Management Of Patients Research Articles

Association of BRAF V600E allele frequency with clinicopathologic outcomes in papillary thyroid cancer.

BRAF V600E mutation is the most common genetic driver of papillary thyroid cancer (PTC), where it is found with various allele frequency (AF), reflecting the proportion of cells carrying the mutant and wild-type gene alleles. To determine whether BRAF V600E AF can improve prognostication and inform initial surgical management of PTC. Retrospective cohort study (2016-2019). UCLA health. Consecutive patients with Bethesda V/VI nodules and isolated BRAF V600E mutation who underwent surgery with histopathology showing PTC. Blinded ThyroSeq v3 molecular analysis after completion of initial management and follow-up. Aggressive histopathology and cancer persistence/recurrence. Of 73 patients, the median BRAF V600E AF was 25.5% (IQR, 16.7-34.3%). Higher median AF was seen in patients classified as American Thyroid Association (ATA) high-risk (37%) vs. intermediate-risk (25.3%, p<0.01) and low-risk (24.7%, p<0.01), largely attributed to higher AF in patients with gross extrathyroidal extension (ETE) (40.1% vs. 25.2% without gross ETE, p=0.02). No differences in AF were observed on the basis of lymph node positivity or presence of aggressive variants of PTC. A higher BRAF V600E AF was also found in patients with tumors ≥2cm vs. <2cm (median 32.0% vs. 24.4%, p<0.01). Over 4.1 years of follow-up, disease persistence/recurrence was found in 7 patients (9.4%) and was associated with higher median AF than those without recurrence (35.3% vs. 25.2%, p=0.02). Higher AF was associated with poorer recurrence-free survival (AF≥35%, HR 7.40, CI 1.4-38.1). Higher AF was associated with gross ETE and increased recurrence risk. This may inform initial management in patients with PTC harboring an isolated BRAF V600E mutation.

Correlation between EtCO2 and PCO2 in patients undergoing critical care transport

ABSTRACT OBJECTIVES End-tidal carbon dioxide (EtCO2) monitoring is widely used as a surrogate for the partial pressure of carbon dioxide (PCO2) in critically ill patients receiving manual or mechanical ventilation in prehospital, emergency, and critical care settings. Specific targets for ETCO2 are a key component of Emergency Medical Services (EMS) protocols, especially for specific patient groups such as those with traumatic brain injury. However, the correlation between EtCO2 and venous or arterial PCO2 is uncertain. We aimed to assess the correlation between EtCO2 and PCO2 in intubated patients undergoing critical care transport (CCT), and in specific subgroups of patients. METHODS We performed a retrospective review of patients undergoing emergency transport by a multi-state CCT agency. Patients were included if they had an advanced airway and both an EtCO2 and PCO2 reading within 5 minutes of each other. We obtained data on patient demographics, transport characteristics, medical categories, vital signs, lab values, and specific interventions. We performed univariable and multivariable binary logistic regression to assess the association between delta PCO2 and these characteristics. RESULTS We included 6,459 patients (mean age 58.4 years [SD 18.5], 57.1% male), of which a subset of 551 patients had multiple EtCO2-PCO2 measurements within 5 minutes. The median (IQR) initial delta PCO2 was 12.9 mmHg (7.1, 21.9). 3,967 (61.4%) patients had a delta PCO2 >10 mmHg and 1,843 (28.5%) had a delta PCO2 >20 mmHg. We identified an independent association between delta PCO2 >10 mmHg and age, male sex, interfacility transport, venous sampling site, respiratory rate, hypotension, hypoxia, and thoracostomy. In patients with multiple blood gas measurements, 76% had delta PCO2 >10 mmHg over the duration of the transport. CONCLUSIONS We identified substantial differences between EtCO2 and PCO2 across patients with medical and traumatic conditions undergoing critical care transport. The PCO2 assessment should be strongly considered as part of ventilatory management in patients encountered in emergency and critical care settings.

Transforming Patient Outcomes: Cutting-Edge Applications of AI and ML in Predictive Healthcare

The integration of Artificial Intelligence (AI) and Machine Learning (ML) in healthcare has emerged as a transformative force, offering unprecedented potential to enhance patient outcomes. This paper explores the cutting-edge applications of AI and ML in predictive healthcare, focusing on how these technologies are revolutionizing early detection, personalized treatment, and patient management. Through advanced algorithms and data-driven insights, AI and ML are enabling healthcare providers to predict disease progression, optimize therapeutic interventions, and improve patient monitoring in real-time. Key applications discussed include predictive modeling for chronic disease management, AI-powered diagnostic tools, and the use of machine learning in precision medicine. The paper also addresses the challenges associated with these technologies, including data privacy concerns, algorithmic bias, and the need for robust validation. By examining current case studies and future trends, this work aims to highlight the transformative impact of AI and ML on patient care, ultimately driving a shift toward more proactive, tailored, and efficient healthcare systems.

The prognostic value of cystography-measured bladder capacity on very early continence rates after radical prostatectomy.

To assess the utility and reliability of cost-effective cystography-measured bladder capacity as a prognostic tool for predicting very early continence recovery following radical prostatectomy. Additionally, the study aims to discuss the clinical implications of the findings, including their potential impact on patient management, postoperative rehabilitation strategies, and the development of personalized care pathways for prostate cancer patients. In this prospective monocentric study, we analyzed 223 patients who underwent either robot assisted radical prostatectomy (RARP) or open radical prostatectomy (ORP) between January 2022 and January 2024. Postoperative cystography was routinely performed 5 days after robot-assisted radical prostatectomy and 7 days after open radical prostatectomy. Very early continence rates were determined using a standardized pad-test conducted on the first day following catheter removal. The bladder capacity during cystography was measured and documented for every patient. The correlation between the rate of continence recovery and the bladder capacity was then assessed. To determine other predictive factors for recovery of continence, several parameters were analyzed using multivariate logistic regression analysis, including age, prostate volume, nerve-sparing technique and surgical procedure. Urinary continence rates at day 1 after catheter removal were 73.5% for patients who underwent RARP and 72.6% for patients who underwent ORP. A strong prognostic value of cystography-measured bladder capacity on very early continence rates was reported (p < 0.001), with a cut-off value calculated to be 140 ml of bladder capacity. After adjusting for additional variables such as age, surgical procedure, prostate volume and nerve-sparing technique, multivariate linear model analysis still found a strong correlation between cystography-measured bladder capacity and very early continence rates (p < 0.001). The cystography-measured bladder capacity may be a good predictor of the recovery of post-prostatectomy urinary continence.

In-hospital management of non-surgical patients treated with gliflozins

In-hospital management of non-surgical patients treated with gliflozins

"The End of the Golden Weather": therapeutic strategies for mantle cell lymphoma relapsed or refractory to covalent BTK inhibitors.

Mantle cell lymphoma (MCL) is a subtype of non-Hodgkin lymphoma which is often characterised by a pattern of continued relapse after frontline chemoimmunotherapy. Although patients are usually able to regain durable disease control with covalent Bruton's tyrosine kinase inhibitors (cBTKi) at first relapse, it is now appreciated that such responses are often not sustained and the management of such patients represents a significant area of unmet need. There is an imperative to better understand resistance mechanisms and identify high-risk subsets of patients for whom cBTKi responses may be particularly short. Allogeneic stem cell transplant has an established role in appropriate candidates, however contemporary consensus is to preferentially offer chimeric antigen receptor (CAR) T-cell therapy. In this Review, we consider the available data on both existing and emerging treatment options, including non-covalent BTK inhibitors, bispecific antibodies, antibody-drug conjugates and Bcl-2 inhibitors and propose a treatment strategy prioritising clinical trials where available.

Septic shock in the prehospital setting: a scoping review.

Septic shock (SS) is a potential life-threatening condition in which an early identification and immediate therapy stand out as the main cornerstones to improve survival chance; in this context, emergency medical services (EMS) become key to reduce the time between diagnosis and management in the ICU or emergency department. However, guidelines for the prehospital management of SS patients remains unclear, and literature around this topic is scant. Our scoping review was conducted following the PICO framework and a search strategy related to septic shock management and diagnosis in prehospital settings was executed in PubMed, Scopus and Virtual Health Library; articles in English and Spanish from 2015, onwards, were screened by the authors and selected by mutual consensus. Our aim is to analyze the prehospital management strategies of SS reported in the literature, and to showcase and summarize the screening tools, demographic factors, clinical manifestations and prognostic factors of SS in the prehospital setting.

Positive and negative syndromes in schizophrenia: analysis of determinants and severity of symptoms in Moroccan patients

Abstract Background Schizophrenia is a debilitating psychiatric condition distinguished by a variety of cognitive, emotional, and behavioral manifestations. It affects an individual’s cognition, emotions, and actions, resulting in challenges in discerning reality from illusion. The objective of the current study was to assess the determinants and severity of symptoms in Moroccan patients hospitalized in Ar-Razi Hospital, Rabat, Morocco using Positive and Negative Syndromes scales (PANSS). Methods One hundred sixty-one schizophrenic patients were admitted to Ar-Razi Hospital in Sale. The PANSS scale, in conjunction with a sociodemographic questionnaire, is utilized as the assessment tool for symptoms. A chi-square test at a 5% error level and a Pearson correlation test were applied to investigate possible associations. Results The findings demonstrate a significant bias towards males (9:1), with 90% being unmarried, and 96.3% originating from urban settings. The breakdown of patients based on symptoms reveals a prevalence of 14.3% for the positive scale, 18% for the negative scale, and 11.2% for the psychopathological scale. The correlation analysis demonstrates a strong relationship between the three scales. The factors that were found to have a notable impact are gender (p &lt; 0.000), functional ability (p &lt; 0.032), socioeconomic status (p &lt; 0.008), living environment (p &lt; 0.05), and use of tobacco and cannabis. Conclusion Confronted with this scenario, healthcare professionals are required to evaluate the key factors in the timely detection of schizophrenia and advocate for the consistent utilization of the PANSS scale in the management and monitoring of patients.

How I approach the treatment of thrombotic complications in patients with myeloproliferative neoplasms.

Arterial and venous thromboses are the most significant complications in patients with myeloproliferative neoplasms (MPN), with the primary treatment goal being thrombotic risk reduction. In MPN with no history of thrombosis, primary prevention mainly involves the use of aspirin and cytoreduction is added in high-risk patients. However, thrombotic complications can unveil an MPN in approximately 20% of cases, necessitating the initiation of both antithrombotic therapy for the thrombosis and cytoreductive treatment for the MPN. The duration of anticoagulant therapy following an initial venous thromboembolic event (VTE) is subject to discussion. Furthermore, the occurrence of a thrombotic complication in patients with a known diagnosis of MPN prompts a reconsideration of both antithrombotic and hematological management. This review employs case-based discussions to explore the management of thrombotic complications in MPN patients. It addresses the nature and duration of antithrombotic treatments, as well as the approach to cytoreduction. Special attention is given to the place of direct oral anticoagulants and to the management of MPN patients with splanchnic vein thrombosis, which is disproportionately common in this group.

Clinical and Structural Parameters in Autosomal Dominant Optic Atrophy Patients: A Cross-Sectional Study Using Optical Coherence Tomography

Background: Autosomal Dominant Optic Atrophy (ADOA) is a hereditary optic neuropathy characterized by retinal ganglion cell degeneration and optic nerve fiber loss. This study examined the correlation between clinical and structural parameters in patients with ADOA using optical coherence tomography (OCT) and explored potential clinical biomarkers. Methods: A cross-sectional, case–control observational study included 27 patients with ADOA and 27 age- and sex-matched healthy controls. Clinical examinations, OCT imaging, and OCT angiography (OCTA) were performed. Statistical analyses were conducted to establish correlations between clinical and OCT parameters. Results: Patients with ADOA exhibited gradual bilateral vision loss, central scotomas, and optic disc pallor. Structural OCT analysis revealed significant reductions in central macular thickness, macular volume, ganglion cell complex (GCC), and peripapillary retinal nerve fiber layer compared with controls. Correlation analysis demonstrated associations between worsening clinical parameters (best corrected visual acuity, Sloan Letters Low Contrast Chart 25%, Pseudoisochromatic Test) and increased OCT damage (structural and OCTA). GCC emerged, at least at exploratory terms, as the most important clinical biomarker in patients with ADOA given its multiple positive functional associations, while OCTA parameters correlated with visual field defects. Conclusions: Our study revealed significant correlations between clinical and structural parameters in patients with ADOA, highlighting the importance of OCT in assessing disease severity. GCC measurement shows promise as a clinical biomarker, aiding in disease monitoring. OCTA parameters offer potential early biomarkers for vascular changes. These findings contribute to understanding ADOA pathophysiology and may improve patient diagnosis and management. Further research is warranted to validate these findings and explore potential therapeutic interventions.

Watch-and-Wait Approach Following Neoadjuvant Chemo-Radiotherapy for Locally Advanced Rectal Cancer: A Retrospective Single-Center Cohort Study.

The watch-and-wait (WW) strategy in patients after complete clinical response (cCR) following chemoradiotherapy for locally advanced rectal cancer (LARC) offers the option of organ preservation. The aim of this study was to assess the oncological outcomes of WW patients treated and followed up in a German referral cancer center. In this retrospective study, we analyzed the clinical records of consecutive patients with LARC who underwent neoadjuvant radiotherapy/chemoradiotherapy at our institution between January 2020 and December 2023 and received non-operative management after cCR. A total of 30 patients undergoing WW for LARC were included. After a median follow-up of 17 months (SD = 10 months), local regrowth occurred in four patients (4/30, 13.3%), and one patient (1/30, 3.3%) developed distant metastasis. No predictor for tumor regrowth could be identified based on radiological findings at diagnosis, including cT4 and/or cN2, involvement of the mesorectal fascia, extramural vascular invasion or infiltration of the anal sphincter/levator. All patients with local regrowth were successfully surgically treated (R0 resection). Nonoperative management for patients with cCR after neoadjuvant therapy for LARC proved to be safe. R0 resection was successfully achieved in all patients who underwent salvage surgery.

Criticism to the revascularization indications attained in the 2023 AHA/ACC/ACCP/ASPC/NLA/PCNA guideline for the management of patients with chronic coronary disease

Clinical practice guidelines are valuable tools that guide doctors' conduct in a series of diseases with high prevalence in the population. The 2023 guideline on chronic coronary disease (CCD), written by the American Heart Association and the American College of Cardiology in conjunction with other American entities is no exception to this rule and although it is designed for application in American medical practice, it gains relevance for use in care of patients affected by this disease worldwide 1. The guidelines help healthcare professionals the best decision-making, with the aim of offering the best possible care to patients, aligned with their expectations, needs and interests. Furthermore, they are important documents for governments, payers and healthcare providers by providing a set of recommendations that help and guide decisions about coverage of diagnostic and therapeutic procedures related to diseases with high prevalence in the population. In this 2023 guideline, the authors say that revascularization is an evolving topic and emphasize that recommendations are typically based on the results of larger randomized controlled trials (RCTs), meta-analyses, or both encompassing a wide range of knowledge on the subject. but they recognize that RCTs do not cover all the nuances involved with the topic, nor do they address all issues comprehensively. Based on this, they made a concentrated effort to stay within the strongest evidence to define these revascularization recommendations in patients with CCD. Within this principle, reviewing chapter 5 dedicated specifically to myocardial revascularization, we are concerned, among other things, with the recommendations resulting from the analysis of some studies that do not clearly reflect the reality of contemporary care provided to patients with CCD, in addition to events that do not reflect the primary outcomes of many of these studies. For this reason, we performed a careful review of the most relevant randomized controlled trials (RCTs), systematic reviews and meta-analyses used in the guideline for revascularization recommendations, which impact a significant number of patients affected by CCD worldwide.

TIPS AND TRICKS IN SURGICAL TREATMENT OF LARGE VESTIBULAR SCHWANNOMAS

Vestibular schwannomas (VS) frequently referred to as acoustic neuromas are the most common tumours of the cerebellopontine angle. They are benign, generally slow-growing tumors that arise from the vestibular portion of the eighth cranial nerve. For patients with large vestibular schwannomas or those exhibiting symptoms from the tumor’s mass effect, surgical intervention remains the preferred treatment approach. This paper discusses the surgical management of patients with large vestibular schwannomas operated in our department and emphasizes the use of intraoperative monitoring for preserving facial nerve function. We review the key surgical steps and highlight the importance of preoperative planning, patient position, and the use of microsurgical techniques to optimize the surgical outcome. Gross total resection of large vestibular schwannomas is associated with worse facial nerve outcomes. Our preferred treatment strategy, especially for older patients, is planned subtotal resection followed by periodic imaging evaluation and radiotherapy in cases of documented tumor growth. This approach may lead to superior facial nerve preservation and improved quality of life for individuals with large vestibular schwannomas. Conclusion The optimal treatment approach for vestibular schwannoma remains a subject of debate. Gross total resection has traditionally been the gold standard for large tumors, but this is often accompanied by a higher risk of postoperative facial nerve dysfunction. Planned subtotal resection with the goal of preserving facial nerve function, followed by closed observation is an alternative approach.

Going with the flow: Implementing a 4D flow MRI program at a children's hospital.

Four-dimensional phase contrast MRI (4D flow) has emerged as a versatile imaging technique for comprehensive visualization and both qualitative and quantitative assessment of cardiovascular blood flow. 4D flow is a three-dimensional, time-resolved acquisition that is gated to the cardiac cycle. 4D flow provides cardiovascular velocity and flow assessment across the volume of acquisition and yields a multitude of advanced hemodynamic parameters that help to assess the impact of cardiovascular disease on flow and vice versa, guiding the clinical and surgical management of patients with congenital and acquired heart disease. In the past, lengthy scan acquisition and complex post-processing workflows hindered 4D flow adoption into routine clinical practice. Decreasing image acquisition times and improvements in post-processing techniques have made 4D flow a clinically useful tool. The purpose of this communication is to facilitate more widespread adoption of 4D flow by describing its clinical utility, technical acquisition, optimization, and post-processing in pediatric cardiovascular imaging at our center.

Multicentre randomised controlled trial comparing Bankart repair with remplissage and Latarjet procedure in shoulder instability with subcritical bone loss (STABLE): study protocol

IntroductionRecurrent shoulder dislocations often cause attrition of the labrum and progressive loss of the anterior bony contour of the glenoid. Treatment options for this pathology involve either soft tissue repair...

Innovative diagnostic technologies: navigating regulatory frameworks through advances, challenges, and future prospects.

Diagnostic tools are key to guiding patient management and informing public health policies to control infectious diseases. However, many diseases still do not have effective diagnostics and much of the global population faces restricted access to reliable, affordable testing. This limitation underscores the urgent need for innovation to enhance diagnostic availability and effectiveness. Developing diagnostics presents distinct challenges, especially for innovators and regulators. Unlike medicines, regulatory pathways for diagnostics are often less defined and more complex due to their diverse risk profiles and wide range of products. These challenges are amplified in low-income and middle-income countries, which often do not have regulatory frameworks for this specific purpose. In the UK, initiatives aim to support innovation by providing clearer regulatory pathways and ensuring that diagnostics are safe and effective. Regulators are also collaborating internationally to expedite diagnostics for high-need regions. Harmonised standards, regulatory frameworks, and approval processes are essential to ensure consistent quality and safety across regions and facilitate faster development and global access. This Series paper explores the regulatory challenges in infectious disease and antimicrobial resistance diagnostics, focusing on the UK's response and the broader global efforts to address these issues.

Mechanisms and Implications of Electrical Heterogeneity in Cardiac Function in Ischemic Heart Disease.

A healthy heart shows intrinsic electrical heterogeneities that play a significant role in cardiac activation and repolarization. However, cardiac diseases may perturb the baseline electrical properties of the healthy cardiac tissue, leading to increased arrhythmic risk and compromised cardiac functions. Moreover, biological variability among patients produces a wide range of clinical symptoms, which complicates the treatment and diagnosis of cardiac diseases. Ischemic heart disease is usually caused by a partial or complete blockage of a coronary artery. The onset of the disease begins with myocardial ischemia, which can develop into myocardial infarction if it persists for an extended period. The progressive regional tissue remodeling leads to increased electrical heterogeneities, with adverse consequences on arrhythmic risk, cardiac mechanics, and mortality. This review aims to summarize the key role of electrical heterogeneities in the heart on cardiac function and diseases. Ischemic heart disease has been chosen as an example to show how adverse electrical remodeling at different stages may lead to variable manifestations in patients. For this, we have reviewed the dynamic electrophysiological and structural remodeling from the onset of acute myocardial ischemia and reperfusion to acute and chronic stages post-myocardial infarction. The arrhythmic mechanisms, patient phenotypes, risk stratification at different stages, and patient management strategies are also discussed. Finally, we provide a brief review on how computational approaches incorporate human electrophysiological heterogeneity to facilitate basic and translational research.

Predictors for colectomy in patients with acute severe ulcerative colitis: a systematic review and meta-analysis

ObjectivesAcute severe ulcerative colitis (ASUC) poses challenges to patient management owing to its high surgical rate. This study aimed to identify predictors of colectomy in patients with ASUC.DesignThis is a...

Comparison and validation of several scoring systems for non-variceal upper gastrointestinal bleeding: a retrospective study.

Various scoring systems have been developed to predict outcomes in patients with non-variceal upper gastrointestinal bleeding (NVUGIB). However, their accuracy remains unclear. This study aimed to compare and validate the predictive performance of several established scoring systems in patients with NVUGIB: Glasgow-Blatchford score (GBS) and the age, blood tests, and comorbidities (ABC), mental status-anesthesiologist score-pulse-albumin-systolic blood pressure-hemoglobin (MAP(ASH)), Japanese, and Charlson comorbidity index-in-hospital onset-albumin-mental status-Eastern Cooperative Oncology Group performance status-steroids (CHAMPS) scores. We retrospectively reviewed the records of 1,241 patients who presented to the emergency department with NVUGIB and subsequently required hospitalization. Each scoring system was evaluated for its ability to predict in-hospital mortality, rebleeding, and the need for radiological or surgical intervention. The ABC score showed the highest accuracy in predicting in-hospital mortality. The MAP(ASH) score was the most effective predictor of rebleeding and the need for interventions. Different scoring systems have been optimized for various clinical outcomes. The ABC score was the best for predicting mortality, whereas the MAP(ASH) score excelled in identifying rebleeding risks and intervention needs. The selection of an appropriate scoring tool based on specific clinical scenarios can improve patient management and resource allocation in NVUGIB.

Observation of patients after cardiac surgery, surgical aspects for pediatricians

The article discusses the practical aspects of caring for children after heart surgery. It provides information on the timing of follow-ups, the frequency of pediatrician visits, and describes the most important aspects of patient management for different groups. The article identifies several groups of patients based on their postoperative risks and follow-up needs. Purpose of the article is to present the observation features of patients who have undergone surgery for congenital heart defects, from the perspectives of surgeons and pediatricians.