Significant Comorbidities Research Articles

Prehospital Cricothyrotomy: A narrative review of technical, educational, and operational considerations for procedure optimization

BackgroundDefinitive airway management is a requisite skill in the prehospital setting, most often accomplished with either an endotracheal tube or supraglottic airway. When clinicians encounter a cannot oxygenate and cannot ventilate scenario, a patient's airway still must be secured. Prehospital cricothyrotomy is a high acuity, low frequency procedure used to secure the airway through the anterior neck. Patients who require cricothyrotomy often have significant comorbid conditions and mortality, and there can be a high rate of procedural complications. The ability to perform a cricothyrotomy is within the scope of practice for many prehospital clinicians and mastery of the procedure is crucial for patient outcomes. Despite this, initial training on the procedure is minimal, and paramedics report discomfort in their ability to perform the procedure. ObjectiveReview and summarize the best available evidence relating to the performance of cricothyrotomies and propose technical, educational, and operational considerations to minimize complications and optimize success of prehospital cricothyrotomies. DiscussionTechnical considerations when performing cricothyrotomy in the prehospital setting can be used to mitigate airway misplacement, mainstem intubation, and hemorrhage. Educational consideration should include focus on a singular technique, use of established curriculum, spaced repetition with either simulation or mental practice, and a focus on intention training of when to perform the procedure. The preferred technique from the National Association of EMS Physician guidelines is the surgical technique. Operational considerations to optimize a successful procedure should include checklists, preassembled kits, and robust quality improvement and insurance after a cricothyrotomy is performed. ConclusionsBy focusing on technical, educational, and operation considerations relating to prehospital cricothyrotomy, prehospital clinicians can optimize the chance for procedural success.

A retrospective cohort review of BMI on SI joint fusion outcomes: examining the evidence to improve insurance guidelines.

The demand for SIJ fusion among obese patients has grown substantially. However, the clinical relevance of obesity in the context of SI joint fusion has not been well investigated specifically, whether there is a BMI cutoff above which the benefit-risk ratio is low. Adult patients ≥ 21 years of age who underwent minimally invasive SIJ fusion between 2020 and 2023. Participants were classified using the National Institutes for Health body mass index (BMI). Patients with a BMI of 30 to 39 with no significant comorbidity are considered obese, patients with a BMI of 35 to 39 with a significant comorbidity or a BMI of 40 or greater are considered morbidly obese. All subjects completed the Visual Analog Scale (VAS) and Oswestry Disability Index (ODI) at baseline and 12 months. One-way analysis of variance was used to examine the impact of BMI category on score changes. Overall, mean VAS improved at 12 months by 2.5 points (p < .006). Over the 12-month follow-up period, BMI category did not impact mean improvement in VAS (ANOVA p = .08). Mean ODI at 12 months improved by 23.2 points (p < .001). BMI category did impact mean improvement in ODI (ANOVA p = .03). This study demonstrates similar benefits across all BMI categories. This data suggests that obese patients do benefit from minimally invasive SIJ fusion, specifically the 35-40 BMI cohort of patients, and should not be denied this procedure based on arbitrary healthcare organizations BMI criteria.

First worldwide use of the hybrid system for extracorporeal circulation in heart transplant

BackgroundThis case report documents the first worldwide use of the Hybrid System from Spectrum Medical in a heart transplant procedure, focusing on its safety and efficacy. Traditional cardiopulmonary bypass systems often use an open reservoir, which increases the blood’s exposure to air, thereby heightening the risk of an inflammatory response and gas embolism. In contrast, the Hybrid System is designed to improve surgical outcomes by significantly reducing the blood-air interface. This system utilizes a dual-chamber cardiotomy-venous reservoir with a collapsible soft bag, effectively minimizing blood contact with air and foreign materials. However, it is important to note that there is currently no evidence supporting the use of this methodology specifically in heart transplants.Case presentationA 41-year-old male managed with a left ventricular assist device because of dilated cardiomyopathy underwent a heart transplant using the Hybrid System. The perioperative and postoperative data provided evidence of the system’s effectiveness. The selection of this patient was due to the absence of significant comorbidities unrelated to his primary cardiac condition, making him an ideal candidate to evaluate the system’s performance.ConclusionThe Hybrid System is safe and efficient. The successful implementation in this case highlights its advantages over traditional cardiopulmonary bypass systems, suggesting a promising future in cardiac surgery. Further studies with routine cardiac surgery patients are required to validate these findings.

Natural Language Processing Applied to Spontaneous Recall of Famous Faces Reveals Memory Dysfunction in Temporal Lobe Epilepsy Patients.

Epilepsy patients rank memory problems as their most significant cognitive comorbidity. Current clinical assessments are laborious to administer and score and may not always detect subtle memory decline. The Famous Faces Task (FF) has robustly demonstrated that left temporal lobe epilepsy (LTLE) patients remember fewer names and biographical details compared to right TLE (RTLE) patients and healthy controls (HCs). We adapted the FF task to capture subjects' entire spontaneous spoken recall, then scored responses using manual and natural language processing (NLP) methods. We expected to replicate previous group level differences using spontaneous speech and semi-automated analysis. Seventy-three (N=73) adults (28 LTLE, 18 RTLE, and 27 HCs) were included in a case-control prospective study design. Twenty FF in politics, sports, and entertainment (active 2008-2017) were shown to subjects, who were asked if they could recognize and spontaneously recall as much biographical detail as possible. We created human-generated and automatically-generated keyword dictionaries for each celebrity, based on a randomly selected training set of half of the HC transcripts. To control for speech output, we measured the speech duration, total word count and content word count for the FF task and a Cookie Theft Control Task (CTT), in which subjects were merely asked to describe a visual scene. Subjects' responses to FF and CTT tasks were recorded, transcribed, and analyzed in a blinded manner with a combination of manual and automated NLP approaches. Famous face recognition accuracy was similar between groups. LTLE patients recalled fewer biographical details compared to HCs and RTLEs using both the gold-standard human-generated dictionary (24%±12% vs. 31%±12% and 30%±12%, p=0.007) and the automated dictionary (24%±12% vs. 31%±12% and 32%±13%, p=0.007). There were no group level differences in speech duration, total word count, or content word count for either the FF and CTT to explain difference in recall performance. There was a positive, statistically significant relationship between MOCA score and FF recall performance as scored by the human-generated (ρ= .327, p= .029) and automatically-generated dictionaries (ρ= .422, p= .004) for TLE subjects, but not HCs, an effect that was driven by LTLE subjects. LTLE patients remember fewer details of famous people than HCs or RTLE patients, as discovered by NLP analysis of spontaneous recall. Decreased biographical memory was not due to decreased speech output and correlated with lower MOCA scores. NLP analysis of spontaneous recall can detect memory dysfunction in clinical populations in a semi-automated, objective, and sensitive manner.

Elective Spinal Transpedicular Ablation of the Basivertebral Nerve of the Vertebral Segment in Adult Spinal Deformity Patients.

Ablation of the basivertebral nerve (BVNA) innervating the vertebral endplate has become a standard treatment of vertebrogenic chronic low back pain (CLBP) arising from vertebral endplate damage. BVNA treatment of CLBP in clinical trials was successful and durable for pain relief and return to daily activities. This case review adds new information about older patients with adult degenerative spinal deformity (ASD) and associated comorbidities not previously described in clinical trials. One hundred and eighteen ASD patients with vertebrogenic CLBP in a community practice setting underwent 503 levels of BVNA (average 4.3 levels). Forty-one patients with minimal comorbidities (Group A) were compared to 77 patients with significant comorbidities (Group B). Visual analog scale (VAS 10 cm) and Oswestry Disability Index (ODI 100-point scale) were obtained before BVNA and at a last follow-up (LFU). Group A VAS at LFU was an average of 2 cm, a 7 cm improvement. Group B VAS at LFU was 3 cm, a 6 cm improvement. At LFU, Group A ODI mean was 14 points or minimal disability, with a 39-point improvement, and Group B improved 28 points to 29 but remained moderately disabled. At LFU, the lumbar stenosis with laminectomy and BVNA subgroup of 26 had mean VAS 2 cm and ODI 28-point improvement but remained on average 21 points with a final low moderate disability. Eleven laminectomy and BVNA patients had continued posterior column pain related to radiculopathy, and or peripheral neuropathy, and sacroiliac joint pain in 30%. Mobile spondylolisthesis in 21 patients in Group B at LFU had a 6 cm improvement of VAS and 25-point improvement of ODI but remained moderately disabled on ODI. At LFU in group B, there was a 20% incidence of continued stenosis and radiculopathy symptoms. At LFU, Lumbar fusion was recommended in 9. Vertebral compression fracture (VCF) occurred in 9 after BVNA (10%) of Group B. These patients were older (mean 78 years), and all had significant osteoporosis. Eight fractures were within the area of the BVNA, and 1 was an S2 sacral fracture. These VCF patients were treated with vertebroplasty or kyphoplasty and continued preventive care with added teriparatide. At LFU, the VCF subgroup had a modest 6 cm improvement in VAS to 4 cm and continued to have significant severe to moderate disability (Oswestry Disability Index average of 38 points). Clinical trials of BVNA treatment of CLBP found success and durability for pain relief and daily activities. Patients with ASD without comorbidities showed durable pain relief of vertebrogenic CLBP and return of daily activities similar to clinical trials. In those with comorbidities, the result was an improvement in pain and disability that could be diminished by the complications related to the comorbidities. This is new information about BVNA for older patients with spinal deformity and other comorbidities. This study could impact research practice and policy to expand indications of BVNA to patients with adult spinal deformity. This case series represents the only literature regarding patients with adult spinal deformity treated with BVNA. The results were predictable and reproducible. Many patients were satisfied, would have the procedure again and would recommend BVNA to friends and family. This finding should encourage acceptance of patients with ASD for BVNA and, in fact, BVNA should probably be done before any fusion to limit and choose levels for inclusion in fusion.

Failed primary repair of blunt duodenal injury managed by tube duodenostomy, gastrojejunostomy and a feeding jejunostomy: a case report

BackgroundThe worldwide increase in road traffic crashes and use of firearms has increased the incidence of duodenal injuries. Upper gastrointestinal radiological studies and computed tomography (CT) in resource settings may lead to the diagnosis of blunt duodenal injury. Exploratory laparotomy remains the ultimate diagnostic test if a high suspicion of duodenal injury continues in the face of absent or equivocal radiographic signs. Although the majority of duodenal injuries may be managed by simple repair, high-risk duodenal injuries are followed by a high incidence of suture line dehiscence and should be treated by duodenal diversion.Case presentationWe report a case of a failed primary repair of a blunt injury to the second part of the duodenum (D2) in a 24-year-old African man. This was successfully managed by a tube duodenostomy, a bypass gastrojejunostomy and a feeding jejunostomy in a low resource setting.ConclusionsDetailed knowledge of the available operative choices in duodenal injury and their correct application is important. When duodenal repair is needed, conservative repair techniques over complex reconstructions should be utilised. The technique of tube duodenostomy can be successfully applied to cases of large defects in the second part of the duodenum (D2), failed previous repair attempts and with defects caused by different aetiology. It may remain especially useful as a damage-control procedure in patients with multiple injuries, significant comorbidities and/or haemodynamic instability.

Reassessing Halm's clinical stability criteria in community-acquired pneumonia management.

Halm's clinical stability criteria have long guided antibiotic treatment and hospital discharge decisions for patients hospitalised with community-acquired pneumonia (CAP). Originally introduced in 1998, these criteria were established based on a relatively small and select patient population. Consequently, our study aims to reassess their applicability in management of CAP in a contemporary real-world setting. This cohort study included 2918 immunocompetent patients hospitalised with CAP from three hospitals in Denmark between 2017-2020. The primary outcome was time to achieve clinical stability as defined by Halm's criteria. Additionally, we examined recurrence of clinical instability and severe complications. Cumulative incidence function or Kaplan-Meier survival curves were used to analyse these outcomes, considering competing risks. The study population primarily comprised elderly individuals (median age: 75 years) with significant comorbidities. The median time to clinical stability according to Halm's criteria was 4 days, with one-fifth experiencing recurrence of instability after early clinical response (stability within 3 days). Severe complications within 30 days mainly comprised mortality, with rates of 5.1% (64/1257) overall in those with early clinical response, 1.7% (18/1045) in the subgroup without do-not-resuscitate orders, and 17.3% (276/1595) among the rest. Halm's clinical stability criteria effectively classify CAP patients with different disease courses, yet achieving stability required more time in this aging population with substantial comorbidities and more severe disease. Early clinical response indicates reduced risk of complications, especially in those without do-not-resuscitate orders.

Proteomic Profiling of Hindlimb Skeletal Muscle Disuse in a Murine Model of Sepsis.

Sepsis leads to multiple organ dysfunction and negatively impacts patient outcomes. Skeletal muscle disuse is a significant comorbidity in septic patients during their ICU stay due to prolonged immobilization. Combination of sepsis and muscle disuse will promote a unique proteomic signature in skeletal muscle in comparison to disuse and sepsis separately. Following cecal ligation and puncture (CLP) or Sham surgeries, mice were subjected to hindlimb suspension (HLS) or maintained normal ambulation (NA). Tibialis anterior muscles from 24 C57BL6/J male mice were harvested for proteomic analysis. Proteomic profiles were assessed using nano-liquid chromatography with tandem mass spectrometry, followed by data analysis including Partial Least Squares Discriminant Analysis (PLS-DA), to compare the differential protein expression across groups. A total of 2876 differentially expressed proteins were identified, with marked differences between groups. In mice subjected to CLP and HLS combined, there was a distinctive proteomic signature characterized by a significant decrease in the expression of proteins involved in mitochondrial function and muscle metabolism, alongside a marked increase in proteins related to muscle degradation pathways. The PLS-DA demonstrated a clear separation among experimental groups, highlighting the unique profile of the CLP/HLS group. This suggests an important interaction between sepsis-induced inflammation and disuse atrophy mechanisms in sepsis-induced myopathy. Our findings reveal a complex proteomic landscape in skeletal muscle exposed to sepsis and disuse, consistent with an exacerbation of muscle protein degradation under these combined stressors. The identified proteins and their roles in cellular stress responses and muscle pathology provide potential targets for intervention to mitigate muscle dysfunction in septic conditions, highlighting the importance of addressing both sepsis and disuse concurrently in clinical and experimental settings.

Treatment Adherence Rates and Long-Term Mortality in a Quaternary Multidisciplinary Heart Team: An Observational Cohort.

A multidisciplinary heart team (HT) approach to patients with complex coronary artery disease has a class IB recommendation, yet there are limited data on adherence to HT treatment recommendations and long-term clinical follow-up. The objective of this study was to assess adherence rates to HT recommendations and assess long-term mortality rates among patients with complex CAD. Six hundred eighty-four sequential HT cases for complex coronary artery disease from January 2015 to May 2017 were reviewed. After excluding cases with significant comorbid valve disease, baseline characteristics were compared based on HT treatment recommendations: optimal medical therapy, percutaneous coronary intervention, and coronary artery bypass grafting. Adherence rates were manually extracted, and 5-year mortality rates were obtained from the Michigan Death Registry. Seventy-two percent of 405 included patients were men (mean age 66±11 years), with high rates of medical comorbidities. Estimated surgical risk scores were lowest in the coronary artery bypass grafting group. Optimal medical therapy was recommended in 138 patients (34%), percutaneous coronary intervention in 95 (23%), and coronary artery bypass grafting in 172 (42%). Adherence to HT recommendations across groups was high (96%) and did not differ between treatment groups. Over 5 years of follow-up, there were 119 deaths, resulting in a cumulative mortality rate of 29%. In the largest HT cohort in the United States to date, high rates of adherence to HT recommendations were observed among high-risk patients with coronary artery disease. High rates of adherence to HT recommendations were observed irrespective of treatment group recommendation, suggesting that HT recommendations were individualized and acceptable to both patients and physicians alike.

Cyclothymic affective temperament and low positive attitude coping strategies as predictors of comorbid depressive symptomatology in adult ADHD patients

IntroductionAttention deficit hyperactivity disorder (ADHD) in adults could be frequently underdiagnosed due to concomitant psychiatric disorders, including depressive symptomatology, which could determine inappropriate treatments. Our study aims at clinically characterizing adult ADHD with or without depressive symptomatology in order to identify the relationship with specific affective temperamental profiles and coping strategies. MethodsA total of 225 outpatients consecutively afferent to our outpatient adult ADHD service since September 2019 were retrospectively screened for eligibility and administered Beck Depression Inventory-II (BDI-II), Coping Orientation to Problems Experienced Inventory (COPE-NV) and Temperament Evaluation of the Memphis, Pisa, Paris and San Diego (TEMPS-M). Results64.7 % of patients displayed a significant comorbid depressive symptomatology. According to the multivariate linear regression model, depressive levels were positively predicted by TEMPS-M cyclothymic subscale (B = 0.567, p = 0.004) and negatively predicted by COPE-NVI “positive attitude” subscale (B = −0.438, p = 0.024) (R = 0.496, R2 = 0.246, F(2,66) = 10.747, p < 0.001). LimitationWhile considering the results, it should be taken in consideration that: the assessment was carried out only at baseline, our sample is constituted only by adult ADHD patients and mostly without a previous ADHD diagnosis, the presence of a discrepancy between the rates of ADHD subtypes, the absence of a healthy control group and emotional dysregulation was not directly assessed. ConclusionAffective temperamental profiles and coping strategies could help in clinically characterizing and personalizing treatment in adult comorbid ADHD-depressive symptomatology patients. Further research is warranted to explore the efficacy of targeted psychotherapeutic and pharmacological interventions within this ADHD sub-sample.

OSA diagnosis goes wearable: are the latest devices ready to shine?

Since 2019, the FDA has cleared nine novel obstructive sleep apnea (OSA)-detecting wearables for home sleep apnea testing, with many now commercially available for sleep clinicians to integrate into their clinical practices. To help clinicians comprehend these devices and their functionalities, we meticulously reviewed their operating mechanisms, sensors, algorithms, data output, and related performance evaluation literature. We collected information from PubMed, FDA clearance documents, ClinicalTrial.gov, and web sources, with direct industry input whenever feasible. In this "device-centered" review, we broadly categorized these wearables into two main groups: those that primarily harness Photoplethysmography (PPG) data and those that do not. The former include the peripheral arterial tonometry (PAT)-based devices. The latter was further broken down into two key subgroups: acoustic-based and respiratory effort-based devices. We provided a performance evaluation literature review and objectively compared device-derived metrics and specifications pertinent to sleep clinicians. Detailed demographics of study populations, exclusion criteria, and pivotal statistical analyses of the key validation studies are summarized. In the foreseeable future, these novel OSA-detecting wearables may emerge as primary diagnostic tools for patients at risk for moderate-to-severe OSA without significant comorbidities. While more devices are anticipated to join this category, there remains a critical need for cross-device comparison studies as well as independent performance evaluation and outcome research in diverse populations. Now is the moment for sleep clinicians to immerse themselves in understanding these emerging tools to ensure our patient-centered care is improved through the appropriate implementation and utilization of these novel sleep technologies.

COMPARATIVE EFFECTIVENESS OF DIFFERENT BARIATRIC PROCEDURES ON WEIGHT LOSS AND COMORBIDITIES

Bariatric surgery has revolutionized the treatment of severe obesity, providing not only significant and sustained weight loss but also improvements in obesity-related comorbidities. Objective: The study's main objective is to compare the effectiveness of different bariatric procedures on weight loss and comorbidities. Methods: This retrospective cohort study was conducted at MTI Lady Reading Hospital Peshawar from 2019 to 2023. Data were collected from 91 patients who wanted weight loss. Participants aged &gt;18 years, with a body mass index (BMI) of 40 or higher or a BMI of 35 or higher accompanied by significant obesity-related comorbidities such as type 2 diabetes, hypertension, or obstructive sleep apnea, were included in the study. All included patients underwent one of the four bariatric procedures. Results: The study included 91 patients who underwent various bariatric procedures at MTI Lady Reading Hospital between 2019 and 2023. The mean age of participants was 42.38 ± 2.35 years. The gender distribution comprised 55 females (60%) and 36 males (40%). The patients' mean preoperative body mass index (BMI) was 45.2 ± 3.01 kg/m². Biliopancreatic diversion with duodenal switch (BPD/DS) demonstrated the highest effectiveness, with an average %EWL of 78% at three years and the highest resolution rates for type 2 diabetes (95%), hypertension (90%), and obstructive sleep apnea (85%). Roux-en-Y gastric bypass (RYGB) also showed substantial weight loss and comorbidity resolution, achieving an average %EWL of 68% at three years. Conclusion: It is concluded that bariatric surgery is a highly effective intervention for achieving significant weight loss and resolving obesity-related comorbidities. Among the procedures studied, biliopancreatic diversion with duodenal switch (BPD/DS) demonstrated the highest effectiveness, with substantial weight loss and resolution rates for type 2 diabetes, hypertension, and obstructive sleep apnea.

TRANSCUTANEOUS LASER IRRADIATION OF BLOOD IN SIMULTANEOUS MODE (S-ILIB) FOR FATIGUE RECOVERY

The modified transcutaneous laser irradiation on blood (ILIB), a systemic modality of photobiomodulation therapy (PBMT), consists of a laser application on the radial artery or other artery in the body, to improve systemic functions and physiological dynamics of the body. The available therapeutic strategies for the management of fatigue due to daily life stress are mainly focused on lifestyle changes associated with nutrition and exercise. Thus, the present study aims to report a series of cases in which transcutaneous modified ILIB therapy in simultaneous mode (S-ILIB), was used to treat fatigue symptoms. Four healthy patients, without any type of significant comorbidity, reported fatigue related to stress. They were treated by the new PBMT protocol with the modified ILIB technique. The intensity or perception of fatigue was rated using a visual analogue scale (VAS). The "simultaneous technique" used in the present study consisted of laser irradiation in four sites of the body: 1- the radial artery region of the right arm; 2- the radial artery region of the left arm; 3- the right dorsal pedis artery; and 4- the left dorsal pedis artery. For PBMT, two laser device were used at 660 nm, on contact mode, with 100 mW of power. The patients reported a clear recovery in the energy sensation after the S-ILIB session. The PBMT protocol seems to be a promising therapy for managing energy recovery in fatigue-stress-related daily routines; however, complementary studies are required to establish the safest and most efficient protocol

Abstract We111: 3D spheroids composed by induced Skeletal Muscle Progenitor Cells and Mesenchymal Stem Cells derived from human Pluripotent Stem Cells can recapitulate embryonic niches in hindlimb ischemia model

Introduction: Peripheral artery disease (PAD) is a significant comorbidity in aging population regarding diminished quality of life and increased mortality rates. There are urgent needs for developing advanced therapeutics for functional limb salvage beyond conventional revascularization. We hypothesized that 3D spheroids composed by induced Skeletal Muscle Progenitor Cells (iSKMPs) and Mesenchymal Stem Cells (iMSCs) could recapitulate embryonic niches and provide promising regenerative potentials in hindlimb ischemia (HLI) models. Methods: We manufactured scaffold-free, self-aggregated 3D spheroids using microcavity plates with ultra-low attachment surface. 3D spheroids were designed into 3 groups according to the induced cell types derived from Human Pluripotent Stem Cells (hPSCs); 1) iSKMPs only, 2) iMSCs only, 3) iSKMPs + iMSCs mixed. We transplanted 3D spheroids into the ischemic area and compared their therapeutic potentials using Laser Doppler Perfusion Imaging (LDPI) and immunohistochemical staining analysis. Results: iSKMPs secreted various angiogenic factors including IGF, HGF and FGF and facilitated tube formation and migration of endothelial cells (ECs). iSKMPs also showed the differentiation potential into myofibers in defined 2D culture condition. During the 28-day follow-up period, the transplantation of 3D mixed spheroids not only increased blood perfusion in ischemia limb, but also significantly reduced amputation rate compared with those of control and other 3D single spheroid groups. Notably, in vivo capacity of muscle regeneration was more potent in 3D mixed spheroid group with higher rate of engraftment, myotube formation, and vascularization. These findings suggested that iSKMPs played a significant role in limb salvage via myogenesis and angiogenesis, and their cell-to-cell interaction with iMSCs within 3D spheroids provided a favorable microenvironment to enhance the engraftment and maturation of iSKMPs in ischemic hindlimb. Conclusion: We demonstrated that the transplantation of 3D spheroids composed by iSKMPs and iMSCs could recapitulate developmental embryonic niches and provide potent regenerative potentials in HLI models. These findings provide compelling evidence that this injectable platform of 3D mixed spheroids can be a promising tool to rescue limb amputation in patients with PAD.

Cluster analysis of Model for End-stage Liver Disease and European System for Cardiac Operative Risk Evaluation for predicting operative mortality after concomitant tricuspid valve surgery

ObjectivePatients requiring concomitant tricuspid surgery represent a heterogeneous cohort with significant comorbidities and varying degrees of organ and right ventricular dysfunction. However, surgeons can rely on little beyond intuition and experience when discussing operative risks. The objective of the study is to assess how the Model for End-stage Liver Disease score complements the European System for Cardiac Operative Risk Evaluation II in risk assessment. MethodsWe performed a single-center retrospective cohort study of 369 consecutive patients who underwent concomitant tricuspid valve surgery from 2011 to 2020. Multivariate analysis of factors affecting operative mortality was performed, producing 2 multivariate risk prediction models, one consisting of European System for Cardiac Operative Risk Evaluation II components and the other consisting of both European System for Cardiac Operative Risk Evaluation II components and Model for End-stage Liver Disease. The models were compared by measuring c-statistic using the Hanley-McNeil method. This was further evaluated with category-free net reclassification improvement index. K-means clustering was performed using Model for End-stage Liver Disease and European System for Cardiac Operative Risk Evaluation II values after scalar transformation as independent variables and operative mortality as the dependent variable. ResultsThe Model for End-stage Liver Disease is an independent predictor of operative mortality, with an adjusted odds ratio of 1.286 per point. Inclusion of the Model for End-stage Liver Disease improves the discriminatory power of the European System for Cardiac Operative Risk Evaluation II for operative mortality, with a difference in area under the curve of 0.128 [0.0341-0.222] (P = .0076). The net reclassification improvement index of incorporating Model for End-stage Liver Disease with European System for Cardiac Operative Risk Evaluation II was 0.959 [0.515-1.392], indicating significant improvement in risk reclassification. Cluster analysis identified a unique cohort of patients with intermediate-to-high Model for End-stage Liver Disease, not previously identified with European System for Cardiac Operative Risk Evaluation II alone, who experienced high operative mortality. ConclusionsModel for End-stage Liver Disease score as a quantifier of hepatorenal dysfunction complements European System for Cardiac Operative Risk Evaluation II in predicting operative mortality after tricuspid valve surgery.

Predicting lymph node metastasis using preoperative parameters in patients with T1 ampulla of vater cancer

BackgroundLymph node (LN) metastasis is an established prognostic factor for patients with surgically resected ampulla of Vater (AoV) cancer. The standard procedure for radical resection, including removal of regional LNs, is pancreaticoduodenectomy (PD); however, local excision has been considered as an alternative option for patients in the early stage cancer with significant comorbidities. In the present study, we elucidated the preoperative factors associated with LN metastasis to determine the appropriate surgical extent for T1 AoV cancer.MethodsWe included patients who underwent surgery for T1 AoV cancer at Samsung Medical Center and Severance Hospital between 2000 and 2019. Risk factors were analyzed to identify the preoperative parameters associated with LN metastasis or regional LN recurrence during follow-up. Finally, using the identified risk factors, a prediction model was constructed.ResultsAmong 342 patients, 311 patients underwent PD, whereas 31 patients underwent transduodenal ampullectomy. Fourty-eight patients had LN metastasis according to pathology report, and two patients presented with regional LN recurrence. Age, carbohydrate antigen 19 − 9 (CA 19 − 9), and tumor differentiation were identified as factors associated with the increased risk of LN metastasis or regional LN recurrence. The area under the curve of the prediction model with these three factors was 0.728.ConclusionOur newly developed prediction model using age, CA 19 − 9, and tumor differentiation can help select patients who require PD over local excision. Nevertheless, additional in-depth analysis is warranted to select appropriate surgical extent for patients with presumed T1 AoV cancer.

Comparing Treatment Effectiveness and Patient-Reported Outcome Measures of Four Treatment Options for Obstructive Sleep Apnea

Continuous positive airway pressure (CPAP), mandibular advancement device (MAD), upper airway stimulation (UAS), and maxillomandibular advancement (MMA) are techniques to reduce apnea hypopnea index (AHI) in obstructive sleep apnea (OSA) patients. Current literature does not include a direct comparison of the 4 methods. The purpose of this study is to measure and compare the efficacy of 4 common OSA treatments: CPAP, MAD, UAS, MMA. This retrospective cohort study examines data from 119 patients treated at Thomas Jefferson University Hospital in Philadelphia receiving CPAP, MAD, UAS, or MMA between January 2018 and December 2020. Patients were excluded for significant medical comorbidities, body mass index ≥45, cognitive limitations, central/mixed apnea history, or pregnancy. The primary predictor variable was type of OSA intervention: CPAP, MAD, UAS, MMA. Treatments were assigned by treating physicians per their presenting OSA severity. The primary outcome variable was efficacy defined as the therapeutic response to treatment measured using mean disease alleviation, a calculated variable (percentage) which employs post-treatment AHI adjusted by compliance (a measure of a patient's device use). Secondary therapeutic measures included remaining AHI and patient-reported outcome measures: Epworth Sleepiness Scale, Sleep Apnea Quality of Life Index, Patient-reported Apnea Questionnaire. Demographic covariates included age, sex, height, weight, socioeconomic status, level of education, neck size, race, and body mass index. Clinical covariates included pretreatment AHI, AHI change, O2 nadir, adjusted compliance, and compliance. Multivariate statistics were computed with alpha level of 0.05, including a regression with the primary outcome variables, treatment variables, and potential covariates. The sample included 119 subjects (mean age=56.12, standard deviation [SD]=5.81) with males at n=72 (60%). MMA demonstrated greatest mean disease alleviation (M=36.08, SD=28.56), compared to UAS (M=22.88, SD=3.16), MAD (M=6.80, SD=8.13), and CPAP (M=5.00, SD=14.80), analysis of variance: P<.001. Both surgical treatments displayed significantly greater effectiveness than CPAP and MAD, suggesting that offering surgical alternatives sooner, particularly to those with severe OSA, may be logical in formulating more effective treatment guidelines.

Combining red photobiomodulation therapy with polydioxanone threads for wrinkle reduction in the glabella region: A randomized, controlled, double-blind clinical trial.

The combination of polydioxanone (PDO) threads with other technologies has garnered significant interest for rejuvenation purposes. Photobiomodulation (PBM) has the potential to improve patient comfort and recovery after minimally invasive rejuvenation protocols and also contribute to the overall efficacy of these procedures, fostering an integrative approach to cutaneous rejuvenation. The objective os this work was to investigate concurrent application of PDO threads and red LED PBM on glabellar static wrinkles, in a parallel randomized sham-controlled trial. Forty individuals with Glogau aging classification levels 3 and 4, static glabellar wrinkles, and no significant comorbidities received PDO threads applied along glabellar line. Effective PBM group received 1.35 J and 630 nm red LED light punctually along threads, twice weekly for nine sessions over 30 days. The outcome measures were swelling assessment, dermal thickness and PDO thread degradation via linear ultrasound. No swelling was detected 24 h post-PDO thread application, hindering PBM effect assessment. PDO threads induced dermal thickening; no added effect with PBM. No significant difference in thread hydrolysis between groups, though some ultrasound records inconclusive on thread presence. The absence of swelling may stem from various factors, including the timing of post-procedure swelling assessment, operator proficiency in thread application, and procedural characteristics. No evidence supports the notion that PBM augments dermal thickening, however other light parameters should be studied. Insufficient data to demonstrate PBM's effectiveness in controlling post-procedure swelling. Combination of PBM with PDO thread application doesn't enhance dermal thickening, nor accelerate thread degradation at the parameters used here.

Clinical profile of patients with non-ST segment elevation acute coronary syndrome: experience of a regional vascular center

Aim. To identify the main clinical and paraclinical characteristics of patients with non-ST segment elevation acute coronary syndrome (NSTE-ACS) of various risk groups for adverse ischemic events, as well as to describe the in-hospital outcomes of the disease.Material and methods. The retrospective analysis included 600 patients who were hospitalized at the regional vascular center from January 2019 to January 2021 with a diagnosis of NSTE-ACS.Results. Patients were stratified into very high — 208 (34,7%), high — 196 (32,7%), moderate — 108 (18%) and low — 88 (14,6%) risk groups. In the highand very high-risk groups, patients were older, characterized by a significant comorbidity index, increased bleeding risk, decreased left ventricular ejection fraction and glomerular filtration rate in comparison with patients of other groups (p&lt;0,05). Very highrisk patients were characterized by associated clinical conditions, predominantly infectious diseases and decompensated heart failure. Unfavorable outcome of hospitalization was observed in 44 (7,3%) patients. The death probability in the very high-risk group (33; 15,9%) was higher than in the low-risk group (2; 2,3%) (Odds ratio 8,1 (95% confidence interval: 1,9-34,6); p=0,01). Regardless of the risk degree, there was a high (53,5%) likelihood of completing invasive coronary angiography as a diagnostic procedure. Most of the observed complications as a result of invasive coronary angiography were characteristic of the high(18,3%) and very high-risk groups (21,5%).Conclusion. NSTE-ACS patients at very high/high risk of adverse ischemic events represent a heterogeneous group with cardiac and noncardiac pathologies with high comorbidity and bleeding risks, decreased left ventricular ejection fraction and glomerular filtration rate, and associated clinical conditions.

Are Routine Postoperative Hemoglobin Tests Justified in All Patients Who Undergo Total Hip Arthroplasty Due to a Displaced Femoral Neck Fracture?

Background: Total hip arthroplasty (THA) is a standard treatment for a displaced femoral neck fracture in the elderly. In contemporary healthcare, there is a global shift towards fast-track treatment modalities, prioritizing early hospital discharge for patients. Consequently, routine postoperative blood tests may become redundant, offering significant time and cost savings. We aim to evaluate postoperative hemoglobin levels in trauma-related THA cases and identify patient profiles for whom these tests hold significance. Methods: A retrospective review of 176 THA procedures performed between 2018 and 2022, focusing on individuals undergoing THA for displaced femoral neck fractures. Multivariable logistic regression analysis was employed to identify factors associated with postoperative hemoglobin levels below 8.5 g/dL. Results: Of the 176 patients included, 109 (61.9%) were women and the mean age was 69.09 ± 8.13 (range 27 to 90) years. The majority of the patients underwent surgery within 48 hours of admission. The mean preoperative hemoglobin (Hb) level was 13.1 ± 1.4 g/dL, while the mean postoperative Hb level was 10.5 ± 1.2 g/dL. Only six patients (3.41%) exhibited postoperative Hb levels of ≤8.5 g/dL. No significant associations were found between postoperative Hb levels ≤ 8.5 and any demographic, surgical, or medical characteristics. Conclusions: Our findings suggest that routine postoperative blood count testing may not be necessary for most patients undergoing THA for displaced femoral neck fractures, particularly those without complications or significant comorbidities.