignancies/precancerous lesions and the competing risks of dying before developing secondary malignancies/precancerous lesions.ResultsThe median patient age at TBI was 42.5 years (interquartile range, 32.5–51.2), while the median follow-up was 15.2 years (interquartile range, 13.0-18.2). Most patients received a myeloablative conditioning (MAC) containing 8 Gy (n = 47) and 12 Gy TBI (n = 11). Reduced-intensity regimens (RIC, 4 Gy TBI) were applied in 31 patients. Of note, patients receiving RIC were older than patients receiving MAC. The most common cancer types were non-squamous cell carcinomas (n = 14) after exclusion of a patient diagnosed with sarcoma within less than a year after TBI. The cumulative incidences of secondary malignancies and precancerous lesions were 8% (95%CI, 4–16), 14% (95%CI, 7–23), and 17% (95%CI, 9–27) at 10, 15 and 20 years, while the cumulative incidences of premature deaths were 59% (95%CI, 48–69), 59% (95%CI, 48–69), and 64% (95%CI, 49–76). In multivariate analyses, higher patient age at TBI was associated with lower rates of secondary malignancies/precancerous lesions, while higher patient age translated into a trend towards premature deaths (before patients could develop malignancies). Higher TBI doses, mainly applied in younger patients, translated into lower rates of secondary malignancies/precancerous lesions while lacking associations with mortality. Chronic GVHD requiring systemic immunosuppression was associated with premature deaths.ConclusionsAlthough this study indicates an inverse relationship between TBI doses applied and treatment-related malignancies, confounding by competing risks is present. The age dependency may be explained by the fact that older patients had a lower life expectancy independent of malignancies, illustrating the pitfalls of competing risks.Trial registrationThe study was retrospectively registered.

Cardiopulmonary exercise testing prior to radical cystectomy: a systematic review and meta-analysis.

To identify the association between cardiopulmonary exercise testing (CPET) and outcomes of radical cystectomy (RC), as RC is historically associated with high rates of short- and long-term morbidity and mortality. This quantitative systematic review and meta-analysis was conducted in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines. An electronic literature search was conducted to identify all relevant studies evaluating the relationship between CPET parameters and RC outcomes. The primary outcome was short-term mortality. Secondary outcomes included hospital length of stay (LOS) and rate of serious adverse events as defined by the Clavien-Dindo classification. The search identified six studies for inclusion. A total of 546 patients underwent CPET prior to RC. There were significantly more deaths following RC observed in patients with poorer cardiopulmonary function (risk ratio RR 5.80, 95% confidence interval 4.96-6.78). There was no significant association between CPET parameters and adverse events or hospital LOS. The present systematic review and meta-analysis identified a greater risk of 90-day mortality in patients with poorer cardiorespiratory function, as measured by CPET. However, there remains a paucity of robust clinical data and further high-quality studies are required to verify these results.

Assessment of joint health in patients receiving prophylaxis for haemophilia A: a cross-sectional survey in five European countries

ObjectivesTo evaluate joint health, pain and health-related quality of life (HRQoL) in patients with moderate/severe haemophilia A in Europe.DesignMultinational, cross-sectional survey, with retrospective data collection. Data were taken from the...