Multicenter Retrospective Study Research Articles

Use of non-specific immunoglobulins in Catalonia in three third-level hospitals: a descriptive analysis of a hospital-prescribed medication registry

BackgroundThe increasing use of non-specific immunoglobulins (NSIGs) and their current shortage show a need for NSIGs’ use prioritization. Data from a clinical perspective are necessary, mainly for pediatric patients.ObjectivesThe aim of the study was to assess the level of clinical evidence (LoE) of the indications that NSIGs are used for, the reasons for discontinuation, and the costs invested.MethodsA retrospective multicentric study was conducted on NSIG incident users between September 2019 and December 2021 retrieved from the Registry of Patients and Treatments (RPT) from Catalonia (Spain). LoE was categorized as A) authorized indications, B) unauthorized with scientific support, C) unauthorized without support, and D) unknown (UNK), following local and the United Kingdom’s guidelines as a sensitivity analysis. We also estimated overall spending and costs per patient visit.ResultsA total of 400 patients were included (17.3% pediatric), with a mean follow-up of 122.1/person-years for adults. The most frequent indications were nervous system and blood diseases. Almost all pediatric patients (56; 81.2%) were treated under A-level indications, as for 217 (65.6%) adults. In the sensitivity analysis, the A-level usage rate decreased to one-third and the B-level usage rate increased by 2–3 times. Furthermore, 37.8% (151) of individuals discontinued. This was predominantly due to remission or no response. The total costs were 868,462.6€/year, with median spending per visit amounting to 1,500€ for adults and 700€ for pediatric patients.ConclusionNSIGs are used in clinical practice mainly for approved indications; however, non-approved indications are still an important issue. This could represent a significant economic burden on the healthcare system, focusing on the pediatric population and those at risk for discontinuation with alternative therapeutic options.

Cutaneous ulcers in anti-MDA5-positive dermatomyositis with rapidly progressive interstitial lung disease: a multicentre retrospective cohort study

IntroductionTo identify the clinical characteristics and risk factors for cutaneous ulcers in patients with anti-melanoma differentiation-associated gene 5 antibody-positive dermatomyositis (anti-MDA5+ DM) combined with rapidly progressive interstitial lung disease (RPILD).Material and methodsWe conducted a retrospective cohort study on the medical records of patients enrolled from the Nanjing Medical University Myositis-associated ILD cohort (NMMI). The clinical characteristics of patients in the ulcer-positive group were compared with those in the ulcer-negative group by chi-square or Fisher’s exact test. Univariate and multivariate logistic regression analyses were used to assess risk factors for the development of cutaneous ulcers.ResultsA total of 246 patients with anti-MDA5+ DM were retrospectively enrolled in the study, including 176 females (176/246, 71.54%) and 70 males (70/246, 28.46%), with a female-to-male ratio of 2.51 : 1. Among the 246 patients, a total of 88 cases (88/246, 35.77%) with anti-MDA5+ DM combined with RPILD were further studied, including 55 females (55/88, 62.5%) and 33 males (33/88, 37.5%), with a female-to-male ratio of 1.67 : 1. Twelve patients (12/88, 13.64%) had cutaneous ulcers. In terms of clinical characteristics, patients in the ulcer-positive group had significantly more proximal muscle involvement (83.33% vs. 38.16%, p = 0.003) and more heliotrope rash (83.33% vs. 43.42%, p = 0.010) than in the ulcer-negative group. In univariate analysis, cutaneous ulcers were associated with proximal muscle involvement (OR = 8.103; 95% CI: 1.657–39.625; p = 0.010) and heliotrope rash (OR = 6.515; 95% CI: 1.336–31.773; p = 0.020). In multivariate analysis, cutaneous ulcers were associated with proximal muscle involvement (OR = 6.436; 95% CI: 1.274–32.524; p = 0.024), and proximal muscle involvement was an independent risk factor for cutaneous ulcers.ConclusionsWe confirmed the association between cutaneous ulcers and proximal muscle involvement and heliotrope rash in patients with anti-MDA5+ DM combined with RPILD. Proximal muscle involvement is an independent risk factor for cutaneous ulcers.

Validation of ACR TI-RADS performance in transition age: results from a multicenter retrospective study by the TALENT study group.

Although thyroid nodules are less common in the pediatric population, the risk of malignancy is higher than in adult patients. The aim of this study was to evaluate the ultrasonographic predictive factors of malignancy in thyroid nodules and to validate American College of Radiologists (ACR) TI-RADS performance in transition age patients. One hundred forty-two patients aged between 14 and 21 years referred to the participating centers for FNA biopsy of a thyroid nodule between 2007 and 2022 were included and ultrasound reports and sonographic images were retrospectively analyzed. Nodule features were defined according to the ACR-TIRADS lexicon. Two reference standards were applied: FNA cytology and surgical histology. The diagnostic performance of single sonographic features was estimated. Significant predictors were then included in a multivariate regression model. Nodules included in ACR-TIRADS categories TR4 or TR5 had 10-fold increased risk of indeterminate or suspicious/malignant cytology [p < 0.001]. In univariate analysis, solid composition [p = 0.016] and presence of hyperechoic foci [p = 0.040] significantly increased the likelihood of malignant histology. In multivariate regression analysis, irregular margins [p = 0.011] and hyperechoic foci [p = 0.019] were independent predictors of indeterminate or suspicious/malignant cytology. Nodules included in ACR-TIRADS categories TR4 or TR5 had 10-fold increased risk of indeterminate or suspicious/malignant cytology in transition age. ACR-TIRADS was not able to rule-out malignancy compared to FNAB alone, suggesting the need to reconsider recommendations in the transition age group.

Management of Severe Pyogenic Spinal Infections: The 2SICK Study by the EANS Spine Section.

Spondylodiscitis management presents significant clinical challenges, particularly in critically ill patients, where the risks and benefits of surgical intervention must be carefully balanced. The optimal timing of surgery in this context remains a subject of debate. This study aims to evaluate the effectiveness of early surgery versus delayed surgery or conservative management in critically ill patients with de novo pyogenic spondylodiscitis. This is an international, multicenter retrospective cohort study involving 24 centers, primarily in Europe. The study included 192 critically ill patients (65.63% male) with a median age of 69 years, all severely affected by pyogenic spondylodiscitis characterized by an initial CRP level >200 mg/l or the presence of two out of four Systemic Inflammatory Response Syndrome criteria upon admission. The primary outcome was 30-day mortality. Secondary outcomes included length of ICU stay, length of hospital stay, and relapse rates of spondylodiscitis. Patients were divided into three groups: early surgery (within three days of admission), delayed surgery (after three days of admission), and conservative therapy. Propensity score matching and multivariate regression analyses were performed to adjust for baseline differences and assess the impact of treatment modalities on mortality and other clinical outcomes. Delayed surgery was associated with significantly lower 30-day mortality (4.05%) compared to early surgery (27.85%) and conservative therapy (27.78%) (p<0.001). Delayed surgery also resulted in shorter hospital stays (42.76 days) compared to conservative therapy (55.53 days) and early surgery (26.33 days) (p<0.001), and shorter ICU stays (4.52 days) compared to conservative therapy (16.48 days) and early surgery (7.92 days) (p<0.001). The optimal window for surgery, minimizing mortality, was identified as ten to fourteen days post-admission (p=0.02). Risk factors for increased mortality included age (p<0.05), multiple organ failure (p<0.05), and vertebral body destruction (p<0.05), whereas delayed surgery (p<0.05) and the presence of an epidural abscess were associated with reduced mortality (p<0.05). Delayed surgery, optimally between 10 to 14 days post-admission, was associated with lower mortality in critically ill spondylodiscitis patients. These findings highlight the potential benefits of considering surgical timing to improve patient outcomes.

Role of Minimally Invasive Reoperation for Postoperatively Diagnosed T2 Gallbladder Cancer: Multicenter Retrospective Cohort Study.

Although T2 gallbladder cancer (GBC) incidentally diagnosed after cholecystectomy requires additional resection, the surgical approaches are technically difficult due to inflammatory adhesion or fibrosis around the hepatoduodenal ligament and gallbladder bed. In this study, we sought to compare the surgical and oncologic outcomes of open and minimally invasive reoperation for postoperatively diagnosed T2 GBC. Patients who underwent open (n = 110) and laparoscopic (n = 38) reoperation for T2 GBC between November 2004 and October 2022 at five tertiary referral centers were included in this multicenter retrospective cohort study. The short- and long-term outcomes were compared between the two groups. There were no differences in clinicopathological characteristics between the open and laparoscopic groups. Liver resection was more frequent in the open group (101 [91.8%] vs. 21 [55.3%], P < 0.001). Compared with open surgery, laparoscopic reoperation was associated with shorter postoperative hospital stay (9.0 [8.0-10.0] vs. 6.0 [3.8-8.3] days, P < 0.001) and a lower postoperative complication rate (24 [21.8%] vs. 1 [2.6%], P = 0.013). Among patients who underwent liver resection, the postoperative hospital stay was shorter in the laparoscopic group (9.0 [8.0-10.0] vs. 6.0 [4.0-9.0] days, P = 0.004). The 5-year disease-free survival (66.7% vs. 76.1%, P = 0.749) and overall survival (75.2% vs. 73.7%, P = 0.789) rates were not significantly different between the two groups. The results indicate that laparoscopic reoperation for postoperatively diagnosed T2 GBC has favorable postoperative outcomes and similar oncologic safety compared with open surgery.

End-to-end deep learning patient level classification of affected territory of ischemic stroke patients in DW-MRI.

To develop an end-to-end DL model for automated classification of affected territory in DWI of stroke patients. In this retrospective multicenter study, brain DWI studies from January 2017 to April 2020 from Center 1, from June 2020 to December 2020 from Center 2, and from November 2019 to April 2020 from Center 3 were included. Four radiologists labeled images into five classes: anterior cerebral artery (ACA), middle cerebral artery (MCA), posterior circulation (PC), and watershed (WS) regions, as well as normal images. Additionally, for Center 1, clinical information was encoded as a domain knowledge vector to incorporate into image embeddings. 3D convolutional neural network (CNN) and attention gate integrated versions for direct 3D encoding, long short-term memory (LSTM-CNN), and time-distributed layer for slice-based encoding were employed. Balanced classification accuracy, macro averaged f1 score, AUC, and interrater Cohen's kappa were calculated. Overall, 624 DWI MRIs from 3 centers were utilized (mean age, interval: 66.89 years, 29-95 years; 345 male) with 439 patients in the training, 103 in the validation, and 82 in the test sets. The best model was a slice-based parallel encoding model with 0.88 balanced accuracy, 0.80 macro-f1 score, and an AUC of 0.98. Clinical domain knowledge integration improved the performance with 0.93 best overall accuracy with parallel stream model embeddings and support vector machine classifiers. The mean kappa value for interrater agreement was 0.87. Developed end-to-end deep learning models performed well in classifying affected regions from stroke in DWI. The end-to-end deep learning model with a parallel stream encoding strategy for classifying stroke regions in DWI has performed comparably with radiologists.

Factors Associated With Early Computed Tomography Imaging in Children Hospitalized With Severe Orbital Infections.

We identified factors associated with computed tomographic (CT) imaging within 24 hours of emergency department (ED) presentation in hospitalized children with severe orbital infections. A multicenter retrospective cohort study was conducted that included children aged 2 months to 18years between 2009 and 2018 who were admitted to the hospital with severe orbital infections, including periorbital and orbital cellulitis. Multivariable modified Poisson regression was used to identify possible factors associated with receiving a CT scan within 24 hours of ED presentation. Of 1144 children, 494 (43.2%) received a CT scan within 24 hours of ED presentation. Factors associated with receiving a CT scan within 24 hours included sex (male; adjusted relative risk [aRR], 1.18; 95% CI, 1.04-1.33), hospitalized at a children's hospital (aRR, 1.80; 95% CI, 1.32-2.45), consulted by both ophthalmology and otolaryngology (aRR, 3.12; 95% CI, 2.35-4.13) or either ophthalmology (aRR, 2.19; 95% CI, 1.66-2.90) or otolaryngology (aRR, 2.66; 95% CI, 1.84-3.86), and had proptosis (aRR, 1.39; 95% CI, 1.24-1.57) or eye swollen shut (aRR, 1.27; 95% CI, 1.13-1.43) as clinical signs upon ED presentation. Children aged younger than 5years were less likely to receive early CT imaging (aRR, 0.63; 95% CI, 0.53-0.74). There were no associations between time of ED triage, temperature greater than 38 °C, or inflammatory markers with early CT imaging. Although several patient and hospital factors associated with early CT imaging decisions in children with severe orbital infections are associated with more severe infections, newly identified risk factors, such as inflammatory markers, were not. These findings will help better the understanding of clinical management and indications for CT imaging.

Sex-Specific Obesity Paradox in Critically Ill Patients With Severe Acute Kidney Injury: A Retrospective Analysis.

Although obesity is typically correlated with adverse outcomes in various diseases, certain acute critical illnesses exhibit a phenomenon known as the obesity paradox. This study evaluated sex-specific differences in the prognostic implications of the body mass index (BMI) of patients with severe acute kidney injury (AKI) requiring continuous renal replacement therapy (CRRT). A multicenter retrospective cohort study. Data from eight tertiary hospitals in Korea. A total of 3805 critically ill patients receiving CRRT. Patients were categorized into four BMI groups: underweight, normal weight, overweight, and obese. None. There were 2308 male and 1497 female patients. The 90-day mortality risk significantly differed among BMI groups in the overall patient population and the male subpopulation but not the female subpopulation. Following adjustment for confounding variables, the 90-day mortality risk was higher in the underweight group than in the obese group (hazard ratio [HR], 1.20; 95% CI, 1.05-1.36; p = 0.006). Among male patients, the 90-day mortality risk was higher in both the underweight and normal weight groups than in the obese group (underweight: HR, 1.30; 95% CI, 1.10-1.53; p = 0.002 and normal weight: HR, 1.18; 95% CI, 1.04-1.35; p = 0.010); however, no such association was observed among female patients. Subgroup analysis demonstrated the obesity paradox in male patients of old age, with septic AKI, or with low albumin levels. There were sex differences in the association between BMI and mortality in critically ill patients with severe AKI. Although the precise distribution of fat mass and muscle mass was not identified, obese male patients had a more favorable prognosis, which was not evident among female patients. These findings highlight the importance of considering sex-specific factors in understanding the complex relationship between obesity and mortality in critically ill patients with AKI.

Epidemiology and Impact of Social Hardships in Children With Multiple Sclerosis in the United States.

Social determinants of health (SDOH) affect patient health outcomes, but the impact on patients with pediatric-onset multiple sclerosis (POMS) has not been well studied. Study objectives were to (1) describe the frequency of adverse SDOH, (2) evaluate social hardships as a potential barrier to the initiation of disease-modifying therapy (DMT), and (3) explore the association between adverse SDOH and disease outcomes in POMS, as well as study attrition. This was a retrospective multicenter observational study conducted through the United States Network of Pediatric MS Centers database. Participants were patients diagnosed with POMS (excluding primary progressive MS). The primary outcome was time to initiation of DMT. Secondary outcomes included most recent Expanded Disability Status Scale (EDSS) score, steroid treatment for the first event, time to second event, and study attrition. Demographic variables and clinical outcomes were compared between patients with and without hardships (maternal education of high school or less, public insurance/no insurance, or single/no-income household). Multivariable regression models were used to assess the impact of social hardship on study outcomes. There were 996 total participants (69% female, mean age at symptom onset and EDSS score [±SD] were 14.2 ± 3 and 1.2 ± 1.1, respectively). Of 768 patients with complete demographic information, 66% reported a hardship. Hardship was associated with younger age at symptom onset and diagnosis. While there was no difference in time to DMT initiation, patients with hardship were more likely to receive steroids for the first event (odds ratio [OR] 1.66, 95% CI 1.21-2.26, p = 0.002). Lack of private insurance was associated with increased risk of study attrition (OR 1.85, 95% CI 1.14-3.00, p = 0.012) and higher EDSS score (β = 0.15, 95% CI 0.01, 0.28). Living in a no-income household (vs dual-income) was associated with a shorter time to second event (hazard ratio 1.33, 95% CI 1.02-1.74, p = 0.034). The experience of hardships is common and associated with younger age at symptom onset and diagnosis, as well as shorter time to second event. Lack of private insurance is associated with study attrition and a higher EDSS score despite no difference in time to initiating DMT. There may be differences in early disease pathophysiology related to social hardship, and future studies are needed to better understand this complex relationship.

Transseptal Sheath Perfused with High Concentration Heparinized Saline for Reducing Sheath-associated Thrombus.

Transseptal catheterization is critical for atrial fibrillation (AF) ablation but risks thromboembolism. Transseptal sheaths (TSS) were suggested for continuous heparinized saline solution flush. The safety and effectiveness of a simple TSS management to reduce sheath-associated thrombus development risk was investigated. AF patients who underwent radiofrequency ablation with the simple TSS management were studied under a retrospective multi-center observation study and a prospective single-center observation study. TSS and dilators were washed and perfused with high concentration heparinized saline (20u/mL). Immediately after two successful transseptal punctures, activated clotting time ≥300s was maintained by heparin infusion. TSS aspiration with negative suction and re-perfusion with high concentration heparinized saline (20u/mL) was performed for the remaining procedure before and after catheter withdrawal. A total of 4765 AF patients underwent 5367 ablation procedures were enrolled in the retrospective study, involving 156 (2.9% per procedure) complications. No acute stroke occurred during all the procedures. Perioperative thromboembolic complications occurred in 10 (0.21%) patients and in 10 (0.19%) procedures. Thromboembolic complications occurred within 24 h, between 24-48 h, and after 48 h post-procedure in six, two, and two patients, respectively. In the prospective observation study, neither sheath- nor catheter-associated thrombus were detected by the intracardiac echocardiography during all 127 procedures, without any perioperative thromboembolic complications. No hemorrhagic cerebrovascular complication was encountered in both observational studies. For AF radiofrequency ablation, it was safe and effective for TSS high concentration heparinized saline infusion only. This approach could avoid sheath-associated thrombus for interventional procedures.

Hierarchically Positioning Laparoscopic Microwave Ablation in the Therapeutic Span of Early Hepatocellular Carcinoma: A Real-Life Comparative Analysis.

Laparoscopic microwave ablation (LMWA) has yet to gain a specific place in treatment guidelines for early hepatocellular carcinoma (HCC). This study compared the outcomes of LMWA and trans-arterial chemoembolization (TACE) for early non-resectable patients with HCC, taking percutaneous radiofrequency ablation (PRFA) as the reference treatment. A retrospective multicenter observational study was conducted, enrolling non-transplantable, non-resectable patients who had early HCC treated with LMWA (n = 658) from Padua and Milan centers, and with PRFA (n = 844), and TACE (n = 425) from the ITA.LI.CA multicenter database. The matching-adjusted indirect comparison (MAIC) method was used to obtain weighted LMWA and TACE populations similar to the reference PRFA population. Laparoscopic ablation showed an excellent safety profile, and MAIC-weighted early postoperative deaths were comparable among the groups. The MAIC-weighted overall survival was similar between the LMWA (1-, 3-, and 5year survival of 91.0 %, 67.9 %, 47.0 %, respectively) and PRFA (1-, 3- and 5year survivals of 90.0 %, 64.7 %, 46.6 %, respectively) groups (p = 0.678) and significantly better for the LMWA group than for the TACE group (1-, 3- and 5year survivals of 84.7 %, 48.8 %, 33.6 %, respectively) (p < 0.001). Weighted multivariate overall survival analysis and competing risk/subgroup analyses confirmed the non-inferiority of LMWA to PRFA and its superiority to TACE. The LMWA- and PRFA-treated patients had a significantly lower risk of HCC-related death (p = 0.004) than the TACE-treated patients (p = 0.001). Conversely, the groups did not differ significantly in terms of non-HCC-related deaths. The non-inferiority of LMWA to PRFA, its superiority to TACE, and its applicability to a wide range of presentations with few contraindications support its inclusion among radical therapies for treating early-HCC patients.

Outcomes of retroperitoneal fibrosis-related hydronephrosis and its risk factors for poor prognosis: a multi-center retrospective cohort study in Chinese patients

ObjectiveRetroperitoneal fibrosis (RPF) is a rare disease characterized by the presence of fibroinflammatory tissue that surrounds the abdominal aorta and the iliac arteries and often entraps the ureters. Hydronephrosis is a common complication of RPF, however, its clinical features and outcomes have not been well elucidated.MethodsA total of 115 RPF-related hydronephrosis patients have been recruited from 9 clinical centers in China since March 2010. They were followed up until death or September 2021, whichever came first.ResultsThe mean age at diagnosis was 58.83 ± 12.13 years, and 80 patients (69.57%) were men. The median disease duration was 3.00 (1.00, 9.00) months. Renal impairment was observed in 88.35% of the patients, and 49.57% showed bilateral ureteral involvement. Elevated ESR and CRP were presented in 80.28 and 62.02% of the patients, respectively. Overall, 28.21% (11/39) of the patients had increased IgG4 levels, and 41.38% (12/29) showed positive pathological IgG4 staining (IgG4+/IgG+ ≥ 40% or IgG4+ ≥ 10/HPF). Among them, three patients were diagnosed as IgG4RD. After 60.43 ± 34.53 months of follow-up, 36 patients had poor prognosis, which was associated with severe kidney impairment, bilateral hydronephrosis and inflammation status (elevated ESR and IgG) at diagnosis by case–control study. eGFR and creatinine were independent risk factors after adjusting for all other significant associations (p = 0.002 and p = 0.067, respectively). Glucocorticoid-based therapy could reduce the time of stenting, decrease the need for long-term ureteral stenting/percutaneous nephrostomy (PNS)/ureterolysis, increase the rate of mass shrinkage, and reduce the new requirement of hemodialysis compared to surgery-only strategy for RPF-related hydronephrosis patients in need of renal drainage, but did not reduce new-onset renal atrophy.ConclusionSeverity of kidney dysfunction and inflammation status were related to the poor prognosis of hydronephrosis induced by RPF. More efficient interventions and strategies are needed to further improve outcomes.

Preventing Severe COVID-19 with Tixagevimab-Cilgavimab in Hematological Patients Treated with Anti-CD20 Monoclonal Antibodies: An International Multicenter Study.

Despite the declining public health emergency status, COVID-19 still poses significant risks, especially for immunocompromised individuals. We aimed to evaluate the effectiveness of tixagevimab-cilgavimab (T-C) prophylaxis in preventing severe COVID-19 in patients with hematologic malignancies (HM) treated with anti-CD20 therapy during the early Omicron variant phase of the pandemic. The European Society of Clinical Microbiology and Infectious Diseases Study Group for Respiratory Viruses (ESGREV) conducted a multicenter retrospective cohort study involving 15 centers from 5 countries. The study included 749 patients with HM treated with anti-CD20 between February 15 and June 30, 2022, comparing 215 who received T-C prophylaxis to 534 who did not. The study revealed a significant reduction in the risk of COVID-19 among patients who received T-C prophylaxis compared to those who did not (11.2% vs 23.4%, p < 0.001), with hazard ratio (HR) of 0.40 (95% CI 0.26-0.63), adjusted for age, sex, vaccination status, baseline HM malignancy and type of anti-CD-20. We also demonstrated a reduction for severe-critical diseases within all study populations, 1.4% vs 5.2%, p = 0.017, HR 0.26 (95% CI 0.08-0.84). T-C prophylaxis effectively prevented COVID-19 and severe-critical COVID-19 in patients with HM treated with anti-CD20 monoclonal antibodies during the early Omicron variant phase of the pandemic. Even though T-C is ineffective against current variants, these findings highlight the importance of additional protective measures and the continued development of monoclonal antibodies to protect immunocompromised individuals to mitigate the impact of COVID-19 and other respiratory viral diseases.

Comparison between in situ fixation and fixation after closed reduction in valgus impacted femoral neck fractures: A Multicenter Study.

The objective of this study was to compare clinical outcomes between in situ fixation and fixation after closed reduction (CR) in patients aged 50 and above with valgus impacted femoral neck fractures using data from multiple centers. Design: Retrospective multicenter cohort study. Five tertiary-care university hospitals. Patients aged 50 and above, treated with operative fixation of valgus impacted femoral neck fractures using multiple cannulated screws from 2003 to 2019. Complications such as fixation failure, osteonecrosis of femoral head (ONFH), and reoperation were compared between the groups (in situ fixation group and fixation after CR group). Postoperative EuroQol-5 Dimension (EQ-5D), Harris Hip Score (HHS), and Koval's grade were compared. The mean age of the 206 patients (161 in situ fixation group, 45 in fixation after CR group) who met the inclusion criteria was 68.9 ± 10.9 years (range, 50 to 95 years). There were 39 men and 167 women. Fixation failure occurred in 11.2% (6.8% of in situ fixation group vs 26.7% of fixation after CR group, p = 0.002). Reoperation was required for 10.2% (7.5% of in situ fixation group vs 20% of fixation after CR group, p = 0.023). Fixation failure and reoperation rates were significantly higher in the fixation after CR group than in the in-situ fixation group (odds ratio = 4.757, p = 0.002 and odds ratio = 3.104, p = 0.023, respectively). At the two-year follow-up, ONFH occurred in 5.8% (9 out of 161, in situ fixation group vs 3 out of 45, fixation after CR group). There was no significant difference in the occurrence of ONFH between the two groups (p = 0.727). The Koval's grade at 6 and 12 months demonstrated better results in the in-situ group (p = 0.027, 0.044, respectively). Postoperative EQ-5D and HHS scores showed no statistically significant differences between the two groups. In patients aged 50 years or older with valgus impacted femoral neck fractures, when fixation was done after reduction, the reoperation rate was higher due to fixation failure compared to in-situ fixation. There was no significant difference in the incidence of ONFH in valgus impacted femoral neck fractures regardless of whether reduction was performed. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Allogeneic hematopoietic stem cell transplantation could overcome the poor prognosis of DNMT3AmutNPM1mutFLT3-ITDmut in acute myeloid leukemia: real-world multicenter analysis in China.

The cooccurrence of NPM1, FLT3-ITD, and DNMT3A mutations (i.e., triple mutation) is related to dismal prognosis in patients with acute myeloid leukemia (AML) receiving chemotherapy alone. In this multicenter retrospective cohort study, we aimed to identify whether allogeneic hematopoietic stem cell transplantation (allo-HSCT) could overcome the poor prognosis of DNMT3AmutNPM1mutFLT3-ITDmut AML across four transplant centers in China. Fifty-three patients with triple-mutated AML receiving allo-HSCT in complete remission were enrolled. The 1.5-year probabilities of relapse, leukemia-free survival, and overall survival after allo-HSCT were 11.9%, 80.3%, and 81.8%, respectively. Multivariate analysis revealed that more than one course of induction chemotherapy and allo-HSCT beyond CR1 were associated with poor survival. To our knowledge, this work is the largest study to explore the up-to-date undefined role of allo-HSCT in patients with triple-mutated AML. Our real-world data suggest that allo-HSCT could overcome the poor prognosis of DNMT3AmutNPM1mutFLT3-ITDmut in AML.

Association between oral loop diuretics duration before discharge and hospital readmission in acute decompensated heart failure: A multicenter retrospective cohort study.

There are uncertainties when to start patients on oral loop diuretics after managing acute decompensated heart failure (ADHF) before discharge. This study aims to investigate the impact of prolonging observation duration on hospital readmissions following the switch to oral loop diuretics before discharge in patients with ADHF. A multicenter retrospective study that included adult patients (>18 years) diagnosed with ADHF and discharged on oral loop diuretics in Saudi Arabia. Patients who received oral loop diuretics were divided into 2 groups based on the observation duration before discharge. The primary outcome was a 30-day readmission rate for all causes; the secondary outcomes were 60- and 90-day readmission rates for all causes; and 30-, 60-, and 90-day readmission rates for heart failure. A total of 400 ADHF patients were included in the final analysis. Patients in group 1 (n = 142; < 24 hours) and group 2 (n = 258; ≥ 24 hours) had similar baseline characteristics (P > .05), except for the length of hospital stay (P = .03) and total observation time (P = <.01). ADHF patients with <24 hours observation durations were significantly associated with higher all-cause 30-day readmissions compared to those with ≥24 hours observations (odds ratio = 1.83, 95% confidence interval = 1.11-3.02, P = .017). Our study showed a significant decrease in all-cause 30-day readmissions for ADHF patients who received oral loop diuretics at discharge with a longer duration of observation. This study emphasizes the significance of standardizing the observational period when initiating oral loop diuretics before discharge following admission to ADHF.

Predictors of pouch failure and quality of life following ileal pouch-anal anastomosis for ulcerative colitis: a retrospective multicenter study.

This study aimed to investigate the causes of failure after the ileal pouch-anal anastomosis (IPAA) procedure for ulcerative colitis (UC) and to determine the independent risk factors affecting their quality of life. This multi-center cohort study included all UC patients who underwent IPAA at nine referral centers in Türkiye from 2010 to 2018. Centers were categorized as high-volume (≥10 cases/year) or low-volume (<10 cases/year). Outcomes assessed included postoperative complications, pouch failure, and QoL using the Cleveland Global Quality of Life (CGQL) and modified Oresland Score. Logistic and linear regression analyses were used to identify risk factors for pouch failure and QoL determinants, respectively. Of 296 patients included, pouches were constructed in 172 (58.1%) as a two-staged and in the remaining patients as a three-staged procedure. The high-volume center had higher rates of biologic (45.1% versus 16%) and steroid use (63.9% versus 22.1%). The overall pouch failure rate was 4.7% at the end of follow-up of 66.1 months. Independent risk factors for pouch failure included pelvic sepsis (OR = 47.47, P = 0.002), biologic use (OR = 13.45, P = 0.033), chronic pouchitis (OR = 14.31, P = 0.013), postoperative blood transfusion (OR = 7.04, P = 0.048), and low annual case volume (OR = 30.86, P = 0.047). CGQL and Oresland scores averaged 0.77 ± 0.1 and 6.3 ± 1.1, respectively. Factors negatively impacting QoL included two-staged procedures, small bowel obstruction, venous thromboembolism, chronic pouchitis, increased frequency of bowel movements, and low annual case volume. IPAA surgery in UC patients in Türkiye demonstrates acceptable rates of complications and pouch failure, with high patient satisfaction in terms of QoL and functional outcomes. Optimizing long-term results requires enhanced surgical expertise and coordinated multidisciplinary management strategies.

Changes of hip fracture in older patients before and after the COVID-19 pandemic: a retrospective multicentre study in Japan

BackgroundThe COVID-19 pandemic had a significant impact on healthcare systems and the general population. However, it remains unclear to what extent these major societal changes have had an impact on the management of hip fractures in older people in Japan. Therefore, we investigated the effect of the COVID-19 pandemic on the number of patients with hip fractures, their characteristics, and their perioperative management as a retrospective multicentre study.MethodsWe included 1894 patients aged ≥ 65 years who underwent surgery for hip fracture at three hospitals between January 2019–December 2021. Patients were classified according to the time of injury; patients treated between January–December 2019, January–December 2020, and January–December 2021 were divided into the pre-COVID-19 group, early COVID-19 group, and late COVID-19 group, respectively. We compared age, sex, body mass index, preadmission residence, surgical procedure, length of hospital stay, waiting time for surgery, in-hospital complications, and in-hospital death.ResultsOur findings suggested that the early COVID-19 and late COVID-19 groups showed a 6.8% and 7.5% reduction in the number of HF patients, respectively, compared to the pre-COVID-19 group. Waiting days for surgery, length of hospital stay, and in-hospital mortality or complication rates did not significantly change before and after the pandemic. However, infection was increased in the early COVID-19 group regarding the subgroup of complications.ConclusionsThe COVID-19 pandemic altered the characteristics of hip fractures in older individuals.

Evaluation of risk factors for postpartum cerebral venous sinus thrombosis, a multicenter retrospective observational study.

The postpartum period is a well-defined risk factor for cerebral venous sinus thrombosis (CVST). However, it is unclear which patients are at risk for CVST in the postpartum period. Thus, determining some CVST risk factors in postpartum patients may be useful for preventing the disorder in this population. Previous studies have shown that preeclampsia (PE) is a risk factor for pulmonary thromboembolism and deep vein thrombosis, but whether it is related to postpartum CVST has not yet been evaluated. This study aimed to determine if this relationship exists. This study was a case-control study of retrospectively screened patients diagnosed with CVST between 2018 and 2023 at the Uludağ University Faculty of Medicine Department of Neurology, the Eskişehir Osmangazi University Faculty of Medicine and the Bursa City Hospital Health Sciences University Department of Neurology. All of the women who delivered between 2018 and 2023 at the Uludağ University Faculty of Medicine Department of Obstetrics and Gynaecology were included in the control group. In total, 57 out of 322 cases and 4299 out of 4452 controls were included in this study. A nonsignificant relationship was found between CVST and spinal anesthesia, but a significant relationship was found between PE and stillbirth. Women with PE who had recently delivered were found to be at increased risk of developing CVST. The primary limitation of this study is that it was retrospective, and the control group was hospital-based. We recommend that these findings be confirmed by multicenter prospective international studies.

Biopsy-Proven T-Cell Mediated Rejection After Belatacept Rescue Conversion: A Multicenter Retrospective Study

After kidney transplantation, conversion to belatacept is a promising alternative in patients with poor graft function or intolerance to calcineurin inhibitors. The risk of acute rejection has not been well described under these conditions. Here we present a retrospective multicenter study investigating the occurrence of acute rejection after conversion in 901 patients (2011–2021). The incidence of cellular and humoral rejection was 5.2% and 0.9%, respectively. T-cell mediated rejection (TCMR) occurred after a median of 2.6 months after conversion. Out of 47 patients with TCMR, death-censored graft survival was 70.1%, 55.1% and 50.8% at 1 year, 3 years and 5 years post-rejection, respectively. Eight patients died after rejection, mainly from infectious diseases. We compared these 47 patients with a cohort of kidney transplant recipients who were converted to belatacept between 2011 and 2017 and did not develop rejection (n = 238). In multivariate analysis, shorter time between KT and conversion, and the absence of anti-thymocyte globulin induction after KT were associated with the occurrence of TCMR after belatacept conversion. The occurrence of rejection after conversion to belatacept appeared to be less frequent than with de novo use. Nevertheless, the risk of graft loss could be significant in patients with already low renal function.