Retrospective Study Research Articles

Epilepsy in Patients With Primary CNS Lymphoma: Prevalence, Risk Factors, and Prognostic Significance.

Epilepsy is a common comorbidity of brain tumors; however, little is known about the prevalence, onset time, semiology, and risk factors of seizures in primary CNS lymphoma (PCNSL). Our objectives were to determine the prevalence of epilepsy in PCNSL, to identify factors associated with epilepsy, and to investigate the prognostic significance of seizures in PCNSL. We performed an observational, retrospective single-center study at a tertiary neuro-oncology center (2011-2023) including immunocompetent patients with PCNSL and no history of seizures. We collected clinical, imaging, and treatment data; seizure status over the course of PCNSL; and oncological and seizure outcome. The primary outcome was to determine the prevalence of epilepsy. Furthermore, we aimed to identify clinical, radiologic, and treatment-related factors associated with epilepsy. Univariate analyses were conducted using the χ2 test for categorical variables and unpaired t test for continuous variables. Predictors identified in the unadjusted analysis were included in backward stepwise logistic regression models. We included 330 patients, 157 (47.6%) were male, median age at diagnosis was 68 years, and the median Karnofsky Performance Status score was 60. Eighty-three (25.2%) patients had at least 1 seizure from initial diagnosis to the last follow-up, 40 (12.1%) as the onset symptom, 16 (4.8%) during first line of treatment, 27 (8.2%) at tumor progression and 6 (1.8%) while in remission. Focal aware seizures were the most frequent seizure type, occurring in 43 (51.8%) patients. Seizure freedom under antiseizure medication was observed in 97.6% patients. Cortical contact (odds ratio [OR] 8.6, 95% CI 4.2-15.5, p < 0.001) and a higher proliferation index (OR 5.7, 95% CI 1.3-26.2, p = 0.02) were identified as independent risk factors of epilepsy. Patients with PCNSL and epilepsy had a significantly shorter progression-free survival (median progression-free survival 9.6 vs 14.1 months, adjusted hazard ratio 1.4, 95% CI 1.0-1.9, p = 0.03), but not a significantly shorter overall survival (17 vs 44.1 months, log-rank test, p = 0.09). Epilepsy affects a quarter of patients with PCNSL, with half experiencing it at the time of initial presentation and potentially serving as a marker of disease progression. Further research is necessary to assess the broader applicability of these findings because they are subject to the constraints of a retrospective design and tertiary center setting.

Presentation, Management, and Outcomes of Patients with Giant Pheochromocytoma: Retrospective Cohort Study.

Data on giant pheochromocytomas (PHEO), defined based on size ≥ 10 cm, are scarce. to compare presentation, management, and outcomes of patients with giant vs non-giant PHEOs. retrospective cohort study, 2000-2023. referral center. consecutive patients with giant PHEO and randomly chosen patients with non-giant PHEO (referents) at a 1:6 ratio. perioperative complications, metastases, mortality. Of 828 patients with PHEO, 31 (3.7%) had giant PHEO (median size 12 cm, IQR 10.0-13.5). In comparison to referents (n=186, median size 4 cm, IQR, 2.9-5.0), patients with giant PHEO had more symptoms of catecholamine excess (median of 2 vs 1, P=.04) and presented with a higher prevalence of severe catecholamine excess (76% vs 30%, P<.0001).Adrenalectomy was performed in 94% of patients with giant PHEOs and 100% referents. In addition to preoperative alpha-adrenergic blockade (89%), metyrosine was used in 14 (7%) patients, mostly in patients with giant PHEO (26% vs 3%, P<.0001). Patients with giant PHEO had a higher perioperative complication rate (31% vs 10%, P=.004).During a median follow-up of 3 years, metastases developed at a higher rate in patients with giant PHEOs (45% vs 4% in referents, P<.0001). Disease-specific mortality was 7% in patients with giant PHEOs and 0% in referents (P=.02). Patients with giant PHEO as compared to referents were more symptomatic, had a higher degree of catecholamine excess, and had a higher rate of perioperative complications. Almost half of patients with giant PHEO developed metastases, warranting a close follow-up.

Outcomes of Adjunctive Corticosteroid Treatment on Hypoxemic Adults Hospitalised for Mycoplasma pneumoniae Pneumonia: a Retrospective Cohort Study.

Corticosteroids appears to be beneficial for severe Mycoplasma pneumoniae pneumonia in children but data in adults are limited. This study investigated effects of adjunctive corticosteroids in hypoxemic adults with M. pneumoniae pneumonia. Adults admitted 2013-2017 with verified M. pneumoniae pneumonia and hypoxemia (SpO2<93% or oxygen treatment) were included in a cohort. Treatment was defined as receipt of at least one glucocorticoid dose.Primary outcome was time to regression of hypoxemia, analysed with a multivariable Cox regression. Secondary outcomes included fever duration, length of stay, and complications. Corticosteroids were given to 31% (122/388) during hypoxemia. Median age was 44 (IQR 34-57) years. Median time to start of corticosteroid treatment was 1.9 (IQR 0.6-3.6) days from admission. Median cumulative dose was equivalent to 15 (IQR 10-19) mg betamethasone. Treatment duration was 5 (IQR 3-6) days. Patients treated with corticosteroids had more severe respiratory disease, longer symptom duration and were more often treated with fluoroquinolones.Time to regression of hypoxemia (HR 0.92 [95% CI 0.72-1.19], P = 0.53) and length of stay (HR 0.91 [95% CI 0.71-1.16], P = 0.44) were not significantly different between corticosteroid treated and controls. Corticosteroid treatment was associated to shorter fever duration (HR 1.44 [95% CI 1.00-2.06], P = 0.046). Complications did not differ significantly between treatment groups. Adjunctive corticosteroids were not associated with reduced time to regression of hypoxemia in adults with M. pneumoniae pneumonia. However, duration of fever was shorter and no increase in complications was seen.

The RACE Act and Pediatric Trials of Adult Cancer Drugs.

Adult cancer drugs have historically been exempted from pediatric testing requirements. In 2017, Congress passed the Research to Accelerate Cures and Equity (RACE) for Children Act to expand mandatory pediatric testing to cancer drugs; the law took effect in 2020. With this study, we sought to evaluate how the pediatric testing of molecularly targeted adult cancer drugs changed after the RACE Act. In this retrospective cohort study, we used publicly available Food and Drug Administration data to compare pediatric post-approval requirements, trials, and trial characteristics, including timing, in adult cancer drugs before and after the RACE Act. Between 2017 and 2024, the Food and Drug Administration approved 61 adult cancer drugs with molecular targets relevant to pediatric cancer; 40 were submitted before 2020, and 21 were submitted after 2020. The 40 pre-RACE Act drugs were associated with no pediatric post-approval requirements, whereas the 21 post-RACE Act drugs were associated with 15 pediatric post-approval testing requirements. Approximately two-thirds (26/40, 65%) of pre-RACE Act drugs and 57% (12/21) of post-RACE Act drugs were evaluated in pediatric trials. Among pre-RACE Act cancer drugs, pediatric trials were initiated a median of 0.04 years after approval (interquartile range: -3.3 to 1.9 years), whereas post-RACE Act trials were initiated a median of 2.8 years before approval (interquartile range: -4.3 to 0.3 years). The RACE Act has been associated with greater numbers of pediatric post- approval testing requirements and the earlier initiation of pediatric trials, although early pediatric trial rates appear unchanged. Formalizing pediatric testing requirements may lead to the timely completion of pediatric studies to the benefit of pediatric patients with cancer.

Mediating role of inflammatory biomarkers in the causal effect of body composition on glycaemic traits and type 2 diabetes.

The aim was to investigate the mediating role of inflammatory biomarkers in the causal effect of body composition on glycaemic traits and type 2 diabetes. A retrospective observational study and a Mendelian randomization (MR) study were used. Observational analyses were performed using data from 4717 Chinese children and adolescents aged 6-18 years who underwent dual-energy X-ray absorptiometry for body composition. MR analyses were based on summary statistics from UK Biobank, deCODE2021, Meta-Analysis of Glucose and Insulin-Related Traits Consortium (MAGIC) and other large consortiums. Inflammatory biomarkers included leptin, adiponectin, osteocalcin, fibroblast growth factor 23 (FGF23) and parathyroid hormone (PTH). In a retrospective observational study, increased fat mass had a positive effect on homeostasis model assessment of insulin resistance (HOMA-IR) and homeostasis model assessment of pancreatic beta cell function (HOMA-β) through FGF23, whereas fat-free mass produced the opposite effects. PTH and osteocalcin played significant roles in the association of fat mass and fat-free mass with fasting glucose, fasting insulin and HOMA-IR (all p < 0.05). Mediation MR results indicated that childhood body mass index affected glycaemic traits through leptin and adiponectin. There existed a causal effect of fat-free mass on type 2 diabetes via FGF23 (indirect effect: OR [odds ratio]: 1.14 [95% CI, confidence interval: 1.01-1.28]) and adiponectin (OR: 0.85 [95% CI: 0.77-0.93]). Leptin mediated the causal association of fat mass (indirect effect: β: -0.05 [95% CI: -0.07, -0.02]) and fat-free mass (β: 0.03 [95% CI: 0.01, 0.04]) with fasting glucose. Our findings suggest that different body compositions have differential influences on glycaemic traits and type 2 diabetes through distinct inflammatory biomarkers. The findings may be helpful in tailoring management of body composition based on inflammatory biomarkers with different glycaemic statuses.

Kiteboarding Injuries: Epidemiology, Common Treatment Strategies, and Time to Return to Kiteboarding Following Injury.

To evaluate the prevalence and types of injuries incurred during kiteboarding (1), along with treatment approaches (2). In addition, the time to return to kiteboarding following injury (3) and factors associated with the rate and type of injury were analyzed (4). Recreational kiteboarding. Retrospective cohort. Three hundred twelve kiteboarders (280 men, 32 women, mean age 42.91 ± 13) were included in the study. Age, sex, experience, and the use of protective gear. Kiteboarding experience, injury location, type, incidence, nonsurgical and surgical treatment modalities, and return-to-kiteboarding data. The number of injuries calculated per 1000 sessions was a mean of 7.82 (4.83-10.81). Patients with less than 2 years of kiteboarding experience were at a greater risk of injury than more experienced kiters (P < 0.001). The knee (24.1%), ankle and foot (18.9%), ribs (12.7%), and shoulder (10.2%) were the body parts most frequently injured. Overall, 14.4% of kiters underwent surgical intervention, with knee surgery being the most common site of operation (41.9%) and the most frequently performed procedure being anterior cruciate ligament reconstruction. The pattern of reported injury was found to be different from that previously reported in the scientific literature among freeriding kiters, with knees, ribs, and shoulders being most frequently involved. Participants with <2 years of experience had a significantly greater risk of injury; therefore, proper technical and physical training is advisable.

Effects of Prolonged Proton-Pump Inhibitor Use on Renal Dysfunction and Bone Fragility: A Retrospective Study.

Proton-pump inhibitor (PPI) use for management of gastroesophageal reflux disease (GERD) consists of a short-duration trial, according to guidelines. Long-term usage is appropriate under certain indications. Literature has increasingly documented an adverse effect profile of PPIs, including kidney disease and bone fragility. To investigate the rate of occurrence of osteopenia, osteoporosis, and chronic kidney disease (CKD) in patients using PPI therapy for longer than the recommended trial period of 8 weeks. Retrospective cohort analysis of a single-site primary care clinic. Patients aged 18 to 65 years with PPI prescriptions longer than 8 weeks were included. Information regarding PPI prescriptions, demographics, and medical diagnoses was collected. The search discovered 293 PPI-users and 1908 never-PPI-users. Demographics varied, with a P-value <0.05 in age, body mass index (BMI), and black population (higher in PPI group). The PPI cohort featured higher rates of osteoporosis/osteopenia and CKD (P < 0.001). The odds ratios (ORs) of diagnosis with PPI use was 2.91 (95% CI = [1.692, 4.979]) in osteoporosis/osteopenia. The OR was 1.14 (95% CI = [1.141, 2.229]) in CKD and PPI use but higher with diabetes, elevated BMI, black race, and male gender. We observed increased occurrence rates of osteoporosis, or osteopenia, and CKD in patients with prolonged PPI use. Demographics varied in age, BMI, and black race proportion. A logistic regression revealed increased likelihood of kidney disease and osteoporosis/osteopenia in association with PPI use. These results add to the evidence regarding long-term PPI use and the development of these conditions, but additional studies are needed.

Lymph node evaluation and nodal metastasis prediction in epithelial ovarian cancers: A retrospective study.

To identify consensus regarding lymph node (LN) evaluation in epithelial ovarian cancer (EOC). The objective of the present study was to evaluate surgico-pathological findings, LN involvement, and the prediction of LN metastasis via preoperative imaging and intraoperative assessment in women with EOC. Women with EOC who underwent cytoreductive surgery (CRS) between Jan 2019 to June 2022 were included. The distribution of histology, stage, and LN metastasis was studied. The predictive value of serum cancer antigen (CA)-125, instead of and radiologically and surgically enlarged LNs with final LN histopathology was studied. A total of 96 women with EOCs underwent CRS. Fifty women (52%) underwent primary CRS and 46 women (48%) underwent interval CRS. Seventy-five women (78.13%) with EOC underwent pelvic and/or para-aortic lymphadenectomy, out of which 23 (30.67%) were histologically positive. High-grade serous carcinoma was the commonest (n=55, 73.33%) histology. The majority of women, 56 (74.67%) were stage III or IV at presentation. Complete cytoreduction was achieved in 59 (78.66%) patients. The receiver operating characteristics curve showed a cutoff for CA-125 of 1360 U/mL (area under the curve 0.702, p=0.002) for LN metastases. Both radiologically and surgically enlarged LNs significantly predicted LN metastasis on histopathology (p=0.02 and 0.006 respectively). The combined sensitivity, specificity, positive predictive value and negative predictive value of both contrast enhanced computed tomography (CECT) and surgically enlarged LNs were 78.26%, 57.69%, 45%, and 85.71%, respectively. Serous histology, high-grade tumors, highCA-125 levels, and suspicious LNs on CECT or during surgery were significantly associated with LN metastasis. However, considering the false-negative rate of 21.74%, the combination of radiologically and surgically enlarged LNs cannot be used as the sole surrogate marker for lymphadenectomy.

Haemodynamic effect of dexmedetomidine during paediatric kidney transplantation.

Dexmedetomidine is increasingly used for its ability to stabilise haemodynamic status during general anaesthesia. However, there is currently no data on paediatric kidney transplant recipients (pKTR). This study investigates the haemodynamic impact of dexmedetomidine administered perioperatively in pKTR. From 2019 to 2023, a retrospective study was conducted at Nantes University Hospital involving all pKTR under 18 years of age. The study compared intraoperative haemodynamic parameters between patients administered dexmedetomidine during kidney transplantation (DEX group) and those who did not receive it (no-DEX group). Mean arterial pressure (MAP) and heart rate (HR) were monitored throughout the duration of anaesthesia and compared. Graft function was assessed based on creatinine levels and glomerular filtration rate (GFR) at specific intervals. The perioperative use of fluids and vasoactive drugs, as well as their administration within 24 h post-surgery, were analysed. Thirty-eight patients were enrolled, 10 in the DEX group and 28 in the no-DEX group. Intraoperative HR was similar between the groups; however, MAP was higher in the DEX group (mean difference 9, standard deviation (SD, 1-11) mmHg, p = 0.039). No differences were found regarding the use of fluid and vasoactive drug therapy between groups. GFR at 1 month post-transplantation was significantly elevated in the DEX group (p = 0.009). pKTR receiving intraoperative dexmedetomidine exhibited higher perioperative MAP compared to those not administered dexmedetomidine. Additionally, the DEX group demonstrated superior graft function at 1 month. The direct impact of dexmedetomidine on immediate postoperative graft function in pTKR warrants further investigation in a prospective multicentre randomised study.

Orthoplastic Management of Lower Limb Traumas: A Retrospective Study on Polytraumas Versus Isolated Injuries.

Open fractures of the lower limb represent a common challenge for trauma centers. Even where national guidelines are available, these standards are frequently missing. Our study evaluates the influence of polytrauma on the adherence to the timing and management required in an orthoplastic approach. A retrospective review was performed on 36 patients affected by a Gustilo-Anderson grade IIIA, IIIB, or IIIC fracture of the lower limb between 2018 and 2022. Data related to patient management were analyzed: time to the first evaluation by a plastic surgeon, time to soft tissue coverage, time to definitive osteosynthesis, days in intensive care unit (ICU), days of hospitalization, and total cost of hospital stay. Patient satisfaction was evaluated through the administration of 2 questionnaires: the Enneking and the Foot Function Index (FFI). In 23 patients (63.9%), a soft tissue reconstruction was required. Of these, 13 were polytraumas (PT) (56.5%) and 10 were affected by an isolated lower limb fracture (ILLF) (43.5%). The median time to wound excision was 7.0 days (IQR, 0-16.0) in the PT group and 12.5 days (IQR, 1-41.0) in the ILLF group, whereas the mean time to soft tissue coverage was 15.0 days (IQR, 4.0-17.0) in the PT group and 38.0 days (IQR, 25.0-65.0) in the ILLF group. Mean time to definitive fixation was 33.0 days (IQR, 6.5-70.0) in the PT group and 16.5 days (IQR, 3.0-26.0) in the ILLF group. Statistically significant difference was reported on mean time to soft tissue coverage, whereas not relevant differences were reported on mean time to plastic surgeon involvement, first debridement, definitive fixation, days of hospitalization, costs, and Enneking and FFI score. This is the first study comparing the effectiveness of the orthoplastic approach between isolated lower limb fractures and polytraumas. According to our study, open lower limb fracture management is paradoxically more effective in polytraumas rather than in isolated injuries because a multidisciplinary approach is mandatory in severely injured and compromised patients.

Development and Assessment of a Predictive Model for Ki-67 Expression Using Ultrasound Indicators and Non-Morphological Magnetic Resonance Imaging Parameters Before Breast Cancer Therapy.

To formulate a predictive model for assessing Ki-67 expression in breast cancer by integrating pre-treatment ultrasound features with non-morphological magnetic resonance imaging (MRI) parameters, encompassing functional and hemodynamic indicators. A retrospective study was conducted on 167 patients. All patients underwent a breast mass biopsy for histopathological and Ki-67 analysis prior to neoadjuvant chemotherapy (NAC) treatment. Additionally, all patients underwent ultrasonography and MRI examinations prior to the biopsy. The recorded variables were Ki-67, apparent diffusion coefficient (ADC) values, Max Slope, time to peak (TTP), signal enhancement ratio (SER), early enhancement rate (EER), time-signal intensity curve (TIC), tumor maximum diameter, tumor margins and boundaries, aspect ratio, microcalcification, color Doppler flow imaging grading, resistance index (RI), and axillary lymph node metastasis. Statistical analysis was performed using the R software package. Normally distributed continuous data are presented as mean ± standard deviation (SD), skewed continuous data as median, and categorical variables as frequency or percentage. The dataset was randomly divided into a modeling group and a validation group following a 7:3 ratio, employing a predetermined random seed. The selection of variables was conducted using the random forest algorithm. Specifically, in the initial analysis, we trained a random forest model using all available variables. By evaluating the Gini importance scores of each variable, we identified those that contributed the most to predicting Ki-67 expression. The predictive model for Ki-67 expression was constructed using selected variables: Maximum Diameter, ADC value, SER value, Max Slope value, TTP value, and EER value. Within the validation group, the evaluation metrics demonstrated an Area under the curve of 0.961 with a 95% confidence interval ranging from 0.865 to 0.995. The model achieved a kappa score of 1.00, precision of 0.949, recall of 1, an F1 score of 0.974, sensitivity of 100%, specificity of 85.71%, a positive predictive value of 94.87%, and a negative predictive value of 100%. The combination of non-morphological MRI parameters and pre-treatment ultrasound features in a breast cancer prediction model powered by RF machine learning demonstrated favorable clinical outcomes and improved diagnostic performance.

Transesophageal ultrasound-guided bronchoscopic Acquire TBNB versus Vizishot2 TBNA needles for neoplastic lesions: A retrospective study

BackgroundLung cancer is often diagnosed at an advanced stage; however, it has shown improved therapeutic efficacy with the introduction of molecularly targeted drugs and immune checkpoint inhibitors, necessitating accurate molecular diagnosis for effective treatment planning. Traditional sampling techniques, including endobronchial ultrasound-guided transbronchial needle aspiration, frequently require multiple biopsies to obtain sufficient tissues for multiplex testing, highlighting the need for more efficient methods. Therefore, we explored the diagnostic utility of endoscopic ultrasound with bronchoscope-guided fine-needle biopsy (EUS-B-FNB) versus fine-needle aspiration (EUS-B-FNA) in patients with lung cancer, focusing on tissue sample collection for molecular testing. The introduction of the Franseen needle in EUS-B-FNB, characterized by three beveled edges, allows for more tissue collection in cylinder form. MethodsWe retrospectively analyzed the data of 97 patients who underwent EUS-B-FNB or EUS-B-FNA at Hakodate Goryoukaku Hospital and evaluated diagnostic yields, safety, and nucleic acid concentrations using collected specimens. ResultsThe diagnostic yields of EUS-B-FNB and EUS-B-FNA were comparable (92.2% vs. 92.3%), with no significant differences in complications. However, EUS-B-FNB provided significantly higher DNA and RNA concentrations (DNA; 41.05 vs. 10.20 ng/mL; P < 0.0001, RNA; 36.80 vs. 11.80 ng/mL; P = 0.0009), essential for comprehensive molecular testing. ConclusionThis study highlights the potential of EUS-B-FNB for enhancing the molecular diagnosis of lung cancer by ensuring adequate tissue sample collection for multiplex testing, paving the way for personalized medicine. This technique is comparable in safety and efficacy to traditional methods while offering a substantial improvement in the quality of molecular diagnostics.

Understanding post-operative refractive outcome in pediatrics after IOL implementation: factors and predictors.

In pediatric ophthalmology, calculating intra-ocular lens (IOL) power can be challenging. It is important to predict if the post-surgery refractive error (RE) will meet the intended refractive goal. In this study, we aimed to investigate the factors and predictors influencing RE outcomes in children undergoing IOL implantation. This was a retrospective cross-sectional cohort study that involved 47 eyes with congenital cataracts underwent IOL implantation. Each patient underwent follow-up visits at two months and two years' post-surgery. The IOL power calculations were conducted using the Holladay 1 formula, and both the prediction error (PE) and absolute prediction error (APE) were calculated. The mean age was 6.52 ± 4.61years, with an age range of 1-15years. The mean IOL power was 20.31 ± 6.57 D, and the mean post-operative refraction was 1.31 ± 2.65 D. The mean of PE and APE were 0.67 ± 1.77 and 1.55 ± 1.06 D, respectively. Whereas PE was correlated to axial length with an R-value of - 0.29 (P = 0.04). The calculation method had a significant negative relationship with APE and PE, with coefficients of - 1.05 (P = 0.009) and - 1.81 (P = 0.009), respectively. High astigmatism was associated with greater errors in the refractive outcome. The calculation methods had the most considerable impact on the post-operative RE. The customization of surgical approaches to accommodate individual characteristics is crucial. Further research with diverse subgroups is needed to comprehensively understand the influence of each factor.

Management of patients with adrenal myelolipoma: experience from a tertiary referral centre.

Adrenal myelolipomas are rare, benign, tumours of the adrenal cortex. This study reports the experience of a tertiary adrenal surgery referral centre's approach to the management of patients with adrenal myelolipoma. A retrospective observational cohort study was conducted on all adult patients (> 18years age) diagnosed with adrenal myelolipoma from January 1, 2014, to December 30, 2022. Demographics, imaging characteristics, histological diagnosis (where applicable) and follow-up data were compared between patients undergoing surgery and those referred to surveillance. Indications for operative intervention were recorded at the time of multidisciplinary team discussion, consisting of surgeons, endocrinology physicians, radiologists, pathologists and specialist nursing representatives. Of the 522 patients with an adrenal lesion discussed in adrenal tumour meeting between 2014 and 2022, n = 15 (2.8%) were diagnosed with adrenal myelolipoma. Of the 15 patients, 4 underwent adrenalectomy at first presentation (27%), while 1 patient underwent adrenalectomy after interval follow-up. Indications for operative intervention were as follows: 'indeterminate lesion' (n = 3), 'abdominal pain and size (> 4cm)' (n = 1) and 'mass effect on adjacent organs' (n = 1). The mean rate of lesion growth in patients referred for surveillance (n = 10) was 0.13cm/year. Histology confirmed adrenal myelolipoma as the diagnosis in all resected tumours. For patients with adrenal myelolipoma, the presence of symptoms and/or indeterminate features on imaging may be more clinically useful indications for operative intervention over size alone. The surveillance of adrenal myelolipomas, even in patients with adrenal lesions > 4cm, is a safe clinical strategy, provided the imaging characteristics are benign and patients remain asymptomatic.

Factors Associated With Sacubitril/Valsartan Continuation and the Methods of Combining Heart Failure Medications in Patients With Heart Failure.

Sacubitril/valsartan (SV) is recommended for patients with heart failure (HF). In addition, a combination of 4 HF medications, including SV, is recommended in patients with HF with reduced ejection fraction (HFrEF). However, evidence on the characteristics of patients who could continue SV and its initiation methods is limited. To investigate the factors associated with SV continuation and methods of combining HF medications. This retrospective cohort study included HF patients who initiated with SV at our institution. The endpoint was SV continuation for 6 months after its initiation. Multivariate analysis was used to extract factors associated with SV continuation. The relationship between the methods of combining HF medications (renin-angiotensin system inhibitors, beta-blockers, mineralocorticoid receptor antagonists, or sodium-glucose cotransporter 2 inhibitors), including the number of HF medications, their combination patterns, and the timing of their initiation, and SV continuation was examined in patients with HFrEF. Of 186 eligible patients, 68.8% had HFrEF, and 79.0% continued SV for 6 months. Significant factors associated with SV continuation were albumin ≥ 3.5 g/dL (odds ratio, 4.81; 95% confidence interval, 2.19-10.59), body mass index (BMI) ≥ 18.5 kg/m2 (4.17; 1.10-15.85), and systolic blood pressure (SBP) ≥ 110 mmHg (2.66; 1.12-6.28). In patients with HFrEF, the proportion of HF medications not initiated simultaneously with SV was significantly higher in the continuation group than in the discontinuation group (67.3% vs 33.3%, P = 0.002). The number of HF medications and their combination patterns were not significantly associated with SV continuation. Albumin, BMI, and SBP are useful indicators for selecting patients who are likely to continue SV. In addition, initiating only SV without simultaneously initiating other HF medications in patients with HFrEF may lead to SV continuation.

High serum progesterone levels on the day of embryo transfer in patients undergoing artificial frozen-thawed blastocyst transfer: Is there a ceiling effect?

To evaluate the potential ceiling effect of high serum progesterone levels on the day of embryo transfer for pregnancy outcomes in patients undergoing artificial frozen-thawed blastocyst transfer (FET) cycles. This retrospective cohort study included 595 patients who underwent artificial FET cycles. We evaluated progesterone levels and found that 40.6 ng/mL corresponded to the 90th percentile and 23.9 ng/mL corresponded to the 50th percentile. Based on these findings, we categorized progesterone levels as <20 ng/mL (n=220, 37.0%), 20-40 ng/mL (n=312, 52.4%), and ≥40 ng/mL (n=63, 10.6%). The primary outcome measures were the clinical pregnancy rate (CPR) and live birth rate (LBR). Blastocyst morphology grades, including expansion, trophectoderm, and inner cell mass grades, were significantly associated with clinical pregnancy (p<0.001 for all). Progesterone levels between 20 and 40 ng/mL were associated with higher CPR (p=0.043). In the multivariate analysis, only blastocyst expansion and inner cell mass grades were independently and significantly associated with CPR [p=0.011, odds ratio (OR)=1.6, (confidence interval) CI 95%=1.13-2.39, and p=0.007, OR=1.65, CI 95%=1.14-2.39, respectively]. The progesterone level and trophectoderm grade were not statistically significant. Regarding LBR, only blastocyst expansion grades 4 and trophectoderm grades A or B were significantly associated. Based on these data, we speculate that if serum progesterone levels exceed 40 ng/mL on the day of embryo transfer in patients undergoing artificial FET cycles, there is no need to reduce the progesterone dose.

Pediatric Clinical Outcomes of Nasal Methicillin-resistant Staphylococcus aureus Polymerase Chain Reaction Utilization.

Methicillin-resistant Staphylococcus aureus (MRSA) is a clinical challenge in selecting empiric antimicrobials for pediatric infections. We implemented nasal MRSA polymerase chain reaction (nMRSA PCR) screening as a diagnostic tool and evaluated its impact on empiric antibiotic use and clinical outcomes. A retrospective single-center study of patients hospitalized with infections who were empirically prescribed anti-MRSA antibiotics was conducted prior to and following the initiation of nMRSA PCR screening. Electronic medical records, pharmacy data and bacterial cultures results were reviewed. Predictive values of nMRSA PCR testing were calculated and the duration of anti-MRSA empiric therapy and clinical outcomes preimplementation and postimplementation were compared. During the preimplementation period, there were 382 distinct episodes (294 unique patients) that met the inclusion criteria and during post-nMRSA PCR implementation, 394 episodes (360 unique patients) were identified. The median time to discontinuation of anti-MRSA antibiotics and proportion of patients prescribed anti-MRSA antibiotics at discharge were significantly lower in postimplementation compared with preimplementation period; 48 versus 56 hours, P < 0.001 and 20.1% versus 40.3%, P < 0.001, respectively. The negative and positive predictive values of nMRSA PCR compared to clinical culture results were 95.6% and 51.2%, respectively. Predefined adverse outcomes were documented in 11 patients who had early anti-MRSA discontinuation with negative nMRSA PCR results but only 3 were restarted on anti-MRSA treatment and none grew MRSA in clinical cultures. Shortened anti-MRSA antibiotic duration, high negative predictive value and low adverse events provide promising evidence that nMRSA PCR is an effective, rapid antimicrobial stewardship tool for hospitalized children.

Predictive Value of Angle of Progression in Term Nulliparous Women: A Comprehensive Study on Spontaneous Vaginal Delivery Correlation and Clinical Implications.

This study aims to explore the correlation between the angle of progression (AOP) and spontaneous vaginal delivery (SVD) for term nulliparous women before the onset of labor. Additionally, it evaluates the diagnostic efficacy of AOP in predicting SVD in term nulliparous women. In this retrospective observational study, data from nulliparous women without contraindications for vaginal delivery, with a singleton pregnancy ≥37 weeks, and before the onset of labor were included. Transperineal ultrasound was performed to collect AOP. The date and mode of delivery were tracked, to assess the correlation between AOP and SVD in term nulliparous women. Receiver operating characteristic (ROC) curve analysis was used to evaluate the diagnostic efficacy of AOP in predicting SVD for term nulliparous women. The SVD-failure (SVD-f) group exhibited a significantly lower AOP compared with the SVD group (88.43° vs 95.72°, P < .001). Logistic regression analysis revealed that AOP was associated with SVD in term nulliparous women (OR = 1.051). ROC curve analysis demonstrated that the area under the ROC curve with AOP 84° as the threshold was 0.663, with a sensitivity of 85.25% and specificity of 43.18%. Considering a sensitivity and specificity of 90%, the dual cut-off values for term nulliparous women for SVD were 81° and 104°, respectively. A positive correlation was identified between AOP and SVD for nulliparous women after 37 weeks and before the onset of labor. Notably, term nulliparous women with AOP exceeding 104° exhibited a higher probability of SVD.

Impact of the COVID-19 Pandemic on Foodborne Disease Healthcare-Seeking Behavior and Diagnoses at a Large Academic Medical System.

The objective of this study was to examine changes in healthcare-seeking behaviors and diagnostic practices around foodborne illness during the COVID-19 pandemic in a large university-based health system. A retrospective cohort study of individuals diagnosed with pathogens commonly transmitted through food between 2015 and 2020 was undertaken using electronic medical record data. Regression models were used to compare measured incidence rates of various foodborne pathogens as well as associated healthcare-seeking behaviors during the pandemic year of 2020 to previous years. Incidence of campylobacteriosis, cholera, and norovirus in 2020 significantly decreased, respectively, by 65.5% (p < 0.01), 90.1% (p = 0.02), and 73.0% (p = 0.03) compared with an average from 2017- to 019. Average annual visits for patients included in our sample significantly increased by 8.0% when comparing the average from 2017-2019 to 2020 (p < 0.01). These results suggest that the pandemic impacted healthcare use related to foodborne disease either due to reduced exposure to foodborne pathogens or reduced willingness to seek healthcare.

Triphasic Learning Curve of Cytoreductive Surgery with Hyperthermic Intraperitoneal Chemotherapy.

Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) is an effective but costly procedure for select patients with peritoneal malignancies. The impact of progression along a learning curve on the cost of these procedures is unknown. We performed a retrospective cohort study of patients undergoing CRS-HIPEC from 2016 to 2022 at a single quaternary center. Our study cohort was temporally divided into four equally sized volume quartiles (A, B, C, and D). We utilized cumulative sum plots and split-group analysis to characterize the institutional learning curve based on cost, operative time, length of stay, and morbidity. Multivariable linear regression was performed to estimate costs after adjusting for covariates. Bivariate analysis was performed using a Kruskal-Wallis test to compare continuous variables and a χ2 test to compare categorical variables. Of 201 patients, the median age [interquartile range (IQR)] was 57 (47-65) years, 113 (56%) patients were female, 143 (71%) were white, and 107 (53%) had private insurance. Median operating room charge [US$42,639 (US$32,477-54,872), p < 0.001] varied between volume quartiles, peaking in quartile C. Stabilization was achieved for 86 cases for operating room cost, 88 cases for routine cost, 96 cases for length of stay, 103 cases for operative time, 120 cases for intensive care unit length of stay, and 150 cases for overall and serious morbidity. The actual operating room and routine costs were similar to predicted costs at the end of the study period. The CRS-HIPEC learning curve is triphasic, with cost stability achieved relatively early compared with other markers of surgical proficiency.