Citations

Abstract Background Perioperative morbidity and mortality remain a point of concern for the Associating Liver Partition and Portal Vein Ligation for Staged hepatectomy (ALPPS) procedure. Post-hepatectomy liver failure (PHLF) after the second step poses the most significant risk factor for futile outcome. Recovery of liver function after the first step of ALPPS is critically important to allow for sufficient liver function after this surgery. The APRI+ALBI score has been proposed as an easily assessable score to monitor liver function and its dynamic recovery. Aims We explored if the APRI+ALBI score was able to assess liver function recovery after the first step of ALPPS and allow for optimal timing of the 2nd step. Methods Based on the ALPPS registry, patients from 2012 to 2020 with available APRI+ALBI score were included. Postoperative outcomes (PHLF A – C, PHLF B + C, 90-day mortality and severe morbidity) were defined as per standard definitions. The APRI/ALBI score was monitored perioperatively. Results Overall, 464 patients from 16 international participating centers in the ALPPS registry were included. Clinically relevant PHLF (B + C) was observed in 7.5 % and of these 63 % of patients ultimately died due to liver failure. The APRI+ALBI score immediately increased after each surgical intervention and continuously decrease thereafter. Failure of the APRI+ALBI score to decrease until the 2nd step of ALPPS predicted PHLF B+C (p = 0.001; AUC 0.78). Particularly patients with high APRI+ALBI scores and short interstage intervals were at risk to develop PHLF B+C. Conclusion The APRI+ALBI score objectifies liver function recovery after the 1st step of ALPPS and failure to sufficiently decreased is associated with a higher risk for PHLF B+C. This might allow for optimized planning of the 2nd step of ALPPS to allow for sufficient liver function recovery to minimize the risk for PHLF B+C and associated futile outcome.

Summary: Preservation rhinoplasty has re-emerged over the past decade and continues to gain traction in the rhinoplasty community. Dorsal preservation rhinoplasty (DPR), one of the tenets of preservation rhinoplasty, centers on preservation of the native osseocartilaginous joint of the dorsum, with changes instead achieved through modification of the underlying septal cartilage and surrounding bony nasal pyramid. However, one complication unique to DPR is the phenomenon of hump recurrence, where tensile forces or memory lead to a recurrent convexity of the dorsal hump. Hump recurrence is the most common complication after DPR and often requires revisionary surgery. Therefore, strategies to reduce the incidence of hump recurrence are highly sought after. In this article, the authors describe the senior author’s (R.J.R.) 5 main tenets of preventing hump recurrence in DPR, focusing on (1) appropriate patient selection; (2) addressing anatomic blocking points; (3) adding mechanical fixation of the cartilaginous vault with suture techniques depending on the level of septal manipulation; (4) applying a graduated approach to DPR procedural selection; and (5) ancillary measures to control the shape of the nasal dorsum. Implementation of each of these 5 tenets is crucial for modern rhinoplasty surgeons to reduce the incidence of hump recurrence in their preservation rhinoplasty practices.

Collaborative quantitative scientists, including biostatisticians, epidemiologists, bioinformaticists, and data‐related professionals, play vital roles in research, from study design to data analysis and dissemination. It is imperative that academic health care centers (AHCs) establish an environment that provides opportunities for the quantitative scientists who are hired as staff to develop and advance their careers. With the rapid growth of clinical and translational research, AHCs are charged with establishing organizational methods, training tools, best practices, and guidelines to accelerate and support hiring, training, and retaining this staff workforce. This paper describes three essential elements for building and maintaining a successful unit of collaborative staff quantitative scientists in academic health care centers: (1) organizational infrastructure and management, (2) recruitment, and (3) career development and retention. Specific strategies are provided as examples of how AHCs can excel in these areas.

Objectives: To assess compliance with chronic coronary artery disease (CAD) secondary prevention guidelines in the USA, to determine time trends, and to identify potential sociodemographic predictors of low compliance. Design, Setting and Participants: We analyzed the National Health and Nutrition Examination Survey (NHANES) data from 1999 to 2010, representative of non-institutionalized civilian population in the USA. We included people with self-reported previous diagnosis of CAD, angina or myocardial infarction (MI). Primary Outcome: Adherence to secondary prevention guidelines including blood pressure control, lipid control, not smoking, normal body mass index, physical activity at goal, and meeting all 5 outcomes (“all-or-none”). Use of antiplatelet therapy was reported and analyzed from 1999-2004. Secondary Outcome: Use of beta-blocker therapy in people with history of MI; in diabetes (DM), use of ACE-inhibitors or angiotensin receptor blocker, and HgbA1C <7%. Age, gender, race, income, education and insurance status were evaluated as covariates. Analyses were weighed according to Center for Disease Control guidelines. Results: There were 62,160 individuals in the cycle data of which 2,615 comprised the study group, representative of 73,574,548 individuals in the USA. Mean age was 65 yr, 58% men, 79% white. Only 2.8% of people with CAD met all 5 main outcomes. Only blood pressure and LDL control showed significant improvement over time, see Figure. Antiplatelet therapy was reported in 58.2%. Of those with history of MI, only 50.5% were on a beta-blocker and of those with history of DM, 59.4% were using either an ACE-I or an ARB; and 54% had a HgbA1C less than 7%. When adjusting for demographics, no significant differences were found regarding compliance with all 5 main outcomes. Conclusions: Adherence to guidelines for secondary prevention of CAD is suboptimal. There is an immense opportunity for improvement in secondary prevention for CAD in the USA.

Background: Epidemiologic studies have demonstrated that the incidence of heart failure varies by race and ethnicity, with the highest incidence occurring in blacks. However, whether these racial and ethnic variations extend to commercially insured populations and whether differences in early outcomes after diagnosis exist requires further exploration. Methods: We utilized administrative claims data from a large U.S. commercial insurance database to retrospectively identify privately insured and Medicare Advantage patients who were diagnosed with heart failure between 2006 and 2014. Published claims-based algorithms were used to identify patients with incident HF and categorize reasons for hospitalization after diagnosis. Results: Among 148,827 patients with incident heart failure (mean age 72.2 years, 51% women), 70% were white, 15% black, 6% Hispanic, 3% Asian and 6% had unknown race/ ethnicity. The incidence of heart failure during the study period was 3.7 per 1000 person-years and was highest among blacks, followed by whites, Hispanics and Asians (9.9, 3.6, 2.5, and 2.0 per 1000 person-years, respectively). In total, 37% of patients were hospitalized at least once in the first year after diagnosis for a total of 93,358 hospitalizations. HF was the most common reason for hospitalization (13% of all hospitalizations), followed by arrhythmia (5%), sepsis (5%), pneumonia (4%), COPD (3%) and acute renal failure (3%). Reasons for hospitalization were similar across racial and ethnic groups. The rate of hospitalizations was highest the first month after diagnosis and then gradually declined. Black patients had the highest rates of hospitalization, while Asians had the lowest (Figure). Conclusions: Even among a commercially insured population that likely have fewer barriers to care, black patients had a higher incidence of HF and higher rates of hospitalization after initial diagnosis compared with other racial and ethnic groups.

Introduction: Soluble ST2 (sST2) is a serum marker of cardiomyocyte stress associated with a large risk of death and heart failure after myocardial infarction (MI). The relationship between sST2 and cardiac structure and function after MI however remains incompletely defined, and greater characterization is required prior to clinical application. Methods: Olmsted County, Minnesota residents who experienced their first MI between 2007 and 2012 were prospectively recruited. MIs were validated using standardized criteria and patients underwent simultaneous comprehensive Doppler echocardiography and sST2 measurement. The association between cardiac morphology and hemodynamics and sST2 were examined. Published normal values were used as referent ranges for sST2 levels. Results: Among 316 patients (mean age 65 [SD 14] years, 67% men, 32% ST-elevation MI), sST2 was measured 2.5 [SD 1.6] days after MI and within 0.7 [SD 2.3] days of echocardiography. Soluble ST2 was elevated in 33% of patients and univariately associated with decreased LV ejection fraction (LVEF), increased LV mass, impaired LV diastolic function and increased pulmonary artery pressure (ePAP) (Table). After adjustment for age, sex, LVEF and key measures of LV filling pressures, elevated sST2 was independently associated with reduced LVEF (p=0.01) mitral valve deceleration time (p=0.03), greater left atrial volume (p=0.03) and mitral regurgitation (≥mild; p=0.09). LVEF and ePAP exhibited the strongest associations with elevated sST2 (both p<0.001). Conclusions: Soluble ST2 is frequently elevated following MI and is strongly associated with the morphologic and hemodynamic determinants of adverse LV remodeling that infer poor long-term outcome after MI.

Background: In peripheral artery disease (PAD), claudication limits exercise performance, functional status and quality of life. Phosphodiesterase III inhibitors improve claudication-limited exercise performance in patients with PAD. K-134, a novel phosphodiesterase III inhibitor, was evaluated in a phase II trial incorporating an adaptive design to assess safety, quality of life and peak walking time (PWT) on a graded treadmill with cilostazol as an active comparator. Design: Patients with PAD were randomized to receive placebo (N = 87), K-134 at a dose of 25 mg (N = 42), 50 mg (N = 85) or 100 mg (N = 84), or cilostazol at a dose of 100 mg (N = 89), each given twice daily for 26 weeks. A Data Safety Monitoring Board (DSMB) implemented adaptive design was used to allow early discontinuation of unsafe or minimally informative K-134 arms. Interim safety assessments at 2 weeks included dosing of study medication at the study site followed by measurements of postural vital signs and symptoms, and at 4 weeks with a treadmill test at peak drug concentration to evaluate for ischemia or arrhythmias. Results: Based on prospectively defined adaptive criteria, the 25 mg K-134 arm was discontinued as the 50 mg and 100 mg doses were adequately tolerated, had no unanticipated safety signals, and were thus most likely to be informative concerning K-134 in the target population. In the intention-to-treat cohorts at 26 weeks PWT increased by 37% in the 100 mg K-134 arm and 23% on placebo (primary analysis p = 0.089). Using a mixed effects analysis in the entire population, 100 mg K-134 and cilostazol were each superior to placebo in improving PWT. In the per protocol population both K-134 100 mg and cilostazol 100 mg increased PWT as compared with placebo at 14 and 26 weeks. K-134 had tolerability and adverse effect profiles similar to that of cilostazol, with gastrointestinal adverse events, headache and dizziness the most common. Both drugs were associated with an increase in withdrawals prior to study completion due to adverse events as compared with placebo. Conclusions: K-134 was generally well tolerated, and at a dose of 100 mg twice daily had a safety profile and effect on treadmill walking performance that was similar to that of cilostazol.

Background: Depression is prevalent in adults with cardiovascular disease; however, the association between depression and death in older adults treated with percutaneous coronary intervention (PCI) is not known. Method: We prospectively studied 596 patients 65 years of age or older undergoing PCI at Mayo Clinic (Rochester, MN and Franciscan Skemp Hospital in La Crosse, WI) from October 2005 through September 2008. Depression was assessed using the validated and reliable Center for Epidemiological Studies Depression (CES-D) scale. Patients were categorized into groups by depression symptom severity: none/mild (CES-D <16; referent), moderate (CES-D 16-21), or moderate/severe (CES-D>21). Patients were followed annually for death. Results: Mean age of patients was 75.0±6.4 years; 31% were women, 98.0% were white. There were 461 patients (77.3%) that were not depressed and 135 patients (22.7%) that were depressed; 67 patients (11.3%) had moderate depressive scores (CES-D 16-21) and 68 patients (11.4%) had moderate/severe scores (CES-D >21). Groups were similar with respect to baseline characteristics. After a median follow-up of 36 months, there were 74 deaths, and patients with moderate/severe depressive symptom scores had a higher cumulative incidence of mortality (p = 0.036 by log-rank) (Figure). In multivariable analysis, CES-D score >21 was independently predictive of all-cause mortality (HR 1.90; 95% CI 1.02-3.53; p = 0.043), along with other covariates, including age (HR 1.88; 95% CI 1.31-2.68), comorbidity (Charlson Index) (HR 1.08; 95% CI 1.02-1.15), and diabetes mellitus (HR 2.04; 95% CI 1.26-3.30). Conclusion: Over one-fifth of older adults undergoing PCI met criteria for depression and those with high depressive scores reflecting greater self-perceived depressive symptoms had worse survival. Recognition of depressive symptoms in older adults treated with PCI identifies a cohort at higher risk of adverse outcomes.

Thais Coutinho, 2011 Finalist and Presenting Author