Citations

Objectives: Examining the effect of demographics and social vulnerability on diagnosis and management of patients with vestibular and balance disorders. Design: Retrospective review of a database of patients presenting with vestibular symptoms to a multidisciplinary tertiary vestibular clinic between January and October 2021. Main outcomes included odds ratios of final diagnosis, treatment response, time to presentation by demographic variable, insurance status, residence, and social vulnerability factors according to the 2018 Centers for Disease Control Social Vulnerability Index. Results: Five hundred thirty-six patients with definitive vestibular diagnoses and treatment outcome data were included. Mean age at presentation was 60.4 ± 16.5 years. Women (n = 389, 72.6%) outnumbered men (n = 147, 27.4%). Most patients self-identified as White (n = 440, 82.1%) and non-Hispanic (n = 521, 97.2%). Overall, 17.4% of participants belonged to a minority group. Socioeconomic status, household composition, geographic location, and insurance status were associated with patient diagnoses received. Patients from the lowest socioeconomic class were more likely to be diagnosed with Meniere’s disease. In addition, patients with private insurance were more likely to be diagnosed with Meniere disease or vestibular migraine than those with Medicare insurance. Geographic distance greater than 60 miles from the clinic was associated with a higher likelihood to present >90 days since initial symptom onset. Housing and transportation vulnerabilities were associated with decreased treatment response. Conclusions: Diagnostic classification, time to presentation, and treatment outcomes differed according to demographic and social vulnerability factors. There was no single unifying theme among vulnerabilities, but the results of this study offer preliminary data to design future investigations on regional and national levels to understand and mitigate the effects of social vulnerability factors on access to specialty vestibular care and outcomes of treatment.

The clenched fist deformity (CFD) in adult patients with upper motor neuron syndrome (UMNS), typically due to a brain or spinal cord injury, can develop from an imbalance of the extrinsic finger flexors relative to the extensors. This brings the fingers into a flexed posture across the metacarpophalangeal (MCP) and interphalangeal (IP) joints and places the fingertips close to or in contact with the palm. The intrinsic musculature of the hand also plays a contributing role to the flexion deformity across the MCP joints whose contribution to the deformity can be masked by the extrinsic flexors. Severity of the CFD is patient specific and ranges over a spectrum dependent upon the involved muscle groups and underlying spasticity, myostatic contracture and/or joint contractures. In addition to markedly decreasing function, patients and caretakers may struggle with hygiene in the hand and even develop wounds within the palm. Surgical correction of the CFD can be classified as procedures implemented for muscles with (functional) or without (non-functional) volitional motor control. Techniques encompass muscle-tendon lengthening, tenotomies, tendon transfers, muscle origin release (slides), joint capsule and/or ligament releases. A comprehensive review of the surgical approach to correcting the CFD for the hand with and without volitional motor control in the fingers will be presented. Level of Evidence: Level V (Therapeutic)

Background This study aimed to provide methodology to create a facial contour-informed normative 60-4 visual field and to apply the reference field to a glaucoma cohort to derive facial contour-informed 60-4 global indices. Methods Participant recruitment was completed at a tertiary medical centre. 60 eyes from 30 participants with no ocular pathology by clinical exam or optical coherence tomography were recruited for the healthy cohort. For the glaucoma cohort, 86 eyes from 43 patients diagnosed with glaucoma by clinical exam were recruited, with 30-2 visual field mean deviation used to stratify glaucoma severity. Results The median (range) age of the healthy participants was 33 (24–61) years old. A facial contour-informed 60-4 visual field reference field was developed. 43 glaucoma patients were recruited with a resulting median (range) age of 65 (30–84). Three algorithms compensating for facial contour were used for the derivation of 60-4 mean deviation and pattern SD. All mean deviation algorithms correlated with 30-2 mean deviation severity (ρ≤−0.62, p<0.0001) and retinal nerve fibre layer thickness (ρ≥0.36, p<0.05). For pattern SD, consideration of inferior nasal defects allowed correlation with both 30-2 mean deviation severity (ρ≥0.49, p<0.001) and retinal nerve fibre layer thickness (ρ≤−0.47, p<0.01). Conclusion This study provides methodology for deriving a facial contour-informed 60-4 reference field and illustrates the feasibility of applying facial contour information to refine global indices of the 60-4 visual field. Obtained metrics compensated for facial contour and correlated with functional and structural disease metrics.

INTRODUCTION: Chronic neurogastroduodenal disorders are heterogeneous and thought to lie on a spectrum of disease encompassing both sensory and neuromuscular pathologies. Abnormalities of interstitial cells of Cajal (ICC), a subset of which generate pacemaker signals and subsequently motility, have been implicated in their pathophysiology. We systematically reviewed the literature to pool ICC deficits observed in chronic neurogastroduodenal disorders. METHODS: Studies quantifying gastric ICC from the corpus or antrum, in adult patients with gastroparesis, functional dyspepsia (FD), or chronic nausea and vomiting syndromes (CNVS) were analyzed (PROSPERO: CRD42024613226). MEDLINE, Embase and CENTRAL databases were searched systematically. Random effects meta-analyses were used to compare ICC counts by disorder group with subgroup analysis by quantification methodology. RESULTS: Overall, 2,158 studies were screened and 22 included. Comparative studies (n = 12) showed patients with chronic neurogastroduodenal disorders (n = 167 with gastroparesis, n = 19 with FD ± CNVS) had lower ICC counts than nondiabetic controls (n = 130); standardized mean difference −1.58, 95% confidence interval −2.09 to −1.07, P < 0.0001, with more severe deficits in gastroparesis compared to FD ± CNVS (standardized mean difference [SMD] −0.44, P = 0.048). A spectrum of ICC deficits was evident in a subgroup of studies using gold-standard methods with c-KIT antibody and 4',6-diamidino-2-phenylindole-stained nuclei confirmation (7 studies, 246 patients: mean ICC counts 2.29 in gastroparesis vs 3.49 in FD ± CNVS, and 5.27 in controls; P < 0.001 all comparisons). Most studies were at high risk of bias (n = 21). DISCUSSION: Marked depletion of ICC is a consistent finding in neurogastroduodenal disorders. A spectrum of disease is revealed, with greater depletion associated with delayed emptying. Techniques for clinically defining ICC-driven gastric neuromuscular dysfunction should be prioritized.

Abstract Aims Mitral and tricuspid regurgitation (MR and TR) are common in older adults and associated with substantial morbidity and mortality. While transthoracic echocardiography (TTE) is the diagnostic gold standard, access remains limited in many care settings. Artificial intelligence (AI)–based echocardiographic analysis may help address this diagnostic gap. Methods and results We externally validated a deep learning algorithm developed by Aisap.ai using TTE studies from the Mayo Clinic Health System (2013–23). The model analyses echocardiographic images to classify atrioventricular regurgitation severity and was evaluated against cardiologist interpretations. Performance was assessed using binary (normal–mild vs. moderate–severe) and ordinal (normal, mild, moderate, severe) classification schemes. Among 1541 eligible TTEs, the model returned predictions for 578 studies (38%). Performance analysis was limited to these cases. The MR cohort included 280 studies and the TR cohort 298. For MR, the model achieved an area under the receiver operating characteristic curve (AUC) of 0.98 [95% confidence interval (CI): 0.97–0.99], with 91% accuracy, 95% sensitivity, and 89% specificity. For TR, the AUC was 0.96 (95% CI: 0.94–0.98), with 84% accuracy, 91% sensitivity, and 80% specificity. Conclusion In cases where a prediction was generated, the model demonstrated high diagnostic performance in identifying clinically significant atrioventricular regurgitation. These findings support the feasibility of AI-assisted echocardiography in diverse populations, while underscoring the need for technical alignment between model requirements and local acquisition practices to ensure real-world applicability.

Abstract Background Being able to estimate the risk of metachronous disease in a patient with colorectal cancer (CRC) could enable risk-appropriate surveillance. The aim of this study was to develop a risk-prediction model to estimate individual 10-year risk of metachronous disease following a CRC diagnosis. Methods A population-based cohort of patients with CRC was recruited soon after diagnosis between 1997 and 2012 from the United States, Canada, and Australia. Cox regression with the least absolute shrinkage and selection operator penalization was used to identify factors that predicted the risk of a new primary CRC diagnosed at least 1 year after the initial CRC diagnosis. Potential predictors included demography, anthropometry, lifestyle factors, comorbidities, personal and family cancer history, medication use, age at diagnosis, and pathological features of the first CRC. Internal validation through bootstrapping was used to evaluate the discrimination and calibration. Results We included 6085 CRC cases; 138 (2.3%) of these cases were diagnosed with metachronous disease over a median of 12 years (IQR = 5-17 years). Metachronous CRC risk was predicted by body mass index; smoking status; level of physical activity; family history of cancer and synchronous CRC; stage, grade, histological type, and DNA mismatch repair status; and age at diagnosis of the first CRC. The model was valid with a C statistic of 0.65 (95% CI = 0.63 to 0.68) and a calibration slope of 0.873 (SD = 0.087). Conclusions Metachronous CRC can be predicted with reasonable accuracy using a prediction model that consists of clinical variables collected as part of routine practice.

Abstract Background Indigenous populations worldwide experience unjust inequities in surgical outcomes. In Aotearoa New Zealand, Indigenous Māori experience poorer health outcomes, including higher rates of postoperative mortality. The aim of this study was to quantify ethnic disparities in ‘failure to rescue’ (FTR), complications, and mortality following gastrointestinal cancer surgery and to analyse trends over time. Methods A retrospective national population-based cohort study of patients undergoing resection for gastrointestinal and hepatopancreatobiliary cancers from 2005 to 2020 was conducted. Self-reported ethnicity data were collected at the time of surgery. The primary outcome was FTR, defined as mortality following a complication within 90 days of surgery. Results In total, 31 185 patients were included; 2479 (7.9%) were Māori, 46.5% were female, and the median age was 71 (interquartile range 62–78) years. Māori patients were younger and had higher levels of socio-economic deprivation and co-morbidity. Māori had higher age-standardized rates of mortality (5.9% versus 3.2%), complications (52.9% versus 42.4%), and FTR (10.8% versus 7.2%), compared with European/Other. Multivariable regression demonstrated higher odds of mortality (adjusted OR (aOR) 1.45 (95% c.i. 1.15–1.82)), complications (aOR 1.30 (95% c.i. 1.17–1.45)), and FTR (aOR 1.29 (95% c.i. 1.01–1.62)) for Māori. Analysis over time showed a significant improvement in risk-adjusted rates of mortality (6.2% in 2005–2008 versus 3.4% in 2017–2020) and FTR (7.3% in 2005–2008 versus 4.0% in 2017–2020) for European/Other, but no change for Māori (rates of mortality were 6.6% in 2005–2008 versus 5.4% in 2017–2020 and rates of FTR were 7.8% in 2005–2008 versus 6.3% in 2017–2020). Conclusion Widening inequities in FTR have worsened disparities in postoperative mortality for Māori patients. ‘Complication rescue’ is a target to reduce inequities and improve perioperative care for Māori patients.