Citations

BACKGROUND AND OBJECTIVES: Enhanced recovery after surgery (ERAS) protocols aim to optimize patient outcomes by reducing the surgical stress response, expediting recovery, and reducing care costs. We aimed to evaluate the impact of implementing ERAS protocols on the perioperative surgical outcomes and financial implications associated with spine surgeries. METHODS: A systematic review and meta-analysis of peer-reviewed studies directly comparing outcome differences between spine surgeries performed with and without utilization of ERAS pathways was conducted along Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. RESULTS: Of 676 unique articles identified, 59 with 15 198 aggregate patients (7748 ERAS; 7450 non-ERAS) were included. ERAS-treated patients had shorter operative times (mean difference [MD]: 10.2 mins; P < .01), shorter hospitalizations (MD: 1.41 days, P < .01), fewer perioperative complications (relative risk [RR] = 0.64, P < .01), lower postoperative opioid use (MD of morphine equivalent dose: 164.36 mg; P < .01), and more rapid mobilization/time to first out-of-bed ambulation (MD: 0.92 days; P < .01). Spine surgeries employing ERAS were also associated with lower total costs (MD: $1140.26/patient; P < .01), especially in the United States (MD: $2869.11/patient, P < .01) and lower postoperative visual analog pain scores (MD = 0.56, P < .01), without any change in odds of 30-day readmission (RR: 0.80, P = .13) or reoperation (RR: 0.88, P = .60). Subanalyses based on the region of spine showed significantly lower length of stay in both cervical and lumbar surgeries implementing ERAS. Type of procedure showed a significantly lesser time-to-initiate mobilization in fusion surgeries using ERAS protocols compared with decompression. CONCLUSION: The present meta-analysis indicates that current literature supports ERAS implementation as a means of reducing care costs and safely accelerating hospital discharge for patients undergoing spine surgery.

AbstractBackgroundImmune checkpoint inhibitor (ICI) therapy has led to significant improvement in outcomes for patients with nononcogene‐driven advanced non–small cell lung cancer (NSCLC). The rate of crossover and receipt of postprotocol ICI in frontline trials for advanced NSCLC has not been systematically evaluated.MethodsClinicalTrials.gov was used to identify phase 3 studies evaluating the use of immunotherapy or combination chemoimmunotherapy against chemotherapy alone in the frontline management of advanced NSCLC. Data on outcomes, rate of crossover and/or subsequent post‐protocol receipt of immunotherapy, and the start dates of these clinical trials were then extracted.ResultsTwenty‐three frontline trials in nononcogene‐driven advanced NSCLC were identified. Six trials with ICI monotherapy/dual ICI therapy and 17 trials evaluating chemotherapy/ICI in first‐line advanced NSCLC were included in the analysis. The crossover rate ranged 0% to 54% in ICI monotherapy/dual ICI trials and 0% to 52% in chemotherapy/ICI trials. Nineteen of 23 trials provided information on subsequent postprotocol therapies. Among the trials not allowing crossover, postprotocol ICI was administered to 17% to 45.8% of patients. Information regarding the eventual receipt of ICI therapy was available for 22 of 23 trials. Of 6631 patients, 2507 (37.8%) randomized to the control arm eventually received ICI therapy.ConclusionThe rate of crossover and postprotocol ICI use was low in frontline trials for first‐line NSCLC incorporating ICI. Given the proven improved overall survival of ICI in a broad population, there is a need to ensure availability of this life‐prolonging therapy in future trials, either by crossover treatment or postprotocol administration.

Background: Roux-en-Y gastric bypass (RYGB) has demonstrated excellent glycemic control and type 2 diabetes mellitus (T2DM) remission for patients with obesity and T2DM. Duration of T2DM is a consistent negative predictor of remission after RYGB. However, the exact timing to offer surgical intervention during the course of the disease is not well elucidated. Material and methods: The authors performed a retrospective cohort study between 2008 and 2020 to establish the exact association between duration of T2DM and remission after RYGB. The authors divided our cohort into quartiles of preoperative disease duration to quantify the change in remission rates for each year of delay between T2DM diagnosis and RYGB. The authors also compared the average time to remission and changes in glycemic control parameters. Results: A total of 519 patients (67.2% female; age 53.4±10.7 year; BMI 46.6±8.4 kg/m 2 ) with a follow-up period of 6.6±3.8 years were included. Remission was demonstrated in 51% of patients. Longer duration of T2DM was a significant negative predictor of remission with an estimated decrease in remission rates of 7% for each year of delay [(OR=0.931 (95% CI: 0.892–0.971); P< 0.001)]. Compared to patients with <3 years of T2DM, remission decreased by 37% for patients with 3–6 years, 64% for those with 7–12 years, and 81% for patients with more than 12 years ( P <0.001). Half of the patients reached T2DM remission after 0.5 and 1.1 years, respectively, for the first and second quartiles, while patients in the other quartiles never reached 50% remission. Lastly, The authors noted an overall improvement in all glycemic control parameters for all quartiles at last follow-up. Conclusion: Patients with a recent history of T2DM who undergo early RYGB experience significantly higher and earlier T2DM remission compared to patients with a prolonged history of preoperative T2DM, suggesting potential benefit of early surgical intervention to manage patients with obesity and T2DM.

Introduction: Artificial intelligence applied to electrocardiograms (ECG-AI) enables early and efficient detection of cardiovascular disease. The technical and clinical impact of different approaches to designing ECG-AI remains under-explored. We consider left ventricular hypertrophy (LVH) and examine the impact of disease-specific labeling of minority etiologies of left ventricular wall thickening- hypertrophic cardiomyopathy (HCM) and cardiac amyloidosis (CA) - on ECG-AI performance. Hypothesis: ECG-AI designed to detect HCM or CA outperforms ECG-AI broadly trained to identify LVH due to differences in attention to key ECG features associated with HCM or CA. Methods: Independent neural networks were trained to identify HCM, CA, and LVH. HCM and CA patients were identified using the full depth of EHR data and validated via clinician adjudication (N = 3,025 and 4,251 patients, respectively). Moderate and severe LVH patients (N = 98,144) were identified using echocardiogram results and international LVH criteria. We compared the ability of disease-specific ECG-AI vs. LVH ECG-AI to detect HCM (or CA) by examining model performance within each of the three test sets. Results: 52.6% of HCM patients and 49.5% of CA patients met LVH criteria. Within the HCM test set, the AUROC, sensitivity, specificity, and positive predictive value (PPV) of the HCM ECG-AI were 0.94, 0.88, 0.85, and 60%, respectively, whereas the same for LVH ECG-AI were 0.83, 0.83, 0.64, and 37%. Within the CA test set, CA ECG-AI achieved AUROC, sensitivity, specificity, and PPV of 0.94, 0.81, 0.91, and 69%, respectively, whereas the same for LVH ECG-AI were 0.75, 0.73, 0.68, and 31%. ECGs positive for HCM exhibited higher P wave area, QRS deflection and R wave amplitude compared to LVH-positive ECGs (Cohen's D > 0.75). ECGs positive for CA exhibited lower R wave amplitude/area, QRS deflection and QRS areas (Cohen's D > 0.6). Conclusion: Models trained using carefully labeled HCM or CA identify distinct signals associated with the diseases, resulting in improved disease discrimination compared to a model trained to identify echocardiographic left ventricular thickening. Labeling choices should be communicated transparently to clinicians to ensure safe and effective use of ECG-AI.

Introduction: Disease-causative variants in LMNA -encoded lamin A/C cause a penetrant dilated cardiomyopathy associated with conduction disease (CD) and ventricular arrhythmias (VA). Prior studies show conflicting results regarding the effect of sex, variant type, and CD on severity and sudden death risk in cardiac laminopathy. Methods: In this retrospective study, we utilized a single-center genetic arrhythmogenic cardiomyopathy registry (N=432) to identify patients with ultra-rare LMNA variants and ascertain the effect of sex, mutation type, and clinical presentation on disease severity. Advanced heart failure (AHF) events were defined as ventricular assist device placement or cardiac transplantation whereas VA events were defined as sudden cardiac arrest, sustained ventricular arrhythmia, or appropriate implantable cardioverter-defibrillator shock. Results: The LMNA variant-positive cohort (N=83) had an age of diagnosis of 36 ± 10 years with 80% showing a cardiac phenotype. No difference in the age at diagnosis (37 vs. 34 years; p=0.3) or prevalence of AHF events (14% vs. 18%; p=0.8) and VA events (34% vs. 36%; p=0.9) was observed between females (N=50) and males (N=33). Furthermore, there was no difference in age of diagnosis (37 vs. 33 years; p=0.1) or prevalence of AHF (14% vs. 12%; p=0.9) and VA events (33% vs. 34%; p=0.9) between individuals with missense (N=42) or frameshift (N=32) variants. Interestingly, in comparison to individuals that presented with isolated CD (N=11) those that first presented with left ventricular dysfunction or arrhythmias (atrial or ventricular) (N=41) were more likely to have VA events (9% vs. 53%; p=0.01) and AHF events (0% vs 29%; p=0.05). In addition, those with structural/arrhythmic presentation had earlier time to VA events (15 years vs. 22 years; p=0.04) and AHF events (23 vs undefined; p=0.09) than those with CD. Conclusions: Contrary to prior studies, in this large single-center cardiac laminopathy study, sex and mutation type were not associated with increased risk of AHF or VA events. However, patients presenting with isolated CD had a lower risk of AHF and VA events. Contemporary multi-center studies are needed to better ascertain risk factors associated with AHF and VA events in cardiac laminopathy.

Background: Catheter ablation is an effective tool to reduce ventricular tachycardia (VT) burden. There is a lack of robust data studying the characteristics and outcomes of VT ablation in patients with ischemic (ICM) versus non-ischemic cardiomyopathy (NICM). Aims: The aim of this study was to assess the impact of ICM vs NICM on outcomes of VT ablation. Methods: A single-center, retrospective study of patients undergoing catheter ablation for VT was conducted. Results: A total of 168 patients, undergoing 200 VT ablation procedures, were included in this study. NICM group (112 procedures) was compared to ICM group (88 procedures). Patients in the ICM group were older (66.6 ± 13.4 vs 58.9 ± 14.4 years) and had higher rates of prior myocardial infarction (65.9% vs 3.6) and coronary artery bypass graft surgery (40.9% vs 1.8%). Overall, ICM group had more comorbidities like hypertension (80.7% vs 52.7%), diabetes mellitus (23.9% vs 12.5%), chronic kidney disease (45.5% vs 35.7%), stroke (17% vs 7.1%), and lower left ventricular ejection fraction (36.8 ± 13.2% vs 43.1 ± 14.7%). The ICM group had lower incidence of prior cardiac valvular surgery (9.1% vs 29.5%). The inducibility of VT (93% vs 93.5%; p= 1.0) and the number of different VT morphologies induced during the case (1.9 ± 1.5 vs 2.3 ± 2.5; p=0.19) was similar between the two groups. There was no acute mortality in either group. There was a non-significant trend towards greater VT recurrence in the NICM group (43.2% vs 33.3%, p= 0.19). However, patients with NICM had a lower VT-free survival as determined by Kaplan-Meier analysis (p=0.05) [Figure]. Long term mortality was higher in ICM group when compared to NICM group (18.2% vs 8.9%, p<0.01). Conclusion: Patients undergoing VT ablation in the NICM group when compared to the ICM group were noted to be younger, had fewer comorbidities, and lower long-term mortality. However, they had significantly less VT-free survival, likely owing to more challenging substrate responsible for VT.

Introduction: Advanced imaging with cardiac magnetic resonance (CMR) or computed tomography (CCT) can be helpful for planning of ventricular tachycardia (VT) ablation procedures by defining the arrhythmogenic substrate. The frequency with which these modalities are utilized in the pre-ablation setting and the associated outcomes remain poorly studied. Objectives: (1) Determine the utilization of advanced cardiac imaging prior to structural VT ablation; (2) establish factors associated with improved VT ablation outcomes Methods: We retrospectively evaluated all VT ablations performed in patients with structural heart disease at a tertiary referral institution during a 2.5 year period (1/2020 - 7/2022). We documented pre-ablation use of cardiac imaging modalities and investigated their association with acute and long-term ablation outcomes. The primary outcome was time to VT recurrence, cardiac transplant, or death. Results: Our dataset included n = 129 subjects. Median post-ablation follow-up was 17 months. Recent echocardiogram, CMR, or CCT (<3 months pre-ablation) had been performed in 113 (88%), 48 (37%), and 31 (24%) patients, respectively. CMR was not associated with procedural success, post-ablation VT recurrence (p = 1), or the composite primary outcome (p = 0.72). Similarly, recent CCT was not associated with procedural success (p = 0.5), VT recurrence (p = 0.3), or the composite primary outcome (p = 0.31). When adjusted for other variables, EF (p = 0.048), recent echo (p = 0.02), and procedural success (p = 0.013) were associated with the primary outcome, but recent CCT (p = 0.11) and CMR (p = 0.4) were not. These results did not differ significantly in patients with ischemic and non-ischemic cardiomyopathy. Conclusions: In this large tertiary care ablation center, CMR and CCT were utilized in only a fraction of patients prior to VT ablations. In multivariate analysis, CMR or CCT were not associated with improved acute or long-term ablation outcomes.

AbstractBackgroundHow variations predicted by pharmacogenomic testing to alter drug metabolism and therapeutic response affect outcomes for patients with disorders of gut‐ brain interaction is unclear.AimsTo assess the prevalence of pharmacogenomics‐predicted drug‐gene interactions and symptom outcomes for patients with disorders of gut‐brain interaction.MethodsPatients who were treated in our clinical practice for functional dyspepsia/bowel disorder underwent pharmacogenomic testing. The change in symptoms from baseline to 6 months was compared for patients with variations in CYP2D6 and CYP2C19, which metabolize neuromodulators, and SLC6A4, which encodes the sodium‐ dependent serotonin transporter.ResultsAt baseline, 79 of 94 participants (84%) had at least one predicted major drug‐ gene interaction, and all 94 (100%) had at least one predicted moderate interaction. For the 44 participants who completed a survey of their symptoms at 6 months, the mean (SD) irritable bowel syndrome‐symptom severity score decreased from 284 (71) at baseline to 231 (95) at 6 months (p < 0.001). Among patients taking selective serotonin reuptake inhibitors, the decrease in symptom severity (p = 0.03) and pain (p = 0.002) scores from baseline to 6 months was greater for patients with a homozygous SLC6A4 long/long genotype (n = 30) (ie, increased serotonin transporter activity) than for patients with homozygous short/short or heterozygous long/short genotypes (n = 64). Symptom outcomes were not affected by CYP2D6 or CYP2C19 variations.ConclusionsThe homozygous SLC6A4 long/long genotype confers better symptom resolution for patients with disorders of gut‐brain interaction who take selective serotonin reuptake inhibitors than do the homozygous short/short or heterozygous long/short genotypes.