Citations

Abstract Coccidioidomycosis can cause severe meningitis, requiring lifelong treatment. In this study, we sought to better understand the potential effect of pharmacogenomic testing on treatment outcomes of patients with coccidioidal meningitis. Of 13 patients with coccidioidal meningitis who underwent pharmacogenomic testing, 11 had genetic variants of CYP2C19 and CYP3A5 that affect antifungal efficacy. These results led to real-time treatment changes and future antifungal planning. Routine pharmacogenomic testing helps to avoid antifungal treatments that are futile or lead to adverse effects.

Objective The 2019 European Alliance of Associations for Rheumatology (EULAR)/American College of Rheumatology (ACR) systemic lupus erythematosus (SLE) classification criteria score (≥20 points) has been associated with poor outcomes. We aimed to evaluate its utility as a predictor for mortality and hospitalisation and to derive and validate an ominosity score based on the SLE classification criteria set. Methods Incident patients with SLE in a population-based cohort were included. The association between the 2019 EULAR/ACR SLE score and mortality and hospitalisation was assessed using Cox regression adjusted for age, sex and calendar year. An ominosity score for mortality was developed based on the SLE criteria set. The least absolute shrinkage and selection operator method was used to estimate model coefficients. Concordance and calibration were assessed by cross-validation and by plotting the observed event rates against the deciles of predicted probabilities. Results Among 374 patients with incident SLE, a EULAR/ACR score ≥20 points was not associated with an increased risk of mortality (HR 1.17, 95% CI 0.67 to 2.03) or first hospitalisation (HR 1.14, 95% CI 0.79 to 1.64) compared with a score ≤19 points. The derived ominosity score for mortality included age, sex, thrombocytopaenia, neuropsychiatric manifestations, subacute cutaneous or discoid lupus, non-scarring alopecia, inflammatory arthritis, renal involvement, antiphospholipid antibodies and hypocomplementaemia. This model demonstrated a concordance=0.76 with adequate calibration. Age and sex were the main predictors, as seen in the model including just age, sex and year (concordance=0.77). Conclusion The 2019 EULAR/ACR SLE criteria score was not associated with mortality and hospitalisation. The derived ominosity score for mortality presented good prediction for mortality but was not better than age and sex alone.

Rosai–Dorfman Disease (RDD), also known as sinus histiocytosis with massive lymphadenopathy, is a rare non-Langerhans cell histiocytic neoplasm. Although the disease classically presents as massive painless lymphadenopathy in young adults, RDD can also involve the central nervous system in some patients. CNS lesions, can cause headaches, neurologic deficits, and even neurologic deficits. The imaging appearance of CNS RDD typically mimics that of meningiomas: well-circumscribed dural-based lesions that often have dural tails. However, some imaging clues also exist that might help a radiologist recognize RDD, even before histopathologic confirmation. This radiology-pathology report of a patient with CNS RDD highlights the most pertinent clinical, imaging, and pathologic features of CNS RDD, and discusses what the neuroradiologist needs to know about the disease.

Objective: In-office tympanostomy tube insertion (TTI) is becoming more available in the practice of pediatric otolaryngology. This study evaluated the tolerability of this procedure in young children. Method: Four methods were used to assess tolerability. (1) Standardized video recordings were collected from 30 patients under 24 months who underwent in-office TTI with a single-pass insertion device with topical anesthesia alone. The videos were then reviewed by 3 independent experts in pediatric care and rated at 5 procedural time points using a defined response scale developed with the U.S. Food and Drug Administration. (2) Separately, overall tolerability was subjectively assessed by the same experts. (3) Patient recovery was assessed by the participating otolaryngologist and support staff. (4) Patient caregivers were surveyed for their impressions of the procedure, including whether they would recommend it to other caregivers. Results: In a total of 90 reviews, 100% of children were successfully treated and were rated as having acceptably tolerated the in-office tympanostomy tube procedure. All patients returned to an acceptable baseline without inappropriate crying and were assessed as fully recovered immediately following the procedure or by the time the child was leaving clinic. For caregivers, 93% agreed or strongly agreed that they would recommend the use of in-office TTI to other caregivers. Conclusions: In-office TTI in young children was determined to be universally well tolerated in young children and is a procedure that patient caregivers would recommend to other caregivers for their children. These results should help reassure otolaryngology specialists and caregivers alike that in-office ear tube placement is a viable option for young children with middle ear disease.

ImportanceThe American College of Surgeons (ACS) operative standards were established to detail critical elements of cancer surgery, reduce technical variation, and improve outcomes. Two of the 6 operative standards target adequate axillary surgery for breast cancer. The potential association of the operative standards with short-term oncologic outcomes, such as nodal yield and nodal positivity rates, is currently unknown.ObjectiveTo evaluate the potential association of the ACS operative standards with short-term oncologic outcomes in breast cancer.Design, Setting, and ParticipantsA cohort study was performed using data on 1 201 317 women 18 years or older who underwent sentinel lymph node biopsy (SLNB) or axillary lymph node dissection (ALND) for invasive breast cancer from January 1, 2012, to December 31, 2020. Patients were identified using the National Cancer Database (NCDB), a clinical oncology database encompassing approximately 70% of new cancer diagnoses, sourced from hospital registry data from 1317 facilities. Statistical analysis was performed from October 2023 to June 2024.ExposureSentinel lymph node biopsy or ALND.Main Outcomes and MeasuresReliability-adjusted facility-level lymph node yield and nodal positivity rate for each procedure were calculated using generalized linear mixed models, Poisson regression, and logistic regression with facility-level random intercepts.ResultsThe cohort included 1 201 317 women with a median age of 62 years (IQR, 53-70 years). Facility-level nodal yield ranged from 1 to 6 for SLNB and from 6 to 22 for ALND. Median facility-level nodal yield for SLNB was 2.6 (IQR, 2.3-3.0) and the nodal positivity rate for SLNB was 12.2% (IQR, 11.0%-13.7%), with rates ranging from 6% to 21%. A weak correlation between facility-level lymph node yield and nodal positivity was observed (Spearman correlation coefficient, 0.17). Median nodal upstaging rate (≥4 positive nodes) for ALND was 30.5% (IQR, 26.5%-35.0%), with rates ranging from 11% to 54%; median nodal yield was 12.2 (IQR, 10.9-13.6). A strong correlation between nodal yield and nodal upstaging rates was observed (Spearman correlation coefficient, 0.53).Conclusions and RelevanceIn this cohort study of women undergoing axillary surgery for invasive breast cancer, facility-level variation in lymph node yield was present for both SLNB and ALND, which could potentially be improved through the ACS operative standards. However, this variation had mixed associations with nodal positivity and upstaging rates, suggesting the association of the ACS operative standards with oncologic outcomes may be mixed.

Abstract Many medical facilities across the United States use ionizing-radiation-producing machines and radioactive materials for diagnostic and therapeutic purposes on a regular basis. While institutions are required to ensure full-term fetal doses are below the regulatory limit, clear guidance on how pre-declaration fetal doses should be estimated is not available. This paper provides a process that can be used to estimate the pre-declaration fetal dose and provides a predictive screening tool for licensees to use to recommend workload adjustments prior to actual fetal dosimetry results that could exceed the institutions derived investigation levels. The evaluation process presented herein serves as a guide for medical licensees when performing fetal dose evaluations for declared pregnant workers.

ABSTRACTIn this first annual review article, the American Society for Apheresis (ASFA) Attending Physician Subcommittee (APSc) of the Physicians' Committee (PC) curated key apheresis literature in 2023 and presented their choices for the 10 most seminal apheresis articles. PubMed and OVID search engines were used to identify manuscripts from four topic areas: donor apheresis, therapeutic apheresis, education, and cellular therapy. To further identify seminal criteria, they had to present at least one of the following: novel findings, practice‐altering outcomes, international scope, randomized controlled trial, relevant to current clinical practice, and/or provide evidence for category III or IV indications based on the ASFA ninth special issue of the Guidelines on the Use of Therapeutic Apheresis in Clinical Practice‐Evidence‐Based Approach. Inclusion criteria included: full‐length, peer‐reviewed, English language, and human subjects. Case reports, review articles, and meta‐analyses were excluded.

Importance Vascular injuries require urgent repair to minimize loss of limb and life. Standard revascularization relies on autologous vein or synthetic grafts, but alternative options are needed when adequate vein is not feasible and when clinical conditions preclude safe use of synthetic materials. Objective To evaluate the performance of the acellular tissue engineered vessel (ATEV) in the repair of extremity arterial injuries. Design, Setting, and Participants Two open-label, single-arm, nonrandomized clinical trials, including 1 prospective civilian study (CLN-PRO-V005 [V005]) and 1 retrospective observational study in a war zone (CLN-PRO-V017 [V017]), were conducted from September 2018 to January 2024 (follow-up ongoing) at 19 level 1 trauma centers in the US and Israel and 5 frontline hospitals in Ukraine. Patients had vascular injury, no autologous vein available for emergent revascularization, and risk factors for wound infection. Data include the subset of patients with extremity injuries and were analyzed from September 2023 to January 2024. Intervention The ATEV is a bioengineered vascular conduit grown from human vascular cells, available off the shelf, and implantable without immunosuppression. Main Outcomes and Measures Primary patency at day 30 was the primary outcome. Secondary outcomes included limb salvage, graft infection, and patient survival. A systematic literature review identified synthetic graft benchmarks in the treatment of arterial trauma for the same end points. Results The arterial extremity injury subset included 51 of 69 participants in V005 and 16 of 17 participants in V017. The majority were male (V005, 38 [74.5%]; V017, 16 [100%]), the mean (SD) ages were similar (V005, 33.5 [13.6] years; V017, 34.2 [9.0] years), and the mean (SD) Injury Severity Scores were similar (V005, 20.8 [10.5]; V017, 20.1 [18.9]). Penetrating injuries dominated (V005, 29 patients [56.9%]; V017, 14 patients [87.5%]). At day 30 for the V005 and V017 trials, respectively, ATEV primary patency was 84.3% (95% CI, 72.0%-91.8%) and 93.8% (95% CI, 71.7%-98.9%); secondary patency was 90.2% (95% CI, 79.0%-95.7%) and 93.8% (95% CI, 71.7%-98.9%); amputation rate was 9.8% (95% CI, 4.3%-21.0%) and 0% (95% CI, 0.0%-19.4%); ATEV infection rate was 2.0% (95% CI, 0.4%-10.3%) and 0% (95% CI, 0.0%-19.4%); and death rate was 5.9% (95% CI, 2.0%-15.9%) and 0% (95% CI, 0.0%-19.4%) (no deaths attributed to the ATEV at day 30). Day 30 synthetic graft benchmarks were as follows: secondary patency, 78.9%; amputation, 24.3%; infection, 8.4%; and death, 3.4%. Conclusions and Relevance Results of analysis in the subset of patients with vascular extremity injuries in 2 single-arm trials in civilian and real-world military settings suggest that the ATEV provides benefits in terms of patency, limb salvage, and infection resistance. Comparing ATEV outcomes with synthetic graft benchmarks demonstrated improved outcomes in the treatment of acute vascular injuries of the extremities. The analyses reported herein are limited to the subset of 67 patients with vascular extremity injuries out of 86 patients enrolled in 2 trials and excluded 19 patients with iatrogenic and torso injuries. Had these 19 patients been included in these analyses, the efficacy and safety findings could have been attenuated. Trial Registration ClinicalTrials.gov Identifiers: NCT03005418 , NCT05873959