Sequential Patients Research Articles

Comparison of sequential versus concurrent chemoradiation regimens in non-metastatic muscle-invasive bladder cancer.

The treatment approach for non-metastatic bladder cancer is guided by an invasion of the muscular layer of the bladder wall. Radical cystectomy is the recommended treatment for muscle-invasive disease. However, it has considerable morbidity and mortality and is not suited for many patients. Trimodality therapy consisting of chemoradiation after transurethral resection of bladder tumor offers a definitive approach with bladder-sparing potential. However, there is a lack of research defining the optimal combination of chemotherapy and radiation in this setting. We extracted patient data from the National Cancer Database to compare survival outcomes and demographic factors in 2,227 non-metastatic bladder cancer patients who were treated with chemotherapy sequential to or concurrently with radiation. Sequential treatment was defined as chemotherapy beginning >14 days before radiation, and concurrent was defined as beginning within 14 days of the first radiation. The sequential treatment group patients were younger (mean age, 74 vs. 78 years; p < 0.001) with more advanced disease. We found no difference in overall survival between patients who received chemotherapy sequential to radiation and those who received concurrent chemoradiation only (p = 0.533). Our data are concordant with a previous prospective study, and support that chemotherapy prior to radiation does not decrease survival outcomes relative to patients receiving only concurrent chemoradiation. Given that the sequential group had an overall higher stage but no difference in survival, downstaging chemotherapy prior to radiation may be helpful in these patients. Further studies including a larger, multi-institutional clinical trial are indicated to support clinical decision-making.

Effect of 2% Topical Lidocaine Gel on Discomfort from Electrical Stimulation During Nerve Conduction Studies- A Prospective Double-Blind Placebo-Controlled Study.

Procedure discomfort can limit electrodiagnostic studies. Reducing discomfort can maximize the benefits of these diagnostic tools. This study targeted the discomfort associated with nerve conduction studies (NCS). This was a prospective randomized double-blind placebo-controlled study comparing the effect of topical lidocaine gel (2%) versus analgesic-free lubricant gel (K-Y gel) on pain perception during NCS. Sequential patients (n=130) referred for routine NCS participated in the study. We applied 1 mL of lidocaine gel to one palm, and 1 mL of K-Y gel to the other as a control. After 20-45 min of application, graded increments of electrical stimulation intensity were delivered to record the median and ulnar mixed palmar nerve responses. Patients were then asked to score the degree of pain felt from electrical stimulation over each palm using the Wong-Baker Faces Pain Scale (WBFPS) and the Numeric Rating Scale (NRS), independent of baseline pain. Mean WBFPS and NRS scores for lidocaine-treated palms were significantly lower than those for controls using parametric paired t-test (3.79 vs 4.37 and 3.35 vs 3.78 respectively, all p-values<0.05). Subgroup analysis showed a significant decrease in mean scores in females, patients aged ≤50 years, patients without a history of previous NCS, and patients without comorbidities (all p-values<0.05). Median scores using nonparametric Wilcoxon ranked test also showed statistically significant differences (all p-values<0.05). The results indicate that topical lidocaine 2% gel reduces discomfort associated with NCS. However, despite the statistical significance, clear clinical significance may be lacking. Clinical implementation may be considered for the subgroups that showed the greatest benefit. Further studies that incorporate more efficient drug delivery methods may yield better results.

Prospective Randomized Comparison of Endoscopist-facilitated Endotracheal Intubation and Standard Intubation for ERCP.

Complex endoscopic procedures are increasingly performed with anesthesia support, which substantially impacts endoscopy unit efficiency. ERCP performed under general anesthesia presents unique challenges, as patients are typically first intubated, then transferred to the fluoroscopy table and positioned semi-prone. This requires additional time and staff while increasing the potential for patient/staff injury. We have developed the technique of Endoscopist-facilitated intubation using an endotracheal tube backloaded onto an ultraslim gastroscope as a potential solution to these issues and evaluated its utility prospectively. Sequential patients undergoing ERCP were randomized to Endoscopist-facilitated intubation or to Standard intubation. Demographic data, patient/procedure characteristics, endoscopy efficiency parameters and adverse events were analyzed. During the study period, 45 ERCP patients were randomized to either Endoscopist-facilitated intubation (n=23) or Standard intubation (n=22). Endoscopist-facilitated intubation was successful in all patients, without hypoxic events. Median time from patient arrival in room to procedural start was shorter in patients undergoing Endoscopist-facilitated intubation vs Standard intubation (8.2 min vs. 29 min, p<0.0001). Endoscopist-facilitated intubations were brisker than Standard intubations (0.63 min vs. 2.85 min, p<0.0001). Endoscopist-facilitated intubation patients reported less post-procedure throat discomfort (13% vs. 50%, p<0.01) and fewer myalgias (22% vs. 73%, p<0.01) than Standard intubation patients. Endoscopist-facilitated intubation was technically successful in every patient. Median Endoscopist-facilitated intubation time from patient arrival in room to procedural start was 3.5-fold lower and median Endoscopist-facilitated intubation time was over 4-fold lower than for Standard intubation. Endoscopist-facilitated intubation significantly enhanced endoscopy unit efficiency and minimized staff and patient injury. General adoption of this novel approach may represent a paradigm shift in the approach to safe and efficient intubation of all patients requiring general anesthesia. While the results of this controlled trial are promising, larger studies in a broad population are needed to validate these findings. NCT03879720.

Performance of admission pathways within acute medicine services: Analysis from the Society for Acute Medicine Benchmarking Audit 2022 and comparison with performance 2019 - 2021

Urgent and emergency care services face increasing pressure, impacting patient care. We evaluated the performance of acute medicine services, assessing clinical quality indicators for unplanned medical admissions to acute hospital services.152 acute UK hospital services accepting unplanned admissions to acute and general internal medicine completed a day-of-care survey incorporating organisational structure questionnaire and patient-level data over a pre-defined 24-hour period in June 2022. Clinical quality indicators were: Early Warning Score (EWS) measurement within 30 min of hospital arrival; clinician assessment within 4 h; assessment by consultant physician within 6 h (daytime) or 14 h (night-time). Results were compared with 2019, 2020, 2021.7293 sequential patients were included (and compared with 19,817 patients across 2019–2021). In 2022, 69% of patients (95%CI 67.7–69.9%) had an EWS documented within 30 min. 79% of patients (95%CI 77.8–79.7%) were reviewed by a clinical decision maker within 4 h of hospital arrival. Patients assessed in Same Day Emergency Care services were more likely to meet this target than those assessed in Acute Medical Units or Emergency Departments (OR 2.4, 95%CI 2.02–2.87, p<0.001). Overall, 50% of patients received consultant physician review within the target time (3065/6161, 95%CI 48.5–51.0%); performance varied with time of arrival and location of initial assessment. Performance against all three clinical quality indicators was lower than 2019, 2020 and 2021 (p<0.001 for all).Performance against all quality indicators within acute medicine services is deteriorating. However, performance in Same Day Emergency Care Units is greater than in Acute Medical Units or Emergency Departments.

Contained specimen morcellation during robotics-assisted laparoscopic supracervical hysterectomy for pelvic organ prolapse.

Robotics-assisted laparoscopic supracervical hysterectomy (RALSH) with concomitant apical robotics-assisted POP repair provides advantages of minimally invasive procedures; however specimen removal without intraperitoneal spillage of potential pathology remains challenging. The primary aim of our study is to determine the factors affecting contained manual morcellation (CMM) of specimens during RALSH for POP surgery. The secondary aim of the study is to report complications associated with CMM and on specimen pathology. A total of 67 sequential patients underwent RALSH with concomitant robotics-assisted sacrocolpopexy or uterosacral vaginal suspension. Factors analyzed to affect CMM were specimen weight, length of skin and fascia incisions, patient age, body mass index (BMI), and estimated blood loss (EBL). Median CMM time was 11min (1 to 46) and specimen weight 62g (19 to 711). Median patient age was 56years (36 to 83), and patient BMI was 28 (18 to 44). Median EBL was 50ml (10 to 150). Median skin and fascial incision lengths were 3cm (1.5 to 7), and 3.5cm (1.5 to 8). CMM time was significantly dependent on specimen weight (p < 0.0001) and length of rectus fascia incision (p < 0.0126). There was no gross tissue spillage or bag ruptures. Uterine pathology revealed normal tissue (26%), leiomyoma (47%), adenomyosis (49%), and endometriosis (14%). 4.5% of specimens had evidence of microscopic neoplasm, and 5years after surgery patients were cancer free. Contained manual extraction of the uterus and/or adnexae at the time of RALSH for POP surgery is a viable, safe, and efficient method of specimen removal.

Superficial Circumflex Iliac Artery Perforator-Free Flaps in Head and Neck Reconstruction: A Report on 10 Cases

Abstract The superficial circumflex iliac artery flap or as it was traditionally called the groin flap has gained a growing interest recently with the concept of perforators that revolutionized our understanding of many other classic flaps like the deep inferior epigastric artery, the thoracodorsal artery-based flaps, and many others. This revisiting process was brought about by further deeper knowledge of the anatomy of these flaps at finer levels. These advances made it possible to raise flaps with minimal donor site morbidities as well as to expand the applications for certain flaps to include different tissue components that serve the reconstructive needs better. Recent studies investigated its vascular supply, and a refined approach was adopted for using it in reconstruction. Another factor for revisiting this flap, is the lymph nodes that lie in its territory that may be used for lymph node transplant in lymphedema cases. Our objective from this report on 10 cases, is to display the flexibility and uses of the superficial circumflex iliac artery perforator (SCIP) free flap. We utilized the SCIP flap for ten sequential patients between November 2019 to August 2020 that were reconstructed with primary or secondary reconstruction in the head and neck region. All were performed by the same primary surgeon and his team. The serial cases incorporated 6 females and 4 males with a mean age of 51.5 years (range 16–80 years). In two cases, this flap was designed in a chimeric fashion including a bony segment from the iliac crest. In conclusion, we have found that the superficial circumflex iliac artery perforator flap has a reliable anatomy which facilitates a fast and easy dissection. Among others, this flap has shown that it has a strong advantage since it displayed minimal donor site morbidity.

Serum total bilirubin level is associated with contrast induced nephropathy after primary percutaneous coronary intervention.

Contrast Induced Nephropathy (CIN) is a major complication of angiographic procedures. Primary percutaneous coronary intervention (pPCI) is the preferred treatment for ST-segment elevation myocardial infarction (STEMI) but is associated with a risk of CIN. Oxidative stress and free radical damage play a role in the pathogenesis of CIN. Bilirubin has anti-inflammatory and antioxidant activity and has been shown to have a protective effect on endothelial cells. The present study aimed to assess the association between serum bilirubin level and development of CIN after pPCI. Sequential STEMI patients (n = 595) who underwent pPCI between January 2021 and December 2022 were enrolled. Among the participants, 116 (19.5%) developed CIN. Serum total bilirubin level was significantly lower in the CIN group (P = .001). In multivariate logistic regression analysis, serum bilirubin level was found as an independent predictor of CIN. Age, gender, contrast volume, and white blood cell count were other independent predictors of CIN. A higher serum bilirubin level is associated with a lower risk of CIN in the present study. In STEMI patients undergoing pPCI, serum bilirubin level may be helpful to predict the risk of CIN and may help ensure early initiation of preventive treatment and careful follow-up.

How May Longer Console Times Influence Outcomes after Robot-Assisted Radical Prostatectomy (RARP)?

this study investigates the influence of operating time on outcomes after RARP in real life settings in a monocentric single surgeon study. a total of 500 sequential patients who were operated on between April 2019 and August 2022 were involved. Men were allocated to three groups short (n = 157; 31.4%), under or equal to 120 min; average (n = 255; 51%), between 121 and 180 min; long (n = 88; 17.6%), above 180 min console time. Demographic, baseline and perioperative data were analyzed and compared between groups. Univariate logistic regression was completed to investigate the association between console time and outcomes and to predict factors which may prolong surgery. hospital stay and catheter days were significantly longer in group 3 with medians of 6 and 7 days (p < 0.001 and <0.001, respectively). Those findings were confirmed in univariate analysis, with p = 0.012 for catheter days and p < 0.001 for hospital stay. Moreover, major complications were higher in patients with longer procedures, at p = 0.008. Prostate volume was the only predictor of a prolonged console time (p = 0.005). RARP is a safe procedure and most patients will be discharged uneventfully. Yet, a longer console time is associated with a longer hospital stay, longer catheter days and major complications. Caution has to be taken in the large prostate to avoid longer procedures, which may prevent postoperative adverse events.

Dose Intensity in Real-World Patients With Metastatic Renal Cell Carcinoma Taking Vascular Endothelial Growth Factor Receptor Tyrosine Kinase Inhibitors.

Tyrosine kinase inhibitors (TKIs) that target the vascular endothelial growth factor receptor (VEGFR) are oral therapies used to treat metastatic renal cell carcinoma (mRCC). VEGFR TKI treatment is often complicated by dose-limiting adverse events (AE). We sought to describe dose intensity and clinical outcomes in a real-world cohort of patients treated with VEGFR TKIs to better characterize dosing patterns and toxicity management compared with previously reported clinical trials. We conducted a retrospective chart review of sequential patients with mRCC treated with VEGFR TKIs at 1 academic medical center from 2014 to 2021. 139 patients (75% male, 75% white, median age 63 years) were treated with 185 VEGFR TKIs in our real-world cohort. Per International Metastatic RCC Database Consortium criteria, 24% had good risk, 54% intermediate risk, and 22% poor risk mRCC. With their first VEGFR TKI, median relative dose intensity (RDI) was 79%. 52% of patients required a dose reduction, 11% discontinued treatment due to AEs, 15% visited the ED, and 13% were hospitalized for treatment-related adverse events. Cabozantinib had the highest rate of dose reductions (72%) but a low rate of discontinuation (7%). Real-world patients consistently had lower RDI than reported clinical trials with more frequent dose reductions, fewer drug discontinuations, shorter progression-free survival, and shorter overall survival. Real-world patients were less able to tolerate VEGFR TKIs compared to patients treated on clinical trials. Low real-world RDI, high dose reductions, and low overall discontinuation rates can inform patient counseling prior to treatment initiation and during therapy.

Persistent Thrombocytopenia Indicates Endoleak After Complex Endovascular Aneurysm Repair

High-pressure endoleaks (types I or III) after fenestrated-branched endovascular aneurysm repair (F-BEVAR) pose an ongoing risk of rupture. Early identification of such endoleaks may facilitate appropriate reintervention and mitigate that risk. The purpose of this study was to determine if persistent thrombocytopenia after F-BEVAR correlates with the presence of a high-pressure endoleak in the early postoperative period. Sequential patients enrolled in a physician-sponsored investigational device exemption study of physician modified and Cook manufactured F-BEVAR endografts were evaluated. Patients with type I endoleak or type III endoleak identified on computed tomography imaging within the first 6 months of follow-up were categorized as high-pressure endoleaks; any type II endoleaks were classified as low-pressure endoleaks. Univariable and multivariable analysis was performed to assess if thrombocytopenia was associated with the presence of endoleaks. We treated 185 patients. Twenty-six patients (14%) developed a high-pressure endoleak and 30 (16%) developed a low-pressure endoleak (Table I). Age, gender, race, indications for the procedure, and preoperative medications did not significantly differ between the endoleak groups. To maximize sensitivity and clinical utility, we selected a cut point of daily average platelet count of <100,000/μL (Table II). The proportion of high-pressure endoleak patients with platelet counts of <100,000/μL was significantly greater compared to patients with low-pressure and no endoleaks on postoperative day (POD) 1 through 4 (POD 4: high-pressure 42%, low-pressure 27%, no endoleak 10%; P ≤ .001). After adjusting for demographics and comorbidities, patients with high-pressure endoleak were over 12-times more likely to have a platelet count of <100,000/μL on POD 4 compared to patients with no endoleak (odds ratio, 12.3; 95% confidence interval, 3.5-43.0). F-BEVAR patients who developed high- or low-pressure endoleak were significantly more thrombocytopenic in the postoperative period. Consideration should be made to perform computed tomography imaging in patients with platelet counts of <100,000/μL persisting at POD 4 after F-BEVAR as these patients have a 35% chance of having a high-pressure endoleak requiring reintervention.Table IProportion of patients with platelet count under 100,000/μL at preoperative (day 0), and postoperative days (POD) 1-7 after F-BEVAR among the type I, II, and III endoleak and no endoleak groupsDay 0Day 1Day 2Day 3Day 4Day 5Day 6Day 7No endoleak (n = 125)12 (10)17 (14)27 (22)28 (22)13 (10)11 (9)4 (3)4 (3)T1E/T3E (n = 26)7 (27)12 (46)15 (58)12 (46)11 (42)3 (12)1 (4)1 (4)T2E (n = 30)5 (17)10 (33)11 (37)13 (43)8 (27)5 (17)3 (10)1 (3)P value.06<.001.001.02<.001.8.6a1.0aT1EL/T3EL, Type I endoleak/type III endoleak; T2EL, type II endoleak.Data presented as number (%).aFisher's exact was used. Open table in a new tab Table IIComparison of the test characteristics of a cutpoint of <100,000/μL at different postoperative days (POD) for predicting the presence of a high-pressure endoleakSensitivity (95% CI)Specificity (95% CI)PPV (95% CI)NPV (95% CI)ROC area (95% CI)Average platelets <100,000/μL on POD 30.46 (0.29-0.66)0.77 (0.70-0.84)0.30 (0.18-0.46)0.87 (0.80-0.92)0.61 (0.51-0.72.)Average platelets <100,000/μL on POD 40.42 (0.26-0.63)0.89 (0.83-0.94)0.45 (0.29-0.67)0.88 (0.82-0.93)0.66 (0.55-0.76)Average platelets <100,000/μL on POD 3 or 40.50 (0.33-0.70)0.76 (0.68-0.83)0.31 (0.19-0.47)0.87 (0.80-0.93)0.62 (0.52-0.73)95% CI, 95% Confidence interval; NPV, negative predictive value; PPV, positive predictive value; ROC, receiver operating characteristic. Open table in a new tab

Improving evaluation for TTR amyloidosis by interactive filtering of Tc-99m PYP SPECT images. The role for "clean blood pool" imaging.

Myocardial imaging with bone agents such as Tc-99m PYP and HMDP has assumed a central role in the evaluation of patients with suspected transthyretin (TTR) amyloidosis. Visual scoring (VS) (0-3 +) and the heart to contralateral lung ratio (HCL) classify many patients as equivocal when mediastinal uptake is apparent but cannot be further differentiated into myocardial uptake versus blood pool. SPECT imaging has been recommended but current reconstruction protocols frequently produce amorphous mediastinal activity that also fails to discriminate between myocardial activity and blood pool. We hypothesized that interactive filtering interactively using a deconvolving filter would improve this. We identified 176 sequential patients referred for TTR amyloid imaging. All patients had planar imaging, 101 had planar imaging with a large field of view camera that allowed HCL measurements. SPECT imaging was performed on a 3-headed digital camera with lead fluorescence attenuation correction. One study was excluded for technical reasons. We created software to allow interactive filtering while reconstructing the images then overlay them on attenuation mu maps to assist localization of myocardial/mediastinal uptake. Conventional Butterworth and an interactive inverse Gaussian filters were employed to differentiate myocardial uptake from residual blood pool. We defined "clean blood pool" (CBP) as recognizable blood pool with no activity in the surrounding myocardium. A scan was determined diagnostic if it showed CBP, positive uptake or no identifiable mediastinal uptake. 76/175 (43%) were equivocal (1 +) by visual uptake. Of these 22 (29%) were diagnostic by Butterworth but 71 (93%) were by inverse gaussian (p < .0001). 71/101 (70%) were equivocal by HCL (1-1.5). Of these, 25 (35%) were diagnostic by Butterworth but 68 (96%) were diagnostic by inverse gaussian (p < .0001). This was driven by a greater than threefold increase in the identification of CBP by inverse gaussian filtering. CBP can be identified in the vast majority of patients with equivocal PYP scans using optimized reconstruction and can greatly reduce the number of equivocal scans.

Quantitative myocardial T2 mapping adds value to Japanese circulation society diagnostic criteria for active cardiac sarcoidosis.

Noninvasive identification of active myocardial inflammation in patients with cardiac sarcoidosis plays a key role in management but remains elusive. T2 mapping is a proposed solution, but the added value of quantitative myocardial T2 mapping for active cardiac sarcoidosis is unknown. Retrospective cohort analysis of 56 sequential patients with biopsy-confirmed extracardiac sarcoidosis who underwent cardiac MRI for myocardial T2 mapping. The presence or absence of active myocardial inflammation in patients with CS was defined using a modified Japanese circulation society criteria within one month of MRI. Myocardial T2 values were obtained for the 16 standard American Heart Association left ventricular segments. The best model was selected using logistic regression. Receiver operating characteristic curves and dominance analysis were used to evaluate the diagnostic performance and variable importance. Of the 56 sarcoidosis patients included, 14 met criteria for active myocardial inflammation. Mean basal T2 value was the best performing model for the diagnosis of active myocardial inflammation in CS patients (pR2 = 0.493, AUC = 0.918, 95% CI 0.835-1). Mean basal T2 value > 50.8ms was the most accurate threshold (accuracy = 0.911). Mean basal T2 value + JCS criteria was significantly more accurate than JCS criteria alone (AUC = 0.981 vs. 0.887, p = 0.017). Quantitative regional T2 values are independent predictors of active myocardial inflammation in CS and may add additional discriminatory capability to JCS criteria for active disease.

Therapeutic limitation in cardiogenic shock: lessons learnt from the Altshock-2 registry

Abstract Funding Acknowledgements Type of funding sources: None. Background Mortality from cardiogenic shock (CS) shows great disparities (1). This evidence reflects variations in access to care and medical practice, related to the lack of clear guidelines for appropriate patient selection for mechanical circulatory support (MCS) application. In this regard, the results of most trials or meta-analyses were neutral on survival, and the costs in terms of patient morbidity/mortality are high and unproven (2). Accordingly, a judicious use of MCS is crucial for an adequate resource allocation and to avoid futility. Purpose To characterize trends in use of support devices and compare outcomes between CS patients included in a contemporary national Cardiac Intensive Care Units (CICUs) registry, treated or not with MCS. Methods 324 sequential patients admitted with CS at a CICUs network between March 2020 and August 2022 were identified. We categorized patients according to treatment with MCS (n=204; 63%) and medical therapy (n=120; 37%). We investigated differences in clinical, laboratory, hemodynamics, echocardiographic and prognostic scores on admission, at 24-hours and at discharge. In-hospital outcome and mid-term survival were described for each treatment cohort. Comparison of continuous variables was performed using Student’s t-test. For categorical variables, the χ2 statistic was used. Results CS was a complication of acute myocardial infarction in 141 patients (44%) and of acute on chronic heart failure in 124 patients (38%); 58 patients (18%) presented with other diagnosis. In MCS cohort, we reported more advanced Society for Cardiovascular Angiography and Interventions (SCAI) shock stages and MCS implantation was more prevalent within 24-hours in SCAI C (48,6% on admission; 51,2% at 24-hours). In-hospital mortality did not differ between the two groups (38% in MCS and 37% in medically treated patients, p=0,874). Chronic kidney disease (OR 2.1, 95%CI 1.2-3.5, p=0,009), elevated lactates and SCAI stage at 24-hours (OR and 95%CI were, respectively, 3.45, 1.99-5.97 and 3.67, 2.46-5.47, p&amp;lt;0,001) emerged as major independent predictors of in-hospital mortality in MCS subgroup. A significant protective association persisted for those monitored with pulmonary artery catheter (OR 0.61, 95%CI 0.51-0.92, p=0.001). Among the 196 patients evaluated at mid-term follow up MCS treatment had not markedly improved cumulative survival compared to medical treatment (51,9% in MCS subgroup versus 55,6% in medical therapy, p=0,806). Palliative care team was rarely engaged (14% in MCS cohort vs 27% in medical therapy, p=0,83). Conclusions In this nation-wide study, mortality in MCS patients was high and no statistically significant difference on in-hospital and mid-term survival emerged between patients receiving MCS compared to medical therapy. Hence, a prompt and constant risk-stratification is mandatory to exclude patients too sick to derive any benefits from invasive therapies, avoiding futility.

Factor structure and psychometric performance of the PCL-5 in a clinical sample of veterans seeking treatment in a VA PTSD outpatient clinic.

There is a clear need to improve the measurement of posttraumatic symptoms in veterans seeking trauma-focused treatment. We evaluated the structure and psychometric performance of the Posttraumatic Stress Disorder (PTSD) Checklist for the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (PCL-5) in a naturalistic sample of veterans engaging in evidence-based therapy in a Veterans Affairs (VA) PTSD outpatient clinic. We collected data from 500 sequential patients at the beginning and end of treatment, evaluating the PCL-5 factor structure followed by psychometric analyses. Results align with recent research following rigorous methods and advanced statistical techniques in suggesting a unidimensional factor structure for the PCL-5, with indications for its items representing a general factor with no clear support for multiple factors or subscales aligned with specific symptom clusters. In addition, psychometric analyses suggest a wider range of potential cutoff scores predicting PTSD diagnosis that may be specific to this population or setting. Given the remaining research questions surrounding the PCL-5 and its structure and functioning specifically, as well as the evolving conceptualizations of PTSD as a psychological disorder, further research is needed to guide clinical practice and future research. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

COVID-19 vaccine uptake trends in SARS-CoV-2 previously infected cancer patients

PurposeCancer patients are at high risk of developing severe illness from SARS-CoV-2 infection, but risk is lowered with receipt of COVID-19 vaccine. COVID-19 vaccination uptake among previously infected cancer patients may be influenced by an assumption of natural immunity, predicted weak immune response, or concerns about vaccine safety. The objective of this study was to evaluate COVID-19 vaccine uptake trends in cancer patients previously infected with SARS-CoV-2. Materials and MethodsMedical records of 579 sequential cancer patients undergoing active treatment at Levine Cancer Institute who tested positive for COVID-19 between January 2020 and January 2021 were evaluated. Patients who died prior to vaccine eligibility were excluded from the analysis. Demographic, clinical, and COVID-19 related characteristics were analyzed to identify prognostic factors for COVID-19 vaccine uptake as this information could be important for health policy design for future pandemics. ResultsEighty-one patients died prior to the availability of COVID-19 vaccines. The acceptance rate of COVID-19 vaccination among 498 previously infected cancer patients was 54.6%. Of the patients with known vaccination dates, 76.8% received their first vaccine by April 17th, 2021. As of November 30, 2021, 23.7.% of eligible patients were boosted. In univariate models, older age, female sex, higher income, solid tumor cancer type, and hormone therapy were significantly associated with higher vaccine uptake, while Hispanic/Latino ethnicity was significantly associated with lower vaccine uptake. In a multivariable model, age (OR 1.18, 95% CI 1.10–1.28; p < 0.001), female sex (OR 1.80, 95% CI 1.22–2.66; p = 0.003), and higher income (OR 1.11, 95% CI 1.01–1.22; p = 0.032), were predictive of COVID-19 vaccine uptake. ConclusionsOverall, vaccine uptake was low among our cohort of previously infected cancer patients. Older age, female sex, and higher income were the only variables associated with COVID-19 vaccine uptake within this vulnerable patient population.

Low prevalence of positive hydrogen breath tests in patients with functional gastrointestinal conditions and hypermobile Ehlers-Danlos syndrome.

Using hydrogen breath testing (HBT) to diagnose small intestinal bacterial overgrowth (SIBO) remains controversial in patients with functional gastrointestinal (GI) disorders, and unknown in those with hypermobility Ehlers-Danlos syndrome (hEDS). We assessed prevalence of positive HBTs in these groups, evaluated the predictive value of GI symptoms and the potential role of proton pump inhibitors (PPIs) on test results. Sequential patients referred for HBT to a tertiary unit were classified into the following groups: GI maldigestion/malabsorption, GI sensorimotor disorders, hEDS, and functional GI disorders. All underwent standardized HBT, and the yield was assessed against symptoms and PPI use. A total of 1062 HBTs were performed over 3 years (70% female, mean age 48 ± 16 years). Overall, 7.5% (80/1062) patients had a positive HBT. Prevalence of positive HBT was highest in patients with GI maldigestion/malabsorption (17.9%; DOR 16.16, p < 0.001), GI sensorimotor disorders (15.9%; DOR 8.84, p < 0.001), compared to functional GI disorders (1.6%; DOR 1.0) (p < 0.0001). None of the hEDS patients tested positive for HBT. A positive HBT was independently associated with increased age (DOR 1.03; p < 0.001) and symptoms of diarrhea (DOR 3.95; p < 0.0001). Patients on PPIs tended towards a positive HBT than patients off PPIs (16.1% vs 6.9%; DOR 2.47; p < 0.0001). Less than 2% of patients with functional GI disorders, and none of the patients with hEDS had a positive HBT. Pre-test probability was higher in patients with: GI structural or neurological disorders; use of long-term PPIs and symptoms of diarrhea. These criteria may be helpful in making appropriate therapeutic decisions and avoiding unnecessary hydrogen breath testing.

The incidence of postoperative vasopressor usage: protocol for a prospective international observational cohort study (SQUEEZE)

BackgroundPostoperative hypotension is common after major non-cardiac surgery, due predominantly to vasodilation. Administration of infused vasopressors postoperatively may often be considered a surrogate indicator of vasodilation. The incidence of postoperative vasopressors has never been described for non-cardiac surgery, nor have outcomes associated with their use. This paper presents a protocol for a prospective international cohort study to address these gaps in knowledge.The primary objectives are to estimate the proportion of patients who receive postoperative vasopressor infusions (PVI) and to document the variation in this proportion between hospitals and internationally. Furthermore, we will identify factors in variation of care (patient, condition, surgery, and intraoperative management) associated with receipt of PVI and investigate how PVI use is associated with patient outcomes, including organ dysfunction, length of hospital stay, and 30-day in-hospital mortality.MethodThis will be a prospective, international, multicentre cohort study that includes all adult (≥ 18 years) non-cardiac surgical patients in participating centres. Patients undergoing cardiac, obstetric, or day-case surgery will be excluded. We will recruit two cohorts of patients: cohort A will include all eligible patients admitted to participating hospitals for seven consecutive days. Cohort B will include 30 sequential patients per hospital, with the single additional inclusion criterion of postoperative vasopressor usage. We expect to collect data on approximately 40,000 patients for cohort A and 12,800 patients for cohort B.DiscussionWhile in cardiac surgery, clinical trials have informed the choice of vasopressors used to treat postoperative vasoplegia; there remains equipoise over the best approach in non-cardiac surgery. Our study will represent the first large-scale assessment of the use of vasopressors after non-cardiac surgery. These data will inform future studies, including trials of different vasopressors and potential management options to improve outcomes and reduce resource use after surgery.Trial registrationClinicalTrials.gov Identifier: NCT03805230, 15 January 2019.

Abstract P6-02-06: Implementation and outcomes of population-based hereditary cancer testing across a diverse multi-location breast imaging center

Abstract Introduction: Up to 10% of all breast cancers (BC) are attributed to inherited pathogenic variants (PV) in BC susceptibility genes, and genetic testing at the time of breast imaging may identify more patients who could benefit from enhanced surveillance and/or risk reduction interventions. Data are limited on the yield of PVs in the setting of a breast imaging center. Hypothesis: Hereditary cancer gene screening at the time of breast imaging may identify patients and families who could benefit from cancer risk management. Methods: This retrospective cohort study included de-identified clinical data and commercial multi-cancer panel (40 genes) test results from sequential patients undergoing breast imaging at 3 centers in Texas over a 17 month period. Patients of providers who elected not to participate were excluded from this cohort. PV prevalence was quantified and stratified based on level of risk for BC and other cancers: high-risk (relative risk &amp;gt;4) for BC, moderate-risk (relative risk 2-4) for BC, high-risk for other cancers, moderate-risk or undefined risk for other cancers. Results: A total of 1,943 patients undergoing breast imaging chose to have genetic testing during the study period. Median age was 66 yrs (range 18-89 yrs). Self-reported race/ethnicity: White (34.5%), Hispanic (27.7%), African American (17.9%), Asian (4.5%), Ashkenazi Jewish (0.6%), Other (3.5%) and unreported (13.0%). A personal history of breast or ovarian-related cancers was reported in 4% (n=78) and a family history of these cancers was reported in 38.9% (n=835) of patients. Among those tested, 44/1,943 (2.3%) had one or more PV in an autosomal dominant clinically actionable gene, further categorized as: high-risk BC gene (36.3%) moderate-risk BC gene (34.1%), high-risk gene for other cancers (13.6%), moderate-risk gene for other cancers (6.8%), or uncertain level of increased risk for other cancers (9.1%). A heterozygous PV in an autosomal recessive gene was present in 31/1943 (1.6%) patients. Overall, 354/1943 (18.2%) patients met current NCCN guidelines for hereditary breast and ovarian cancer (HBOC) gene testing. Only 15/44 (34.1%) patients with an autosomal dominant clinically actionable PV met current NCCN guidelines for HBOC testing. Genetic education was provided to 20/44 (45.5%) patients by lab-based genetic counselors and/or the patient’s healthcare provider. Conclusions: Offering genetic testing in a diverse breast imaging center population was associated with a significant yield (4%) of both dominant and recessive clinically actionable PVs. Of note, almost 2/3 of PVs in hereditary cancer genes were among women who did not meet NCCN testing guidelines. Identification of a PV enables risk stratification, cascade testing of family members and an opportunity to access enhanced surveillance and risk reduction interventions. Citation Format: Darlene Miltenburg, Laura Westbrook, Vivienne Souter, Melissa K. Maisenbacher, Katherine L. Howard, Youbao Sha, Maygol Yavari, Nicholas Kypraios, Sofia Hurtado, Mayra Rodas, Jeffrey N. Weitzel. Implementation and outcomes of population-based hereditary cancer testing across a diverse multi-location breast imaging center [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P6-02-06.

Vitamin D deficiency Associates with Disease Severity in Rheumatoid Arthritis Patients

Vitamin D considered as a key player in various autoimmune disorders, such as rheumatoid arthritis, due to its immunological modulatory effect. Together with Anti-double stranded DNA (Anti-dsDNA), Anti-cyclic citrullinated peptide (Anti-CCP) is considered among the indicators of the disease severity in rheumatoid arthritis. The present study aimed to measure the level of vitamin D in RA patients besides measuring anti-dsDNA, anti-CCP, RF, complete blood count (CBC) and Erythrocyte Sedimentation Rate (ESR) for comparing it with its corresponding level in healthy control group. This study was a descriptive cross-sectional study involving sequential RA patients who visited the Rheumatology clinic for outpatients during three-months period starting from July 2018, at the Baghdad Teaching Hospital. Sixty individuals (30 RA patients and 30 age and gender matched healthy control) were enrolled in this study. Blood samples were collected and serum levels of anti-dsDNA, 25-hydroxy vitamin D (25[OH]), anti-CCP and RF besides C3, C4, CBC and ESR were measured. A highly significant decrease was displayed in the mean level of vitamin D in RA patients (18.67±17.70 ng/mL) when compared to its level in the control group (35.07 ±3.71 ng/mL), (normal value: 20 and 40 ng/mL), whereas, anti-dsDNA level normal value: (&lt;30.0 IU/mL) was significantly increased in RA patients (122.27±65.89 IU/ml) as compared to its mean level in the control group (17.77±3.56 IU/ml) with an inverse relationship between anti-dsDNA levels vitamin D levels in RA patients. No statistical difference noted in C3 and C4 levels between patients and control groups. Rheumatoid arthritis patients with positive RF had statistically higher anti-CCP (normal value: less than 20 U/ml) than those with negative RF (39.83±11.449 vs 21.67±4.658 u/ml). As expected, a highly significant increase was observed in ESR of patients when compared to that of the control. In addition, an alteration was noted in some circulating blood cells count.

Abstract No. 177 Quantification of Lower Gastrointestinal Bleed Characteristics on Computed Tomography and Relationship with Findings During Catheter Angiography

Many patients who present with lower gastrointestinal (LGI) bleeding and active contrast extravasation on computed tomography angiography (CTA) do not demonstrate active bleeds during catheter angiography (CA). Bleeding stops spontaneously in many patients, and CA represents an unnecessary procedural risk. The purpose of this study is to determine whether a subset of patients with slow extravasation on CTA are unlikely to have positive catheter angiography. Retrospective review of 100 sequential patients from November 3, 2018, to August 30, 2022, who presented with LGI bleeding and positive CTA and underwent CA from was performed. Volume of extravasated contrast on arterial and portal venous phases was measured by a senior resident and attending abdominal radiologist using 3-dimensional segmentation in Visage Client version 7.1.17. Volume and time between imaging phases was used to calculate hemorrhage rate. Extravasation volume and rate were correlated with active contrast extravasation during CA. Patient age, bleed etiology, blood transfusion volume, hemoglobin, and time from CTA to CA were included for multivariate analysis. Majority of patients in our cohort were males presenting with diverticular bleeds. 55% of patients were found to have active extravasation on CA and of those 63% underwent coil embolization. Using a binary cutoff of bleed rate less than or greater than 0.5 mL/min, there was a significantly greater rate of positive CA with calculated hemorrhage rates greater than 0.5 mL/min than less than 0.5 mL/min (61% vs 25%, P = 0.008). For absolute hemorrhage rate, there was a trend toward more likely positive CA with greater hemorrhage rate which was not statistically significant (P = 0.1). Percent increase of bleed volume between arterial and portal venous phase for patients with positive CA was 297% versus 146% for patients with negative CA (P < 0.05). Additionally, decreased time between CTA and CA approached statistical significance in a multivariate analysis (P = 0.08). While patients with a bleed rate less than 0.5 mL per minute were less likely to have positive CA, 25% of these patients still had a positive CA, suggesting that even patients with a slow bleed by CTA may warrant intervention. There was no correlation between absolute hemorrhage rate and positive CA. Interestingly, percentage increase in extravasated volume between arterial and venous phase was a predictor of CA. These findings may assist in identifying patients likely to have ceased bleeding by the time of CA and would benefit from conservative management rather than intervention.