Medical Center Research Articles

Real-world Evaluation of Imipenem/cilastatin/relebactam across US Medical Centers

We assessed 160 patients who received imipenem/cilastatin/relebactam for ≥2 days. At treatment initiation, median Charlson Comorbidity Index was 5, 45% were in the intensive care unit, and 19% required vasopressor support. The in-hospital mortality rate was 24%. These data advance our understanding of real-world indications and outcomes of imipenem/cilastatin/relebactam use.

Traumatic injury to the posterior fossa: a secondary analysis and description of case series from the NEXUS head injury dataset

Traumatic brain injuries involving the posterior fossa are rare and case reports indicate they often result in severe outcomes. We seek to describe characteristics and outcomes of traumatic posterior fossa injuries. We performed a planned secondary analysis of all patients with posterior fossa injuries enrolled in the NEXUS head computed tomography (CT) validation study dataset. The dataset includes prospectively collected data on all patients undergoing non-contrast cranial CT following blunt traumatic head injury from April 2006 to December 2015, at four emergency departments comprising community and university sites, as well as urban, suburban and rural settings in California (Antelope Valley Hospital, San Francisco General Hospital, UCLA Ronald Reagan Medical Center, UCSF Fresno Community Regional Medical Center). We classified each patient into one of three injury patterns: Type I-notable traumatic injuries primarily above the tentorium, with minimal posterior fossa involvement; Type II-notable traumatic injuries both above and within the posterior fossa; and Type III-notable traumatic injuries primarily within the posterior fossa. We extracted demographic data for each patient as well as physician assessments of the NEXUS head CT and Canadian Head CT rule clinical criteria, mechanisms of injury, patient outcomes, and the location and types of intracranial injuries sustained. Of 11,770 patients in the database, 184 (1.6%) had posterior fossa injuries on CT imaging. Mean age was 55.4 years (standard deviation 22.5 years, range 2-96 years); 131 (71.2%) were males. We identified 63 patients with Type I injuries, 87 with Type II injuries, and 34 Type III injuries. The most common mechanisms of injury were falls (41%), pedestrian vs automobile (15%), and motor vehicle collisions (13%). On presentation most patients had altered mental status (72%), abnormal behavior (53%), or a neurologic deficit (55%). The majority of individuals, 151 (82%), had clinically important injuries and 111 (60%) required neurosurgical intervention. The dispositions for the subjects included 52 deaths (28%), 49 (27%) patients discharged home, and 48 (26%) discharged to rehabilitation facilities. When compared to individuals with Type I and Type II injuries, patients with Type III injuries had lower mortality (6% vs 30% and 35%) and higher percentage of patients discharged home (60% vs 19% and 21%). Patients with Type I and II injury patterns (those that involve both the posterior fossa and supratentorium) experienced high mortality and disability. Patients with Type III injuries (isolated posterior fossa) had a better prognosis. None.

Causes of Acquired Methemoglobinemia – a Retrospective Study at a Large Academic Hospital

Methemoglobinemia is a potentially life-threatening condition caused by the formation of methemoglobin, a form of hemoglobin that cannot bind oxygen. While there are some rare congenital causes of methemoglobinemia, most cases are acquired from the effects of specific drugs or environmental exposures. In this retrospective study, we analyzed a large data set of whole blood samples analyzed for methemoglobin at an academic medical center in Midwestern United States that provides both pediatric and adult services. For a 14 year timeframe (May 2009- June 2023), we performed detailed chart analysis of all patients with a methemoglobin concentration of 3.1% or higher. For an earlier 13 year timeframe (January 1996-April 2009), we performed chart review for all patients with a methemoglobin concentration of 10.0% or higher. For the 2009-2023 data, dapsone was the most frequent cause of methemoglobinemia (methemoglobin 3.1% or higher) in both pediatric (73.3%, 115 clinical encounters, 105 unique patients) and adult (65.3%, 195 clinical encounters, 190 unique patients) populations. Inhaled nitric oxide as medical therapy was the next most frequent cause in both pediatric (18.1%) and adult (13.2%) populations. Causes associated with two or more unique episodes with methemoglobin concentrations of 10.0% and higher included the following: dapsone (n=40 episodes), benzocaine (n=10), recreational use of amyl or isobutyl nitrite (n=3), suicide attempt with sodium nitrite (n=3 with 1 fatality; all 3 cases within last 3 years), food contaminated with nitrates (n=2), and sepsis (n=2). A total of 18 patients received treatment with methylene blue including 5 cases associated with benzocaine and all of the cases associated with amyl nitrite, isobutyl nitrite, sodium nitrite, and contaminated food. Only 3 patients with dapsone-associated methemoglobinemia received methylene blue, reflecting primary management by dose reduction or discontinuation of drug. Overall, our data reinforce previous studies showing dapsone, inhaled nitric oxide, and nitrites as common agents causing methemoglobinemia in a patient population seen at a medical center. Our data also are consistent with recent epidemiology trends showing increase in suicide attempts using sodium nitrite.

Distribution of Traditional Chinese Medicine syndromes in diabetic kidney disease chronic kidney disease 1-5: a correlation study.

To analyze the distribution of Traditional Chinese medicine (TCM) syndromes in patients with diabetic kidney disease (DKD) and its related factors. We enrolled 435 patients with DKD, who were not undergoing dialysis, admitted to the Department of Nephrology, First Medical Center, Chinese PLA General Hospital from April 2020 to August 2021. Analysis of their TCM syndromes and related factors was carried out. The 435 patients included 109, 117, 86, and 123 chronic kidney disease (CKD) 1-2, CKD3, CKD4, and CKD5 cases, respectively. With the progression of CKD1-5, the proportion of Yin deficiency and dry heat syndrome, and that of Qi and Yin deficiency syndrome showed a downward trend, whereas the proportion of spleen-kidney Yang deficiency, blood deficiency, blood stasis, water stagnation, and phlegm turbidity syndromes showed an upward trend; the differences were statistically significant (P < 0.05). Multivariate logistic regression analysis showed that Yin deficiency and dry heat syndrome was positively correlated with hemoglobin [odds ratio (OR) = 1.022, P = 0.005], albumin (OR = 1.058, P = 0.006), and estimated glomerular filtration rate (eGFR) (OR = 1.020, P < 0.001) but negatively correlated with male sex (OR = 0.277, P = 0.004). Qi and Yin deficiency syndrome was positively correlated with albumin (OR = 1.056, P < 0.001) and eGFR (OR = 1.008, P = 0.022) but negatively correlated with age (OR = 0.977, P = 0.023). Liver-kidney Yin deficiency syndrome was positively correlated with age (OR = 1.028, P = 0.021) and glycosylated hemoglobin (OR = 1.223, P = 0.007) but negatively correlated with total cholesterol (OR = 0.792, P = 0.006). Spleen-kidney Yang deficiency syndrome was negatively correlated with hemoglobin (OR = 0.977, P < 0.001), albumin (OR = 0.891, P < 0.001), and eGFR (OR = 0.978, P < 0.001) but positively correlated with high density lipoprotein (OR = 3.376, P = 0.001). With CKD1-5 progression, TCM syndromes changed from Yin deficiency and dry heat syndrome to syndrome of deficiency of both Qi and Yin, liver-kidney Yin, and spleen-kidney Yang deficiency syndromes. TCM syndromes were correlated with laboratory test results.

Contrast-enhanced Imaging in Peripheral Pulmonary Lesions: The Role in US-guided Biopsies.

Purpose To compare the tissue adequacy and diagnostic accuracy of US-guided biopsies of peripheral pulmonary lesions (PPLs) with and without contrast agents. Materials and Methods A retrospective study was conducted at four medical centers in patients with PPLs who underwent US-guided percutaneous transthoracic needle biopsy (PTNB) between January 2017 and October 2022. The patients were divided into contrast-enhanced US (CEUS) and US groups based on whether prebiopsy CEUS evaluation was performed. Tissue adequacy and the diagnostic accuracy of PTNB, stratified by lesion size, were analyzed and compared between groups. A propensity score matching (PSM) analysis was conducted using the nearest-neighbor matching method. Results A total of 1027 lesions were analyzed, with 634 patients (mean age, 59.4 years ± 13.0 [SD]; 413 male) in the US group and 393 patients (mean age, 61.2 years ± 12.5; 270 male) in the CEUS group. The CEUS group produced more acceptable samples than the US group (98.2% vs 95.7%; P = .03) and achieved higher diagnostic accuracy (96.9% vs 94.2%; P = .04), with no evidence of a difference in sensitivity (96.7% vs 94.0%; P = .06). PSM and stratified analyses (n = 358 per group) indicated higher tissue adequacy (99.0% vs 95.7%; P = .04) and diagnostic accuracy (98.5% vs 92.9%; P = .006) in the CEUS group compared with the US group for 2-7-cm PPLs but not for lesions larger than 7 cm. Conclusion PTNB with prebiopsy CEUS evaluation demonstrated significantly better tissue adequacy and diagnostic accuracy compared with US guidance alone for PPLs ranging from 2 to 7 cm, with similar biopsy performance achieved between groups for lesions larger than 7 cm. Keywords: Contrast Material, Thoracic Diseases, Ultrasonography, Image-Guided Biopsy © RSNA, 2024.

Cochlear Implantation in Patients With Osteolytic Labyrinthitis: A Case Series.

To describe the rare process of osteolytic labyrinthitis, previously referred to as labyrinthine sequestrum, which involves progressive obliteration of the bony and membranous labyrinth with eventual supplantation with soft tissue and, in some cases, bony sequestrum. Three patients with diverse presentations of osteolytic labyrinthitis from two tertiary care academic medical centers. Case series report analyzing the relevant clinical, radiologic, pathologic, and surgical data on our patients with osteolytic labyrinthitis and comparing these index cases to the existing literature. We describe the varying image findings seen in osteolytic labyrinthitis on computed tomography and magnetic resonance imaging. Also, we report successful surgical intervention and hearing rehabilitation with cochlear implantation in patients with osteolytic labyrinthitis. Our three patients presented with profound sudden sensorineural hearing loss and vertigo consistent with labyrinthitis. None of the three patients had a history of chronic otitis media. Imaging workup revealed varying degrees of erosion to the otic capsule bone demonstrating the spectrum of disease seen in osteolytic labyrinthitis. Although two cases showed osteolytic changes to the semicircular canals and vestibule, the first case revealed frank bony sequestrum within the obliterated labyrinth. The three cases were taken for surgical debridement and cochlear implantation. We propose the new term, osteolytic labyrinthitis-previously referred to as labyrinthine sequestrum-to describe the rare spectrum of disease characterized by destruction of the osseous and membranous labyrinth and potential supplantation with bony sequestrum. Cochlear implantation is a viable option in selected patients with osteolytic labyrinthitis.

Successful Implementation of the AIUM Standardized 4-Year Residency Ultrasound Curriculum in Obstetrics and Gynecology: Lessons Learned and Way Forward.

Significant disparities in sonographic education exist in Obstetrics and Gynecology programs in the United States. To address the lack of standardization in ultrasound teaching, the American Institute of Ultrasound in Medicine (AIUM) assembled a multi-society task force in 2018 that resulted in the publication of a Consensus Report outlining a standardized ultrasound curriculum and competency assessment. The primary objective of the study was to implement the AUIM standardized curriculum within an Obstetrics and Gynecology residency program at a tertiary medical center, and report on the early implementation experience. The secondary objective was to assess current national practices in ultrasound training in Obstetrics and Gynecology residency programs. Study design was an effectiveness-implementation hybrid study of a structured ultrasound educational program based on the 2018 AIUM Consensus Report. The theoretical portion of the curriculum consisted of 26 hours of didactic lectures distributed over 4 years. For the practical component, residents received instruction from faculty and sonographers and independently acquired the required images as part of their regular clinical work. Simulator app access was also provided for additional opportunities to practice and acquire images. Deidentified images for the required competencies were uploaded to a WhatsApp group for review. Theoretical knowledge was assessed with a series of multiple-choice exams. Practical skills were assessed through grading of images submitted through WhatsApp as well as direct observations of resident scans. At the completion of 4 years, the assessment of both theoretical knowledge and practical skills was carried out using the ISUOG Basic Training Examination. National patterns in the area of ultrasound education were assessed with a four-question electronic survey of Obstetrics and Gynecology program directors in the United States. Analysis of both portions of the study was primarily descriptive. Four Obstetrics and Gynecology residents completed the curriculum spanning postgraduate years 1 through 4. The number of competencies completed ranged from 7 to 19 out of 41. All of the residents passed the theoretical and practical components of the ISUOG Basic Training Examination. For the residency program director survey portion of the study, response rate was 20% (59 of 290). Among the respondents, 55.9% reported having a structured curriculum and 34.4% reported implementing the AIUM curriculum. The two most commonly cited obstacles to implementation of structured ultrasound teaching were uncertainty with how to start the process (49.2%) and lack of faculty engagement (49.2%). Implementation of the AIUM Curriculum within the framework of an Obstetrics and Gynecology residency program at a tertiary medical center is feasible. In our experimental group, completion of the curriculum resulted in passing of an internationally recognized validated assessment. Obstacles to implementation in our program included a wide range of engagement and participation among residents, and limited opportunities to obtain some of the required competencies. Identification of obstacles to implementation from the perspective of residency program directors is critical for developing targeted approaches to ensure widespread implementation. Successful standardized validated sonographic training of graduating Obstetrics and Gynecology residents is crucial for this operator-dependent modality that has tremendous implications on patient safety and clinical care.

Real-time identification of life-threatening necrotizing soft-tissue infections using indocyanine green fluorescence imaging.

Necrotizing soft-tissue infections (NSTIs) are life-threatening infections with a cumulative case fatality rate of 21%. The initial presentation of an NSTI is non-specific, frequently leading to misdiagnosis and delays in care. No current strategies yield an accurate, real-time diagnosis of an NSTI. A first-in-kind, observational, clinical pilot study tested the hypothesis that measurable fluorescence signal voids occur in NSTI-affected tissues following intravenous administration and imaging of perfusion-based indocyanine green (ICG) fluorescence. This hypothesis is based on the established knowledge that NSTI is associated with local microvascular thrombosis. Adult patients presenting to the Emergency Department of a tertiary care medical center at high risk for NSTI were prospectively enrolled and imaged with a commercial fluorescence imager. Single-frame fluorescence snapshot and first-pass perfusion kinetic parameters-ingress slope (IS), time-to-peak (TTP) intensity, and maximum fluorescence intensity (IMAX)-were quantified using a dynamic contrast-enhanced fluorescence imaging technique. Clinical variables (comorbidities, blood laboratory values), fluorescence parameters, and fluorescence signal-to-background ratios (SBRs) were compared to final infection diagnosis. Fourteen patients were enrolled and imaged (six NSTI, six cellulitis, one diabetes mellitus-associated gangrene, and one osteomyelitis). Clinical variables demonstrated no statistically significant differences between NSTI and non-NSTI patient groups (). All NSTI cases exhibited prominent fluorescence signal voids in affected tissues, including tissue features not visible to the naked eye. All cellulitis cases exhibited a hyperemic response with increased fluorescence and no distinct signal voids. Median lesion-to-background tissue SBRs based on snapshot, IS, TTP, and IMAX parameter maps ranged from 3.2 to 9.1, 2.2 to 33.8, 1.0 to 7.5, and 1.5 to 12.7, respectively, for the NSTI patient group. All fluorescence parameters except TTP demonstrated statistically significant differences between NSTI and cellulitis patient groups (). Real-time, accurate discrimination of NSTIs compared with non-necrotizing infections may be possible with perfusion-based ICG fluorescence imaging.

Therapeutic apheresis in kidney transplantation: Emerging trends.

The use of therapeutic apheresis (TA) either as stand-alone or adjunctive treatment in kidney transplantation has increased over the years to become a leading indication. This study shows recent trends in indications for TA related to kidney transplantation, adverse events, and patient outcome in this cohort. This is a retrospective cohort review of adults who received TA for kidney transplant-related indications from January 1, 2017, to December 31, 2022, at the University of Virginia Medical Centre, Charlottesville, VA, USA. Data extracted include basic demographics, indication for apheresis, number of procedures, procedure characteristics, procedure-related adverse events (complications), and serum ionized calcium and serum creatinine. Data were analyzed using statistical package for social sciences (SPSS 2022 IBM Inc). Data from a total of 131 patients who received 860 TA procedures were analyzed. Indications for TA were antibody-mediated rejection (65.5%), recurrent focal segmental glomerulosclerosis (15%), thrombotic microangiopathy (5%), desensitization for ABO incompatibility (4.5%) and for HLA-incompatibility (4.5%), and recurrent IgA nephropathy (1%). Some adverse events were encountered in 16.7% of the procedures and include hypocalcemia (7%), vascular access malfunction (0.7%), hypotension (1.2%), arrhythmia (0.6%), and depletion coagulopathy (0.6%). The overall case mortality rate was 8.4% over the 6-year period. There was one death recorded on machine during TA resulting in a procedure-mortality rate of 0.12%. Antibody-mediated rejection was the most common indication for TA related to kidney transplantation. Adverse events were minor and patient survival over the time was within usual limits.

Infantile Hemangioma with Minimal or Arrested Growth: Different Clinical Presentations in a Retrospective Case Series

Objectives: Infantile hemangioma with minimal or arrested growth (IHMAG) has been established as a subtype of infantile hemangioma (IH) due to positive glucose transporter-1 staining; however, it is clinically differentiated by a proliferative component of &lt;25% of its total surface area. IHMAG can be misdiagnosed as a capillary malformation, an IH precursor, a noninvoluting congenital hemangioma, or an arteriovenous malformation among others. In this case series, we aim to further illustrate the various clinical characteristics of IHMAG and the features that distinguish this unique entity from the other vascular entities. It is important to recognize the differentiating characteristics to avoid unnecessary evaluation and provide patients with the appropriate management plan. Methods: A retrospective chart review approved by the University of Rochester Medical Center Institutional Review Board was performed from January 2014 to December 2020, with the search terms: “infantile hemangioma with arrested or minimal growth,” “IHMAG” and “abortive hemangioma.” In total, 29 IHMAGs were identified in 27 patients. Charts were reviewed for demographic and clinical characteristics as well as workup, response to treatment, and outcomes. Results: In total, we identified 29 IHMAGs in 27 patients. Female to male ratio was 2:1. Average gestational age was 40 weeks. Lesions were present at birth in 22/27 patients. Out of the 29 IHMAGs, 18 were focal (62%) and 11 were segmental (38%). In most patients, skin examination revealed fine telangiectatic patches with focal areas of bright red papules. Out of 29 IHMAGs, 20 involved the lower body and 18 were focal, whereas 11 were segmental. PHACES syndrome (posterior fossa anomalies, infantile hemangioma, arterial anomalies, cardiac anomalies, eye anomalies, and midline skin defects) was identified in 2 of 2 patients with facial segmental IHMAGs. LUMBAR syndrome (lower body infantile hemangiomas and other skin defects; urogenital anomalies and ulceration; myelopathy; bony deformities; anorectal malformations and arterial anomalies; and rectal anomalies) was ruled out in 2 of 2 patients with extensive IHMAGs involving the sacral area. Semicircular lipoatrophy was seen in 1 patient with segmental circumferential IHMAG of the leg. Ultrasonography was the most used modality. Out of 27 infants, 18 were treated with topical timolol, 4 were treated with oral propranolol, and 2 patients were treated with a combination of both. Conclusion: Trends of the epidemiologic, clinical, and prognostic data of our 27 cases are in concordance with prior reports on IHMAG, further consolidating our understanding of this peculiar entity. IHMAG typically presents as a telangiectatic pink to violaceous patch present at birth in term newborns predominantly involving the lower half of the body. It is important to keep a high index of suspicion for the other vascular anomalies in the differential diagnosis. A segmental IHMAG should prompt providers to screen for associated syndromes such as PHACES and LUMBAR. Additional studies are warranted to better elucidate the pathogenesis of IHMAG and its associated anomalies. Level of evidence: Original report (case series).

The Efficacy and Safety of Radiation-Free Retrograde Intrarenal Surgery: A Prospective Multicenter-Based, Randomized, Controlled Trial.

Fluoroscopy is usually required during retrograde intrarenal surgery (RIRS). Although fluoroscopy is considered necessary for effective and safe RIRS, there is growing awareness regarding radiation exposure risk to patients and surgeons. We conducted a multicenter-based, randomized, controlled trial to compare the safety and effectiveness of radiation-free (RF) RIRS with radiation-usage (RU) RIRS for kidney stone management. From August 2020 to April 2022, patients with a unilateral kidney stone (≤20 mm) eligible for RIRS were prospectively enrolled in 5 tertiary medical centers after randomization and divided into the RF and RU groups. RIRS was performed using a flexible ureteroscope with a holmium:YAG laser. The primary end point of this study was the success rate, defined as complete stone-free or residual fragments with asymptomatic kidney stones ≤ 3 mm. The secondary end point of this study was ascertaining the safety of RF RIRS. The success rates were analyzed using a noninferiority test. Of the 140 consecutive randomized participants, 128 patients completed this study (RF: 63; RU: 65). The success rates (78% vs 80%, P = .8) were not significantly different between the groups. The rate of high-grade (grade 2-4) ureter injury was not significantly higher in the RF group compared to the RU group (RF = 3 [4.8%] vs RU = 2 [3.1%], P = .6). In RF RIRS, the success rate was noninferior compared to RU RIRS (the difference was 2.2% [95% CI, 0.16-0.12]). This study demonstrated that the surgical outcomes of RF RIRS were noninferior to RU RIRS.

Liver histology is associated with long-term clinical outcomes in patients with metabolic dysfunction-associated steatohepatitis.

Few studies have examined the risk of long-term clinical outcomes in patients with metabolic dysfunction-associated steatohepatitis in relation to liver histology. We aimed to study this using a real-world cohort. Adults (N = 702) recorded on Vanderbilt University Medical Center's Synthetic Derivative database (1984-2021) with evidence of metabolic dysfunction-associated steatohepatitis on liver biopsy were followed from the first biopsy until the first clinical event or last database entry (median: 4.7y). Risks of cirrhosis (N = 650), other noncirrhotic liver-related (N = 702) and cardiovascular-related outcomes (N = 660), and mortality due to liver, cardiovascular, or cancer events (N = 660) were determined as a function of baseline histology (fibrosis stage [F], lobular inflammation grade [LI], hepatocyte ballooning grade [HB], and steatosis score) adjusting for sex, age, diabetes, and weight-loss surgery. Cirrhosis risk was reduced for lower versus higher fibrosis stage (HR: F0-1 vs. F3: 0.22 [95% CI: 0.12-0.42]), LI1 versus LI2-3 (0.42 [0.19-0.97]), and HB1 versus HB2 (0.20 [0.08-0.50]). Lower fibrosis stage was associated with significantly lower risks of liver-related outcomes versus F4 cirrhosis (eg, F0-1: 0.12 [0.05-0.25]), whereas no differences were seen across baseline lobular inflammation, hepatocyte ballooning, and steatosis grades/scores. Lower versus higher lobular inflammation grade was associated with lower risks for liver-related outcomes in patients with weight-loss surgery. There was a trend for lower risks for cardiovascular-related and any long-term outcomes with lower versus higher fibrosis stage. Fibrosis stage and lobular inflammation and hepatocyte ballooning grades predict the risk of long-term outcomes, supporting the use of these histological features as potential surrogate markers of disease progression or clinical outcomes.

Patient Consent for Medical Student Pelvic Exams under Anesthesia: An Exploratory Retrospective Chart Review.

We conducted an exploratory retrospective chart review of electronic consent forms at a single academic medical center using contingency tables, logistic regression, and nonparametric tests to explore relationships between patient and physician characteristics and consent. We identified and downloaded electronic consent forms for a census of 4,000 patients undergoing gynecologic surgery from September 2020 through calendar year 2022. Forms were linked to anonymized medical record information. Of the 4,000 patients, 142 (3.6%) were removed from analysis because consent forms were incomplete. Of 3,858 patients, 308 (8.0%) were asked for EUA consent more than once, 46 of whom were not consistent. Overall, 3,308 (85.7%) patients consented every time asked, and 550 (14.2%) refused or limited EUA consent at least once. Nine patients limited their consent to female students, and two patients refused medical student participation at all. We performed exploratory multiple logistic regression analyses exploring differences in rates of consent across patient and physician demographic groups. We find that some patients are more likely than others to refuse a pelvic EUA, magnifying the dignitary harm from a nonconsensual invasion of intimate bodily integrity and perpetuating historic wrongs visited upon vulnerable people of color and religious minorities. Patients' rights to respect and control over their bodies require that physicians take seriously the ethical obligation to inform their patients and ask them for permission.

Off-Label Reduced Dose Apixaban in Older Adults With Atrial Fibrillation and Associated Outcomes.

Apixaban is commonly used to prevent stroke in older adults with nonvalvular atrial fibrillation (AF). Although its package insert has specific dose reduction criteria, providers may dose reduce outside of these parameters based on clinical scenarios. The primary objective was to determine the incidence of apixaban off-label reduced dosing, while secondarily determining the safety and efficacy outcomes associated with such dosing. A retrospective analysis of patients aged 65 and older with orders for apixaban for AF was institutional review board (IRB)-approved and conducted across 3 academic medical centers. Patients receiving off-label reduced-dose apixaban (ie, "underdosed") were matched to a cohort of patients dosed according to the package insert at the standard dosing (5 mg twice daily) using stratified random sampling. Secondary outcomes included 1-year incidence of major bleeding, clinically relevant non-major bleeding (CRNMB), stroke or transient ischemic attack (TIA), and mortality. The Fisher exact tests were used to compare between-group differences. Of the 1172 patients meeting initial inclusion criteria, 201 (17%) were dosed off-label, with 175 (15%) "underdosed." The 147 "underdosed" patients with documented follow-up were matched with 139 patients receiving standard Food and Drug Administration (FDA)-labeled dosing. There were no significant differences in incidence of stroke (2.7% vs 2.2%), major bleeding (0% vs 0.7%), and CRNMB (2.7% vs 1.4%) in the off-label reduced dosing versus standard dosing groups. All-cause mortality was higher in the off-label reduced-dose group (16 [10.9%] vs 2 [1.4%], P < 0.05). Older adults with nonvalvular AF are commonly prescribed lower-than-recommended doses of apixaban. However, no significant association was found between empiric off-label reduced dosing and stroke or bleeding outcomes.

Design and Methods of the Early Age-Related Hearing Loss Investigation Randomized Controlled Trial.

Hearing loss has been identified as a major modifiable risk factor for cognitive decline. The Early Age-Related Hearing Loss Investigation (EARHLI) study will assess the mechanisms linking early age-related hearing loss (ARHL) and cognitive impairment. Randomized, controlled, single-site, early phase II, superiority trial. Tertiary academic medical center. One hundred fifty participants aged 55 to 75 years with early ARHL (severity defined as borderline to moderate) and amnestic mild cognitive impairment will be included. Participants will be randomized 1:1 to a best practice hearing intervention or a health education control. The primary study outcome is cognition measured by the Alzheimer Disease Cooperative Study-Preclinical Alzheimer Cognitive Composite. Secondary outcomes include additional measures of cognition, social engagement, and brain organization/connectivity. Trial enrollment will begin in early 2024. After its completion in 2028, the EARHLI trial should offer evidence on the effect of hearing treatment versus a health education control on cognitive performance, social engagement, and brain organization/connectivity in 55- to 75-year-old community-dwelling adults with early ARHL and amnestic mild cognitive impairment.

Foveal Changes after Uneventful Phacoemulsification Surgery for Senile Nuclear Cataract

Objective: To describe foveal thickness and foveal anatomical changes after uneventful phacoemulsification surgery. Design: Interventional case control study. Participants: Both eyes of healthy phakic patients presenting to the American University of Beirut Medical Center Eye clinic for phaco-emulsification surgery in one eye (the study eye). The fellow eye served as control. Methods: OCT images of the macula were taken pre-operatively, then on a weekly basis for 12 weeks post-operatively. Outcomes: post op foveal thickness and morphological changes. Results: From the originally recruited 66 patients, 52 patients (104 eyes) completed the study. A transient increase in foveal thickness was observed in 36/52 (69%) eyes mostly between weeks 4 and7 post operatively. Twenty-seven eyes developed anatomic changes including: microcysts in 15 eyes (55%), regular cysts in 6 eyes (22%), and epiretinal membranes in 6 eyes (11.5%). Changes appeared as early as 1 week post operatively, and lasted on the average 4 weeks. Conclusion: Uncomplicated cataract surgery can lead to transient thickening of the macula as well as morphological changes.

Serial neutrophils count as a stratifying tool for early follicular tonsilitis remission

Background/Aim: This study examines the correlation between sequential serum neutrophil levels and the overall improvement status or reduction rate of intravenous antibiotic administration. This study seeks to identify a cost-effective and easily accessible biomarker that can accurately predict the need for hospitalisation in patients with acute tonsillitis who are receiving intravenous broad-spectrum antibiotics. The goal is to determine the patients' suitability for early discontinuation of intravenous antibiotics and discharge. Methods: This study was conducted at the King Hussein Medical Centre in Jordan, focusing on patients with severe acute tonsillitis who did not respond to oral antibiotics. Data was collected from the electronic medical record system (Hakeem) from January 2018 to May 2021. The study classified serial serum neutrophil measurements during the first week of hospital admission into four categories. The levels were compared between the non-penicillin Cohort (Group I) and penicillin Cohort (Group II) using an Independent-T Test. The outcomes of interest included a drop in neutrophil counts exceeding 50%, a decrease in the use of intravenous antibiotics in favor of oral antibiotics, and early eligibility for discharge. The study also examined serial neutrophil counts over the tested days and compared to the outcomes of positive and negative states using receiver operating curve analyses. The optimal cutoff operating point for each ROC curve was determined by selecting the highest Youden's index of each prognosticator day level. The analysis of all results was conducted using SPSS version 20 with a significance level set at p-value &lt;0.05. Results: This study analyzed 1638 adult and elderly patients admitted to KHMC, RMS, Amman, Jordan between January 2018 and May 2021. The average age was 51.88±16.22 years, with patients dependent on intravenous penicillin being slightly older. The distribution of males and females was significant, with males making up 2.55 times the number of females. The odds ratio for positive outcomes was 4.12, with a high rate of poor outcomes in 1318 out of all eligible patients. A total of 994 (60.7%) medical patients were treated with intravenous administration, while 644 (39.3%) surgical patients were scheduled for a tonsillectomy procedure. The risk estimate for patients admitted from medical wards compared to surgical wards was an odds ratio of 0.562. The study also provided sensitivity analysis for the four tested serial neutrophil prognosticators at different day levels. Conclusion: The study supports the use of Somatic Nucleated Cell (SNC) as a reliable measure for evaluating EFR in cases of catarrhal acute tonsillitis. The maximum SNC count in Group one was 11,269 cells per cubic millimeter. Acute streptococcal infection often exhibits an ESR higher than 40, but this may be concealed by other complications. The SNC test has advantages like simplicity, quickness, and cost-effectiveness, but lacks specificity. Monitoring SNC and EFR fluctuations can initiate treatment cessation, preventing relapse and severe complications during recovery.

Hazard functioning modeling for dextrose fluids associated hemodilution; Cox-regressional analysis for patients’ Hematocrit Hemoglobin Ratio

Aims: This study looks at the cox-regressional relationships between hematocrit to hemoglobin ratio (HHR) and a group of outcomes of interest (cOI). These outcomes include death from any cause, acute myocardial infarction, stroke, and severe dilutional hyponatraemia incidence. Additionally other outcome of interest in this study will be prolongation of admission days, infection rate, acute kidney injury, and mandating the transition to the critical unit and mechanical ventilation intubation. The study also will investigate the performances of the tested ratio and will explore their sensitivity, specificity, and accuracy indexes. Methods: Between 2018 and 2022, a retrospective study was conducted at the King Hussein Medical Centre in Amman, Jordan, involving 926 patients. The study aimed to determine the potential risk of dilution of red blood cells in circulation caused by dextrose-containing fluids in patients with chronic kidney disease. The study aimed to determine the ideal threshold levels of the investigated ratio (HHR) to enhance clinical outcomes and safety margins, particularly in patients with severe renal impairment or chronic kidney disease in a hospital setting. The study included patients with fluctuating kidney function, renal replacement therapy, uncontrolled diabetes, and conditions necessitating specific fluid regimens. The study used binary logistic regression and cox-regression proportional hazard modelling to examine the correlation between the hematocrit to haemoglobin ratio and the composite outcomes of interest (cOI) in patients from Jordan. The findings suggest that higher cOI likelihood indicates a more advantageous condition, while lower values suggest a less advantageous condition. Results: A retrospective study at the KHMC in Amman, Jordan, involved 1306 patients from 2018 to 2022. The study focused on the hematocrit to haemoglobin ratio (HHR) and achieved correct classification rates of 70.8%. The best HHR was 2.555:1, with a 42.8% chance of occurring at this level. Cox-Regression Proportional Hazard Modelling revealed a censored percentage of 83.4% in HHR&gt;2.555 stratum and 51.5% in HHR≤2.555 stratum. The study found a high percentage of HD patients processed in the analysis. Conclusion: Intravenous dextrose fluids associated hemodilutional state is linked to all-cause mortality in admitted medically and surgically patients and cardiovascular death. Low ratio increases the risk. Factors such as malnutrition and kidney function loss contribute to prognosis. Future studies should focus on mechanistic pathways, optimal targets, age, and sociodemographic factors.

Clinical manifestations, diagnosis and long-term prognosis of adult autoimmune enteropathy: Experience from Peking Union Medical College Hospital

BACKGROUND Autoimmune enteropathy (AIE) is a rare disease whose diagnosis and long-term prognosis remain challenging, especially for adult AIE patients. AIM To improve overall understanding of this disease’s diagnosis and prognosis. METHODS We retrospectively analyzed the clinical, endoscopic and histopathological characteristics and prognoses of 16 adult AIE patients in our tertiary medical center between 2011 and 2023, whose diagnosis was based on the 2007 diagnostic criteria. RESULTS Diarrhea in AIE patients was characterized by secretory diarrhea. The common endoscopic manifestations were edema, villous blunting and mucosal hyperemia in the duodenum and ileum. Villous blunting (100%), deep crypt lymphocytic infiltration (67%), apoptotic bodies (50%), and mild intraepithelial lymphocytosis (69%) were observed in the duodenal biopsies. Moreover, there were other remarkable abnormalities, including reduced or absent goblet cells (duodenum 94%, ileum 62%), reduced or absent Paneth cells (duodenum 94%, ileum 69%) and neutrophil infiltration (duodenum 100%, ileum 69%). Our patients also fulfilled the 2018 diagnostic criteria but did not match the 2022 diagnostic criteria due to undetectable anti-enterocyte antibodies. All patients received glucocorticoid therapy as the initial medication, of which 14/16 patients achieved a clinical response in 5 (IQR: 3-20) days. Immunosuppressants were administered to 9 patients with indications of steroid dependence (6/9), steroid refractory status (2/9), or intensified maintenance medication (1/9). During the median of 20.5 months of follow-up, 2 patients died from multiple organ failure, and 1 was diagnosed with non-Hodgkin’s lymphoma. The cumulative relapse-free survival rates were 62.5%, 55.6% and 37.0% at 6 months, 12 months and 48 months, respectively. CONCLUSION Certain histopathological findings, including a decrease or disappearance of goblet and Paneth cells in intestinal biopsies, might be potential diagnostic criteria for adult AIE. The long-term prognosis is still unsatisfactory despite corticosteroid and immunosuppressant medications, which highlights the need for early diagnosis and novel medications.

Remote monitoring of sleep disorder using FBG sensors and FSO transmission system enabled smart vest

Optical sensors, particularly fiber Bragg grating (FBG) sensors have achieved a fast ingress into the fields of medical diagnostic and vital signs monitoring. Wearable smart textiles equipped with FBG sensors are catching huge research attention in different applications for measurement and monitoring of physiological parameters. In this paper, we report a simple technique for remote monitoring of sleep disorder using a smart vest implemented with four FBG stress sensors located at different sides of the vest and free space optics (FSO) transmission system. The sleep disorder of the patient is monitored in real time through shifts in the original Bragg wavelengths of sensors by stress loading during random changes in patient’s sleeping postures. The reflected wavelength from a stress loaded sensor at a certain posture is transmitted over 0.5 km long FSO channel towards remote medical center, photodetected, and then can be processed in a PC to record the restlessness in a certain time interval in terms of total number of times sleeping postures are changed, total time spent at a certain posture etc. To correctly detect the stress loaded FBG sensor at the medical center, various parameters of FBG sensors and demultiplexer are carefully adjusted to minimize the power leakages from unloaded sensors that may result into errors in the detection. Maximum dynamic range around 45 dB has been achieved ensuring accurate detection. This study not only provides a cost-efficient and non-intrusive solution for monitoring the sleep disorder of patients but also can be used for real-time monitoring of various other ailments, such as lung, brain, and cardiac diseases in future.