Citations

Background: Periacetabular osteotomy (PAO) is the most common treatment for symptomatic acetabular dysplasia, or developmental dysplasia of the hip (DDH), in skeletally mature patients. The purpose of this multicenter cohort study was to delineate the long-term radiographic natural history of the dysplastic hip following PAO. Methods: We evaluated all patients undergoing PAO from 1996 to 2012 at 3 academic institutions in the United States. Inclusion criteria were PAO for DDH with a minimum 5-year radiographic follow-up. Exclusion criteria were PAO for isolated acetabular retroversion, neurogenic dysplasia, Legg-Calvé-Perthes disease, and prior hip surgery including osteotomies and arthroscopy. There were 288 patients, 83% of whom were women; the mean age and body mass index (BMI) were 29 years and 25 kg/m 2 , respectively. The mean clinical and radiographic follow-up was 9.2 years (range, 5.0 to 21.1 years). Every preoperative and postoperative hip radiograph was assessed to determine the degree of osteoarthritis according to the Tönnis classification. Survivorship was analyzed by multistate modeling, enabling assessment of progression through the Tönnis grades rather than just individual transitions as with Kaplan-Meier techniques. Results: At the time of final follow-up, 144 patients (50%) had progressed at least 1 Tönnis grade, with 42 patients (14.6%) undergoing total hip arthroplasty. The mean number of years spent in each Tönnis grade following PAO was 19 for Tönnis grade 1, 8 for Tönnis grade 2, and 4 for Tönnis grade 3. The probability of progression to total hip arthroplasty increased significantly on the basis of a higher initial Tönnis grade (p < 0.001). The most marked difference occurred between Tönnis grade 0 or 1 and Tönnis grade 2; for Tönnis grade 1, the probability of progression to total hip arthroplasty at 5 and 10 years was 2% and 11%, respectively, compared with 23% and 53%, respectively, for Tönnis grade 2. Conclusions: PAO effectively alters the natural history of DDH. Precise radiographic progression based on the Tönnis grade can now be used to ascribe prognosis for the native hip. Importantly, this investigation demonstrates a stark increase in progression to total hip arthroplasty within 10 years of PAO for patients with preoperative Tönnis grade-2 osteoarthritis compared with those with Tönnis grade-0 or 1 osteoarthritis. Level of Evidence: Therapeutic Level IV . See Instructions for Authors for a complete description of levels of evidence.

Intragastric balloons (IGBs) are the most widely available endoscopic bariatric therapy for class I and II obesity in the United States. Although simple in application and reversible by nature, these devices may help patients initiate the important first steps in weight loss maintenance, provided that parallel efforts are in motion to prevent weight recidivism. Too often, therapeutic nihilism stems from unrealistic expectations of a given therapy. In the case of IGBs, this sentiment may occur when these interventions are applied in a vacuum and not within the purview of a multidisciplinary program that actively involves dieticians, endocrinologists, gastroenterologists, and surgeons. There is a clear and present need to apply different tactics in the remissive strategy to control the obesity pandemic, more so in a struggling landscape of an ever-widening gap in bridging interventions. With such demand, the IGB is an available tool that could be helpful when correctly implemented. In this exposition, we summarize the current state of IGBs available worldwide, discuss their mechanism of action, relay evidence for their short- and long-term efficacy, address safety profile concerns, and suggest procedural considerations in the real-world quotidian application.

Background The overall effectiveness of aspiration therapy (AT) for obesity relies on optimal aspiration timing after a meal, which can vary depending on a patient’s rate of gastric emptying (GE). Our aim was to identify if baseline GE rates were associated with differences in aspiration efficiency (AE). Methods Subjects from an ongoing AT clinical trial were enrolled in this study. AE was calculated as the absolute gastric residual and calories aspirated at 20 and 40 min. Participants were then divided by baseline GE rate into two groups (slow vs fast). Wilcoxon rank-sum test was used to compare AE at 20 and 40 min between the groups. Exploratory linear regression was used to assess relationship between GE and AE. Results 7 patients (85% female) were coenrolled in the study. Mean age and body mass index were 39.8±9.44 and 43±5, respectively. AE did not significantly differ between the 20 and 40 min time points for the group as a whole (34.3% vs 36.9%; p>0.5). However, those with fast GE aspirated more calories than those with slow GE (20 min: 200 kcal vs 72.5 kcal; 40 min: 154 kcal vs 63 kcal) (p=0.05). On linear regression, delayed GE was associated with poorer aspiration (20 min: β=−107 calories; p=0.019; R2=0.7). 4/7 patients had significant differences in residual/caloric aspiration across the two time points. Conclusion Patients undergoing AT may benefit from a GE test to optimise their AE. Paradoxically faster GE times saw better aspiration. Prospective studies are revealing a personalised approach to obesity.

We hypothesize that the prevalence of chronic kidney disease (CKD) among patients with cirrhosis has increased due to the increased prevalence of CKD‐associated comorbidities, such as diabetes. We aimed to assess the characteristics of hospitalized patients with cirrhosis with CKD and its impact on renal and patient outcomes. The North American Consortium for the Study of End‐Stage Liver Disease (NACSELD) prospectively enrolled nonelectively admitted patients with cirrhosis and collected data on demographics, laboratory results, in‐hospital clinical course, and postdischarge 3‐month outcomes. CKD positive (CKD+) patients, defined as having an estimated glomerular filtration rate (eGFR; Modification of Diet in Renal Disease–4 variable formula) of ≤60 mL/minute for >3 months, were compared with chronic kidney disease negative (CKD–) patients for development of organ failures, hospital course, and survival. There were 1099 CKD+ patients (46.8% of 2346 enrolled patients) who had significantly higher serum creatinine (2.21 ± 1.33 versus 0.83 ± 0.21 mg/dL in the CKD– group) on admission, higher prevalence of nonalcoholic steatohepatitis cirrhosis etiology, diabetes, refractory ascites, and hospital admissions in the previous 6 months compared with the CKD– group (all P < 0.001). Propensity matching (n = 922 in each group) by Child‐Pugh scores (9.78 ± 2.05 versus 9.74 ± 2.04, P = 0.70) showed that CKD+ patients had significantly higher rates of superimposed acute kidney injury (AKI; 68% versus 21%; P < 0.001) and eventual need for dialysis (11% versus 2%; P < 0.001) than CKD– patients. CKD+ patients also had more cases of acute‐on‐chronic liver failure as defined by the NACSELD group, which was associated with reduced 30‐ and 90‐day overall survival ( P < 0.001 for both). A 10 mL/minute drop in eGFR was associated with a 13.1% increase in the risk of 30‐day mortality. In conclusion, patients with CKD should be treated as a high‐risk group among hospitalized patients with cirrhosis due to their poor survival, and they should be monitored carefully for the development of superimposed AKI.

Background Steps towards the development of diagnostic criteria are needed for children with the radiologically isolated syndrome to identify children at risk of clinical demyelination. Objectives To evaluate the 2005 and 2016 MAGNIMS magnetic resonance imaging criteria for dissemination in space for multiple sclerosis, both alone and with oligoclonal bands in cerebrospinal fluid added, as predictors of a first clinical event consistent with central nervous system demyelination in children with radiologically isolated syndrome. Methods We analysed an international historical cohort of 61 children with radiologically isolated syndrome (≤18 years), defined using the 2010 magnetic resonance imaging dissemination in space criteria (Ped-RIS) who were followed longitudinally (mean 4.2 ± 4.7 years). All index scans also met the 2017 magnetic resonance imaging dissemination in space criteria. Results Diagnostic indices (95% confidence intervals) for the 2005 dissemination in space criteria, with and without oligoclonal bands, were: sensitivity 66.7% (38.4–88.2%) versus 72.7% (49.8–89.3%); specificity 83.3% (58.6–96.4%) versus 53.9% (37.2–69.9%). For the 2016 MAGNIMS dissemination in space criteria diagnostic indices were: sensitivity 76.5% (50.1–93.2%) versus 100% (84.6–100%); specificity 72.7% (49.8–89.3%) versus 25.6% (13.0–42.1%). Conclusions Oligoclonal bands increased the specificity of magnetic resonance imaging criteria in children with Ped-RIS. Clinicians should consider testing cerebrospinal fluid to improve diagnostic certainty. There is rationale to include cerebrospinal fluid analysis for biomarkers including oligoclonal bands in planned prospective studies to develop optimal diagnostic criteria for radiologically isolated syndrome in children.

Objectives To describe and analyze Twitter activity associated with American Headache Society (AHS) conferences and evaluate the potential for Twitter to promote education and public outreach. Background Many medical and scientific conferences have adopted Twitter as a method of promoting discussion among attendees as well as increasing visibility. Relatively little is known, however, about the composition of conference Twitter activity, the participants, and the impact on broader Twitter discussions. Methods We analyzed Twitter data from 5 AHS conferences held from 2014 to 2016 using their respective hashtags. Using the Symplur Healthcare Hashtags open social media search platform, we gathered data on numbers of tweets, impressions, participants, and mentions during a 10‐day period surrounding each conference, as well as samples of Twitter accounts participating. Prominent accounts were categorized as individual medical professionals, other individuals, host organizations, health‐related organizations, medical centers, and industry by cross‐checking their Twitter profiles and conference registration lists. Larger samples of accounts participating in the 2016 conferences were also obtained and categorized similarly, with individual person accounts classified by conference registration status. A related prominent hashtag (#migraine) was also identified and Twitter usage before, during, and after each conference was analyzed to evaluate the impact of conference activity on broader Twitter conversations. Results Nineteen thousand nine hundred thirty‐six tweets were generated across the 5 conferences, with 11,531 (58%) created by the Top 10 participating accounts in each conference, which were primarily individual medical professionals and host organizations. Thirty‐two million six hundred eighty‐three thousand impressions were generated across the 5 conferences, with 24,656,000 (75%) coming from the Top 10 participants in each, particularly host organizations and other individuals. An average of 331 accounts participated in each conference. The Top 10 mentioned accounts in each conference (consisting of 21 unique accounts with 14 accounts in the Top 10 across multiple conferences, primarily individual medical professionals) received a total of 15,093 mentions. Among 135 unique accounts participating actively in the two 2016 conferences, 39% were individual medical professionals, 38% other individuals, 16% health‐related organizations (including the 2 host organizations), 4% medical centers, and 2% industry. From these samples, 34 of 70 (49%) and 43 of 66 (65%) individual person accounts participating in the Twitter discussion at each conference were not registered conference attendees, indicating substantial outside participation via Twitter. #migraine usage during conferences showed a significant increase from baseline in number of tweets (6080 in a 10‐day period vs 3721, P < .0001) and participants (2332 vs 1830, P < .0001) but the increase was not significant for impressions (30,155 vs 25,361, P = .240). Conclusions Consistent with the dynamics of Twitter conversations on other topics, AHS conference discussions featured a small group of accounts creating the bulk of content, with individual medical professionals and host organizations generating the largest shares of tweets and mentions while host organizations and other individuals produced the most impressions. Participating accounts were mainly individuals and health‐related organizations, with more non‐attendee participants than expected. Conference Twitter activity correlated with a significant increase in #migraine usage, suggesting a perceptible influence on the discussion of health‐related topics beyond the conference itself.

The tyrosine kinase inhibitor sorafenib improves hepatopulmonary syndrome (HPS) in an experimental model. However, the efficacy and adverse effect profile in patients with HPS are unknown. We aimed to determine the effect of sorafenib on the alveolar‐arterial oxygen gradient (AaPO2) at 3 months in patients with HPS. We performed a randomized, double‐blind, placebo‐controlled parallel trial of sorafenib in patients with HPS at 7 centers. A total of 28 patients with HPS were randomized to sorafenib 400 mg by mouth daily or a matching placebo in a 1:1 ratio. We found no statistically significant difference in the median change in AaPO2 from baseline to 12 weeks between the patients allocated to sorafenib (4.5 mm Hg; IQR, –3.8 to 7.0 mm Hg) and those allocated to placebo (–2.4 mm Hg; IQR, –4.8 to 8.2 mm Hg; P = 0.70). There was also no difference between the groups in terms of degree of intrapulmonary shunting by contrast echocardiography. Sorafenib significantly reduced circulating levels of angiogenic markers, including vascular endothelial growth factor receptors (P < 0.01) and TIE2‐expressing M2 monocytes (P = 0.03), but it reduced the mental component scores of the Short Form 36 (P = 0.04), indicating a worse quality of life. In conclusion, sorafenib did not change the AaPO2 or other disease markers at 3 months in patients with HPS. Alternative antiangiogenic therapies or treatments targeting other pathways should be investigated.