Citations

Background. The Fontan procedure has transformed the management of congenital heart defects characterized by single ventricle physiology, yet it predisposes individuals to Fontan-associated liver disease. Combined heart and liver transplantation (CHLT) emerges as a therapeutic option, but evidence of its efficacy and safety remains limited. This study aimed to comprehensively evaluate CHLT in Fontan patients, focusing on patient characteristics, perioperative outcomes, and posttransplant morbidity and mortality. Methods. Following Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines, a systematic search of PubMed, Embase, and the Cochrane Central Register of Controlled Trials was conducted. Studies meeting the intervention of CHLT in Fontan patients were included, and data were collected and synthesized using proportion meta-analysis techniques. Statistical analysis was carried out using R software. Results. Four studies met inclusion criteria, comprising 67 Fontan patients undergoing CHLT. All included studies were observational retrospective cohorts performed in the United States. The 1-y survival rate post-CHLT was 88% (95% confidence interval [CI], 70%-98%). Liver graft rejection rates were low, 4% (95% CI, 0%-22%), and no heart graft rejection greater than mild was reported. Postoperative complications included acute kidney injury 75% (95% CI, 50%-93%), temporary dialysis 27% (95% CI, 9%-51%), neurologic events 7% (95% CI, 0%-26%), infection 23% (95% CI, 3%-55%), and unplanned medical procedures 40% (95% CI, 23%-59%). Conclusions. CHLT in Fontan patients demonstrates promising survival rates, but graft rejection and postoperative complications pose challenges. The rate of renal complications is particularly notable and requires further evaluation. Future research should prioritize comparative different management strategies and long-term follow-up to refine protocols and optimize outcomes.

ABSTRACT Background Dementia often goes undetected in hospital settings, where cognitive assessments are challenging due to illness severity and delirium. This study aimed to (1) evaluate the accuracy of the Clinical Dementia Rating (CDR), based solely on knowledgeable informant reports, for detecting preexisting dementia and cognitive impairment in hospitalized patients compared to a gold‐standard diagnosis, (2) and compare its performance to the 16‐item Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE‐16). Methods This cross‐sectional study assessed consecutive patients aged ≥ 65 admitted to inpatient units from five hospitals in Brazil. The informant‐based CDR was administered to knowledgeable informants within 48 h of admission, capturing patients' cognitive status 3 months before hospitalization to avoid the influence of acute cognitive impairments. Blinded experts provided a gold standard clinical diagnosis of dementia or cognitive impairment no dementia (CIND) based on a 90‐min comprehensive assessment, including a standardized neuropsychology battery. Areas under the curve (AUC) examined diagnostic accuracy. Results Of 65 participants (mean age = 79.4 years; women = 54%), 34% had dementia and 32% had CIND . Compared to the gold standard, the informant‐based CDR showed excellent diagnostic accuracy for detecting dementia ( AUC = 0.92; 95% confidence interval [ CI ] = 0.86–0.98) and cognitive impairment ( AUC = 0.93; 95% CI = 0.88–0.98), with a cutoff of ≥ 1 showing 98% specificity for dementia and a cutoff of ≥ 0.5 showing 98% sensitivity for cognitive impairment. Compared to the IQCODE ‐16, the informant‐based CDR had similar performance in detecting dementia and a nonsignificant slight advantage in identifying cognitive impairment ( AUC = 0.93 vs. 0.84, p = 0.069), reducing unrecognized cognitive impairment based on medical record documentation from 70% to 2%. Conclusions Informant‐based CDR is a valid and efficient tool for detecting dementia and cognitive impairment in hospitalized older adults, supporting early diagnosis and guiding multidisciplinary interventions in acute care. Its use in routine hospitals may help clinicians reduce undetected cognitive impairment, enhance decision making, and improve patient care.

Abstract Robots have been used effectively in plastic and reconstructive surgery (PRS) for reconstruction. The utilization of robotics in all surgical specialties is expanding with the goal of offering the most appropriate patient-centered care possible, especially in complex multidisciplinary cases. Despite the safety, efficiency, and reproducibility of robotics in PRS, there is a paucity of required and formalized training in PRS residency programs. The ACGME and industry published guidelines were investigated. Robotic surgery case logs of Mayo Clinic Arizona General Surgery residents were analyzed with attention to equivalency certification (EQ). Over the past 5 years, the equivalency certification from Intuitive (Sunnyvale, CA) was obtained by 30% of all general surgery residents at our institution (range, 0–100). The case numbers to obtain the equivalence certification are industry recommendations, and proficiency is determined by the program director. The ACGME does not mandate robotics training in general surgery residency. According to the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES), trainees must complete 20 console cases and 10 bedside cases to become industry certified. With respect to training and advancing the field, PRS residents could successfully obtain certification in their residency programs. The minimum case requirement recommended by SAGES is not burdensome and can ensure robotic privileges in PRS practice immediately following graduation. By improving the training for minimally invasive robotic surgery in plastic surgery, patients and healthcare systems benefit from improved quality of life outcomes and decreased postoperative length of stay, which results in less strain on our entire medical system.

AbstractAlthough guidelines have historically recommended deferring decisions about learning genomic information for conditions not actionable in childhood until adulthood, youth have increasing access to personal genomic information through research, clinical, and direct‐to‐consumer testing. However, little is known about young people's reactions to, and perceived future utility of learning genomic information actionable in adulthood. We conducted qualitative interviews with 28 youth ages 15–22 without clinical indications for genetic screening who, through enrollment in a genomic decision‐making research study, learned they were carriers of an autosomal recessive condition, or anticipated being carriers but received negative results. Semi‐structured interviews occurred virtually between 3 and 16 months after the return of results. Interpretative description guided deductive and inductive coding of transcripts. Of the 28 participants, 21 received positive carrier results, and 7 received negative results. Although some carriers felt the result was unexpected, they expressed relief overall and did not feel worried about their result. Participants with negative results also felt relief about their results. All participants correctly described what a carrier result means, but some carriers could not remember the condition associated with their result. No participant regretted learning personal genomic information, and all reported their results helped them better understand risks to future children. Carriers who perceived the condition for which they were carriers as more severe and/or those familiar with the condition were more likely to remember their result and consider future reproductive options. Carriers also felt testing at their respective age allowed increased familiarity with results and more time to gather information and decide on the personal utility of the information. Our findings suggest early access to genomic information for some youth may allow integration of carrier information over time with minimal adverse effects. More research is needed to assess long‐term outcomes among carriers.

Abstract Background The prevalence of delirium in intensive care units (ICUs) is high and has a major impact on patient outcomes. Aim To describe delirium assessment instruments, prevalence, interventions and barriers in delirium management in adult and paediatric ICUs; and to explore the association between delirium prevalence and reported interventions and barriers at unit level. Study Design A secondary analysis of the cross‐sectional World Delirium Awareness Day Delirium Survey on 15 March 2023. This was a prospective study to assess the one‐day point delirium prevalence, practices and quality improvement efforts across healthcare systems. Data was analysed descriptively and using multiple linear regression. Results Data of 1612 assessments in 123 ICUs from three German‐speaking countries were analysed. The most frequently used delirium assessment instrument was the Intensive Care Delirium Screening Checklist (43.9%, n = 54). The prevalence of delirium at 8 AM was 18.6% and at 8 PM 20.4% from the 94 ICUs included in the regression analyses. Prevalence for adult and paediatric and mixed ICUs are comparable. Main reported over all unit‐level interventions were ‘pain management’ (95.9%, n = 118), ‘mobilization’ (94.3%, n = 116) and ‘verbal re‐orientation’ (84.6%, n = 104). Main reported over all unit‐level barriers were ‘shortage of staff’ (53.7%, n = 66) and ‘patients who are difficult to assess’ (44.7%, n = 55). Interventions such as ‘avoidance of bladder tubes/catheters’ in all ICUs, ‘use of ear plugs and/or sleep glasses’ in adult ICUs and ‘mobilization’ in paediatric and mixed ICUs were associated with reduced delirium prevalence. Across all ICUs, as well as in both adult and paediatric ICUs, ‘lack of appropriate scores for delirium assessment’ was identified as a significant barrier. Conclusions One fifth of assessed ICU patients suffer from delirium. Several reported unit‐level interventions and barriers may have an impact on delirium prevalence, suggesting an approach for future studies and clinical practice. Relevance to Clinical Practice In clinical practice, unit‐level ‘avoidance of bladder tubes/catheters’, ‘use of ear plugs and/or sleep glasses’ and ‘mobilization’ may be used as delirium prevention and treatment interventions.

AbstractBackgroundOvarian juvenile granulosa cell tumors (juvGCT) are rare sex cord‐stromal tumors that occur primarily in children and adolescents. This study summarizes the clinical presentation and outcomes of patients with juvGCT.MethodsPatients were enrolled in the International Ovarian and Testicular Stromal Tumor and/or International Pleuropulmonary Blastoma/DICER1 Registries. Available medical records were abstracted, and pathology was centrally reviewed. Surgical staging was classified using the 2014 International Federation of Gynecology and Obstetrics (FIGO) criteria.ResultsIn total, 70 patients with juvGCT enrolled and were diagnosed between 2001 and 2024; most patients (81%, 57 of 70) presented with FIGO stage I disease. Adjuvant chemotherapy was given in 30% (21 of 70); all regimens were platinum‐based. Three‐year event‐free survival among patients with stage IA tumors was 80.2% (95% confidence interval [CI], 62.4%–100.0%), IC1 was 87.4 (95% CI, 72.4%–100.0%), IC2‐IC3 was 63.6% (95% CI, 40.7%–99.5%), and II‐IV was 48% (95% CI, 24.6%–93.8%). Of the patients with recurrent juvGCT with known mitotic index (MI), all had MI greater than 19 mitoses per 10 high power fields (HPF) at diagnosis.ConclusionOutcomes were worse for patients with FIGO stage ≥IC2 disease and for tumors with >19 mitoses per 10 HPF. Given the prognostic significance of MI, the authors strongly recommend the assessment of MI for all juvGCTs. More information about tumor biology is critical to identify which patients may benefit from adjuvant chemotherapy and to facilitate the development of novel therapies.

Abstract Quantitative computed tomography (CT) enables the measurement of biophysical processes characterized by morphology, composition, flow, and/or motion to aid in clinical diagnosis and intervention. Since its initial application for determining bone mineral density for skeletal fragility assessment, quantitative CT has continued to evolve alongside CT’s technological advancements. A key challenge facing quantitative CT is the lack of standardization pertinent to image acquisition, reconstruction, and image analysis. With the introduction of spectral CT involving dual-energy approaches and photon-counting detectors (PCD), we are now able to obtain detailed information regarding mass densities of endogenous and exogeneous materials. Furthermore, energy-resolved CT yields spectral image types (eg, virtual monoenergetic image) that are, in principle, independent of tube potential and patient size. This paves the way for workflow standardization and helps improve the consistency and reproducibility of CT-derived measurements. In this article, we review clinical applications of quantitative CT, discuss key challenges associated with quantitative CT and its adoption into routine practice, and outline the unique benefits ushered by new CT technologies such as PCD-CT towards improving quantitative imaging.