Citations

OBJECTIVE: To evaluate the effect of joint preparation and patient factors on outcomes and complications in patients treated acutely with hindfoot fusion nails for ankle and pilon fractures. METHODS: Design: Retrospective chart review. Setting: Thirteen US trauma centers and 2 UK trauma centers. Patient Selection Criteria: Ankle and pilon fractures (AO-OTA types A-C) from 2010 to 2020 acutely treated definitively with hindfoot fusion nail were reviewed. Patients at least 18 years old and with minimum 6 months follow-up or earlier diagnosis of complication were included. Exclusion criteria included nonambulatory at baseline, prior internal fixation that failed and underwent revision, and prior tibiotalar or subtalar arthrodesis. Outcome Measurements and Comparisons: The primary outcome was final postoperative ambulatory status. Secondary outcomes were infectious and fracture-related complications. RESULTS: One hundred forty-nine patients (75 men; 74 women; age 20–99; median 63 years) were treated for ankle (104) or pilon (45; 8A, 13B, 24C) fractures. Eighty-five patients (44%) had open fractures and 55 (37%) had diabetes. Thirty-six patients (24%) had joint preparation at the time of surgery. Forty-five (30%) were made weight bearing as tolerated postoperatively; the median time to mobilize was 1.5 days (0–210) and to full weight bearing was 35 days (0–1462). Fifty-seven patients (85%) returned to their preinjury ambulatory status, which was not affected by joint preparation (50% vs. 59%, P = 0.327). Joint preparation led to higher articular fusion rates (94% vs. 24%; P = 0.001) and fewer hardware removals (19% vs. 42%, P = 0.013), but trended toward a higher fracture nonunion rate (19% vs. 8%, P = 0.053). Forty-five patients (30%) had infectious complications, 60 (40%) had a fracture-related complication, and 67 (45%) had additional procedures. Open fractures did not lead to any differences in superficial or deep infection. Insulin-dependent diabetes was associated with higher rates of infectious complications (31% vs. 15%, P = 0.028) and amputation (17% vs. 4%, P = 0.029). CONCLUSIONS: Hindfoot fusion nails for acute ankle and pilon injuries had high complication rates. More complications occurred in patients with insulin-dependent diabetes. While 95% regained ambulation, only 57% returned to preoperative status. Joint preparation led to higher rates of articular fusion (94% vs. 24%, P < 0.001) but not fracture union (81% vs. 66%, P = 0.106). LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Purpose: A variety of care pathways are offered to females with chronic pelvic pain (CPP) and pelvic floor myofascial pain (PFMP), which may affect treatment outcomes. This study aims to compare care pathways and describe health care utilization and characteristics of patients with CPP and PFMP referred for physical therapy (PT) at a tertiary care center. Methods: A retrospective cohort analysis was conducted on females with CPP and PFMP referred for PT. Patients received PT, medication management, injection therapy, or a combination of treatments. We collected data on health care utilization, comorbidities of interest, and patient-reported outcome measures (PROMs). Wilcoxon rank-sum tests were used to compare patients with pre- and posttreatment PROM scores. Results: A total of 1172 patients were referred for PT treatment, but 19.5% (n = 229) did not attend any PT sessions, and only 18% (n = 211) of patients attended the recommended number of PT sessions. Comorbid urinary (48.5%, n = 569) and bowel dysfunction (43%, n = 512) were prevalent. Patients consulted with multiple providers. Most patients (57.1%, n = 669) utilized opioid medications. Less than 20% completed both pre-and posttreatment PROMs. Discussion: Care pathways vary widely for the treatment of PFMP. Low adherence to PT and a trend toward greater than 5 subspecialty appointments indicating higher health care utilization reflect the range of inconsistent patient experience likely affecting outcomes. Outcomes of care are uncharted territory. Optimal care pathways for CPP and PFMP need to be established, along with further investigation of PROMs, to determine which treatments result in effective outcomes that matter to patients.

Abstract Patients at risk for progression from myeloid precursor states (idiopathic cytopenia of undetermined significance [ICUS] and clonal cytopenia of undetermined significance [CCUS]) to myelodysplastic syndrome (MDS) are not well defined. Epidemiologic risk factors, clonal changes for MDS development, and evolution from one MDS state to another were available in the MDS Natural History Study (NHS), a prospective cohort enrolled at diverse US sites. Extensive clinical data and biospecimens were collected at baseline and follow-up. A total of 1177 (56%) individuals with MDS or MDS-related precursor conditions (ICUS/idiopathic dysplasia of undetermined significance [IDUS], CCUS, and MDS/myeloproliferative neoplasm overlap) were enrolled and diagnosed in the MDS NHS. The median age was 74 years, with 89% aged ≥60 years, and most were male patients. Median follow-up time was 1.6 years and was similar among ICUS/IDUS, CCUS, and MDS. During follow-up period, 68% of participants terminated the study, 35% died, and 38% had disease progression. Using a refined clinical definition of progression, the greatest proportion of progression was observed among higher-risk-MDS (116 [73%]), followed by lower-risk-MDS (170 [52%]); fewer progression events were observed among participants with CCUS (65 [22%]) and ICUS/IDUS (46 [17%]). Predictors of progression are delineated, including female sex, higher quantity of mutations, the presence of TP53 mutation, and poor/very poor cytogenetic score. Based on these prospective data, guidelines for clinical management including monitoring and surveillance are outlined. The MDS NHS provides real-world data to illustrate how clinical and genotypic differences inform the classification, disease course, and approach to therapy, with informed monitoring guidelines for patients. This trial was registered at www.ClinicalTrials.gov as NCT02775383.

BACKGROUND: Recent years have seen considerable growth and significant changes in the anesthesiology residency application process. Although the National Residency Match Program provides data on attributes of successfully matching applicants, it does not provide detailed characteristics of applicants’ research portfolio. This single-program retrospective analysis aims to characterize granular aspects of applicant research experiences to determine whether research involvement is linked to higher odds of matching. METHODS: Applications from interviewed United States allopathic (US-MD) and osteopathic (US-DO) applicants at a single anesthesiology residency program were analyzed for research experience. The primary outcome assessed was the association of any research experience with odds of ranked-to-match and the association of specific types of research experience with ranked-to-match. Secondary outcomes included the association of medical degree type (US-MD vs US-DO) or affiliation of medical school with an anesthesiology residency program to the number of research experiences, and the association of research experiences with the United States Medical Licensing Examination (USMLE) Step 1 score type (Pass/Fail vs Scored). RESULTS: Applicants with at least one research experience were more likely to be ranked-to-match than applicants without research experience (odds ratio [OR]: 2.16, 95% confidence interval [CI], [1.55–3.02], P < .001). Similar odds were demonstrated for applicants with at least one peer-reviewed publication compared to no peer-reviewed publications (OR: 2.25, 95% CI, [1.79–2.82], P < .001), and at least one anesthesiology-related research experience compared to no anesthesiology-related research experience (OR: 1.76, 95% CI, [1.36–2.26], P < .001. Applicants from US-MD schools were more likely to have research experience than those from US-DO schools ( P < .001); applicants from a medical school affiliated with an anesthesiology residency were more likely to have research experience than applicants from unaffiliated medical schools ( P < .001); and applicants with Pass/Fail USMLE Step 1 examinations were more likely than their Scored counterparts to report at least one research experience ( P < .001). CONCLUSIONS: Applicant research is associated with greater odds of being ranked-to-match in anesthesiology residency. Applicants from US-MD schools and schools affiliated with anesthesiology residency programs have significantly greater rates of reporting at least one research experience. There is a trend toward a higher incidence of reporting at least one research experience with the change of USMLE Step 1 policy toward a Pass/Fail examination.

Background: Losmapimod is an orally administered small molecule and selective p38α/β mitogen-activated protein kinase (MAPK) inhibitor able to reduce aberrant expression of DUX4 in vitro and thereby potentially slowing disease progression in patients with facioscapulohumeral muscular dystrophy (FSHD). Objective: This global, randomized, placebo-controlled, double-blind phase 3 study in patients with FSHD1 and FSHD2 examined the efficacy and safety of losmapimod over a 48-week treatment period compared to placebo (NCT05397470, EUDRACT 2022-000389-16). Methods: The primary endpoint was change in quantification of reachable workspace (RWS) expressed as relative surface area (RSA). Other endpoints included measures of muscle composition (fat content and lean muscle) using magnetic resonance imaging (MRI), muscle strength using quantitative dynamometry, and quality of life measures. Results: 130 participants received losmapimod and 130 participants received placebo, with 252 participants completing the 48-week treatment period. There were no statistically significant differences between groups in change in RSA and all secondary efficacy endpoints from baseline to Week 48. Losmapimod treatment was well-tolerated, and most adverse events were mild. Conclusions: Losmapimod was generally well tolerated with a favorable safety profile at a dose of 15 mg twice daily. Although none of the efficacy endpoints were met, study design and data from the study may inform future studies of FSHD therapies.

Abstract In a real-world analysis of brexucabtagene autoleucel recipients with relapsed/refractory B-cell acute lymphoblastic leukemia (N = 278), lack of response to prior blinatumomab correlates with significantly worse following chimeric antigen receptor T-cell therapy outcomes.

BACKGROUND AND OBJECTIVES: Myelomeningocele is defined by the presence of a fluid-filled sac that contains the neural placode and cerebrospinal fluid (CSF) at the level of the spinal defect. Alternatively, the term myeloschisis is used when the neural placode is not contained within a CSF-filled sac. While both are eligible for prenatal closure, few studies have characterized the impact of the type of lesion on postnatal outcomes. This study compares the outcomes of these 2 types of open spinal dysraphism using data from the Fetal Myelomeningocele Consortium registry sponsored by the North American Fetal Therapy Network. METHODS: The prospective observational Fetal Myelomeningocele Consortium registry was used to extract deidentified data corresponding to patients who underwent fetal closure of myelomeningocele vs myeloschisis. Demographics, operative characteristics, perioperative complications, and postnatal outcomes were collected. RESULTS: A total of 1327 patients were identified, including 991 (74.7%) with myelomeningocele and 336 (25.3%) with myeloschisis. Compared with myelomeningocele, myeloschisis was associated with lower rates of prenatal talipes (11% vs 24%, P < .001) and higher rates of favorable prenatal movement (94% vs 86%, P < .001). Postnatally, myeloschisis conferred higher rates of leg movement (97% vs 90%, P = .002) and an increased likelihood of ambulation in the household (10.4% vs 4.1%, P = .009) and outside (7.2% vs 1.9%, P = .004) at 1 year. However, myeloschisis was also linked to greater use of skin patches during closure (49% vs 27%, P < .001), higher CSF leak rates among those with wound dehiscence (26% vs 8%, P = .014), and more frequent CSF diversion and tethered cord surgeries at follow-up. CONCLUSION: Myeloschisis and myelomeningocele demonstrate distinct clinical profiles. Although patients with myeloschisis may have favorable motor outcomes, they are also characterized by higher rates of CSF leakage, CSF diversion, and tethered cord surgery. These findings highlight the need for lesion-specific prognostication and may inform surgical planning and parental counseling in the context of prenatal spina bifida closure.

Background Breast arterial calcifications (BAC) are commonly observed as an incidental finding on screening mammography and have been linked to cardiovascular disease. Whether BAC is independently associated with stroke risk remains uncertain. Methods We conducted a systematic review and meta-analysis in accordance with PRISMA 2020 guidelines. PubMed, Embase, and Scopus were searched from inception to May 2024 for cohort studies evaluating the association between BAC and stroke. Eligible studies included women undergoing mammography with documented BAC status and subsequent stroke outcomes. Data on patient characteristics and vascular risk factors were extracted. Study quality was appraised using the Joanna Briggs Institute (JBI) Critical Appraisal Checklist. Random-effects meta-analyses with restricted maximum likelihood (REML) estimation were performed to pool risk ratios (RRs) and mean differences (MDs). Heterogeneity was assessed with the I 2 statistic, and publication bias with Egger’s test. Results Ten cohort studies including 52,413 women were analyzed. The presence of BAC was associated with more than a twofold increased risk of stroke (RR 2.09, 95% CI 1.58–2.75; I 2 = 64.4%). This association persisted after adjustment for age, diabetes, hyperlipidemia, and menopausal status. Compared with BAC-negative women, those with BAC were significantly older (MD 7.07 years, 95% CI 5.44–8.70) and more frequently hypertensive (RR 1.48, 95% CI 1.23–1.78), diabetic (RR 1.67, 95% CI 1.38–2.02), hyperlipidemic (RR 1.27, 95% CI 1.07–1.51), and postmenopausal (RR 1.26, 95% CI 1.00–1.59). Interestingly, BAC was less common among smokers (RR 0.62, 95% CI 0.45–0.86). Egger’s test showed no evidence of publication bias ( p = 0.143). Conclusion BAC detected on screening mammography is independently associated with an increased risk of stroke, even after accounting for traditional risk factors. These findings support BAC as a promising, underutilized imaging biomarker of cerebrovascular risk in women and highlight the need for standardized reporting and prospective validation.