Citations

Abstract Objective: To analyze operating room (OR) efficiency by evaluating fixed and variable OR times for open (OPN) and robotic-assisted partial nephrectomies (RAPN).Methods: We analyzed consecutive OPN and RAPN performed by one surgeon over a 24-month period. All patients were placed in the lateral decubitus position and secured with a beanbag regardless of approach. Fixed (nonprocedural) OR times were prospectively collected and defined as: in room to anesthesia release time (IRAT), anesthesia release to cut time (ARCT), and close to wheels out time (CTWO). Variable OR time was procedural cut to close time (CTCT). Comparison of fixed and variable OR time points between OPN and RAPN were performed using the Wilcoxon rank sum test. Results: 146 RAPN and 31 OPN were evaluated from 2019-2020. Median IRAT was similar for RAPN versus OPN [20 min (IQR: 16-25) vs. 20 min (IQR: 16-26), P=0.57]. Median ARCT was longer for RAPN than it was for OPN [40 min (IQR: 36-46) vs. 34 min (IQR: 30-39), P<0.001]. Median CTWO was similar for OPN (12 min, IQR: 9-14) and RAPN (11 min, IQR: 7-15) (P=0.89). Median CTCT was longer for RAPN (202 min, IQR: 170-236) compared to OPN (164 min, IQR: 154-184) (P<0.001).Conclusions: In a single surgeon partial nephrectomy series with the same patient positioning, utilization of robotic technology was associated with longer surgeon operating time as well as less efficient fixed OR times, specifically ARCT.

Abstract Background Population-based studies of Staphylococcus aureus bacteremia (SAB) in the United States are limited. We provide a contemporary evaluation of SAB incidence in Olmsted County, Minnesota, from 2006 to 2020. Methods This was a retrospective population-based study of all adult patients with SAB residing in Olmsted County from 1 January 2006 through 31 December 2020. Initial episodes of SAB were identified using the microbiology laboratory databases at both Olmsted Medical Center and Mayo Clinic Rochester. Results Overall, 541 incident SAB cases were identified with a median age of 66.8 (interquartile range, 54.4–78.5) years, and 60.4% were male. Among these cases, 298 (56.2%) were due to methicillin-susceptible S aureus (MSSA) and 232 (43.8%) cases of methicillin-resistant S aureus (MRSA). The overall age- and sex-adjusted SAB incidence rate (IR) was 33.9 (95% confidence interval [CI], 31.0–36.8) cases/100 000 person-years (PY). Males had a higher age-adjusted IR of 46.0 (95% CI, 41.0–51.0) cases/100 000 PY compared to females (IR, 24.4 [95% CI, 21.1–27.7] cases/100 000 PY). Age- and sex-adjusted SAB IRs due to MSSA and MRSA were 18.7 and 14.6 cases/100 000 PY, respectively, and the percentage of incident SAB cases due to MRSA fluctuated across the study period. There was no apparent temporal trend in SAB incidence over the study period (P = .093). Conclusions Our investigation represents the only contemporary population-based study in the United States. Despite the impression that SAB incidence may have increased based on Centers for Disease Control and Prevention surveillance data, our finding of no change in SAB incidence was somewhat unanticipated.

INTRODUCTION: Limited guidance exists for the postdischarge care of patients with ulcerative colitis hospitalized for moderate-severe flares. METHODS: RAND methodology was used to establish appropriateness of inpatient and postdischarge steroid dosing, discharge criteria, follow-up, and postdischarge biologic or small molecule initiation. A literature review informed on the panel's voting, which occurred anonymously during 2 rounds before and after a moderated virtual session. RESULTS: Methylprednisolone 40–60 mg intravenous every 24 hours or hydrocortisone 100 mg intravenous 3 times daily is appropriate for inpatient management, with methylprednisolone 40 mg being appropriate if intolerant of higher doses. It is appropriate to discharge patients once rectal bleeding has resolved (Mayo subscore 0–1) and/or stool frequency has returned to baseline frequency and form (Mayo subscore 0–1). It is appropriate to discharge patients on 40 mg of prednisone after observing patients for 24 hours in hospital to ensure stability before discharge. For patients being discharged on steroids without in-hospital biologic or small molecule therapy initiation, it is appropriate to start antitumor necrosis factor (TNF) therapy after discharge for anti-TNF-naive patients. For anti-TNF-exposed patients, it is appropriate to start vedolizumab or ustekinumab for all patients and tofacitinib for those with a low risk of adverse events. It is appropriate to follow up patients clinically within 2 weeks and with lower endoscopy within 4–6 months after discharge. DISCUSSION: We provide recommendations on the inpatient and postdischarge management of patients with ulcerative colitis hospitalized for moderate-severe flares.

SIGNIFICANCE A rigorously designed and calibrated symptom questionnaire for childhood intermittent exotropia would be useful for clinical care and for research. PURPOSE The aim of this study was to Rasch‐calibrate and evaluate the previously developed Child Intermittent Exotropia Symptom Questionnaire using data gathered as part of a randomized clinical trial. METHODS The questionnaire was administered to 386 children aged 3 to 10 years with intermittent exotropia who were enrolled in a randomized clinical trial comparing overminus with nonoverminus spectacles. Participants were followed at 6 and 12 months while on treatment and at 18 months off treatment. Factor analysis determined dimensionality, and Rasch analysis evaluated questionnaire performance. Logit values were converted to 0 (best) to 100 (worst). We evaluated differences in questionnaire scores between treatment groups and time points, and correlations with control scores. RESULTS The Child Intermittent Exotropia Symptom Questionnaire was unidimensional. Rasch analysis indicated that there was no notable local dependence and no significant differential item functioning for sex or age. There was suboptimal targeting (mean logit, −1.62), and person separation was somewhat poor (0.95). There were no significant differences in the Child Intermittent Exotropia Symptom score between overminus spectacles and nonoverminus spectacles at 6, 12, and 18 months. Combining data from both treatment groups, there was significant improvement from baseline at all follow‐up visits (e.g., mean change from baseline to 12 months, −6.6 points; 95% confidence interval, −8.6 to −4.6). Child Intermittent Exotropia Symptom scores were not correlated with distance or near control scores at 12 months. CONCLUSIONS The seven‐item Rasch‐scored Child Intermittent Exotropia Symptom Questionnaire is limited by suboptimal performance. Future study is needed to determine whether it may be useful for clinical practice and for research.

Lay Summary Biosimilar medications have the potential to significantly reduce the cost of treatment in patients with inflammatory bowel disease. Observational studies have shown similar efficacy and safety of biosimilars to biologic reference products. Shared decision-making is crucial to the successful implementation of these agents.

AbstractLeukocyte adhesion deficiency type II (LAD II, also known as SLC35C1‐congenital disorder of glycosylation) is an autosomal recessive disorder characterized by growth and cognitive impairment, peripheral neutrophilia, recurrent infections, and the Bombay blood phenotype. A subset of patients with a milder presentation has been described with short stature and developmental delay but minimal immune and hematologic features. Some patients with LAD II benefit from oral fucose therapy, though this has not been previously studied in patients with milder disease. In this study, we describe two new patients from separate families with the milder variant of LAD II and review the published literature on this rare disorder. We demonstrate improvement in speech and cognition, CD15 expression, and core fucosylation of serum glycoproteins after 27 months of oral fucose supplementation in one patient. These patients further support the stratification of this disorder into distinct subtypes, a classical severe and an attenuated variant, and provide preliminary evidence of benefit of fucose therapy in the latter group.

Abstract Donation after circulatory death (DCD) liver transplantation (LT) outcomes have been attributed to multiple variables, including procurement surgeon recovery techniques. Outcomes of 196 DCD LTs at Mayo Clinic Arizona were analyzed based on graft recovery by a surgeon from our center (transplant procurement team [TPT]) versus a local procurement surgeon (non‐TPT [NTPT]). A standard recovery technique was used for all TPT livers. The recovery technique used by the NTPT was left to the discretion of that surgeon. A total of 129 (65.8%) grafts were recovered by our TPT, 67 (34.2%) by the NTPT. Recipient age (p = 0.43), Model for End‐Stage Liver Disease score (median 17 vs. 18; p = 0.22), and donor warm ischemia time (median 21.0 vs. 21.5; p = 0.86) were similar between the TPT and NTPT groups. NTPT livers had longer cold ischemia times (6.5 vs. 5.0 median hours; p < 0.001). Early allograft dysfunction (80.6% vs. 76.1%; p = 0.42) and primary nonfunction (0.8% vs. 0.0%; p = 0.47) were similar. Ischemic cholangiopathy (IC) treated with endoscopy occurred in 18.6% and 11.9% of TPT and NTPT grafts (p = 0.23). At last follow‐up, approximately half of those requiring endoscopy were undergoing a stent‐free trial (58.3% TPT; 50.0% NTPT; p = 0.68). IC requiring re‐LT in the first year occurred in 0.8% (n = 1) of TPT and 3.0% (n = 2) of NTPT grafts (p = 0.23). There were no differences in patient (hazard ratio [HR], 1.95; 95% confidence interval [CI], 0.76–5.03; p = 0.23) or graft (HR, 1.99; 95% CI, 0.98–4.09; p = 0.10) survival rates. Graft survival at 1 year was 91.5% for TPT grafts and 95.5% for NTPT grafts. Excellent outcomes can be achieved using NTPT for the recovery of DCD livers. There may be an opportunity to expand the use of DCD livers in the United States by increasing the use of NTPT.

Objective: We previously derived the Unruptured Intracranial Aneurysm Treatment Score (UIATS), designed using a multidisciplinary consensus approach among neurovascular specialists from diverse geographic and practice backgrounds. Here, we report on the development and validation of the final version of UIATS. Method: An international, multidisciplinary (neurosurgery, neuroradiology, neurology, clinical epidemiology) group of 69 (39 panel members and 30 blinded external reviewers) specialists in the research and treatment of UIAs was convened. A web survey-based Delphi consensus process consisting of 7 rounds was utilized to rate numerous features of potential relevance in the assessment and treatment of UIAs and to develop the UIATS. Mean ratings were repeatedly used to determine statistical weight for each factor and then transformed into corresponding scores for every item to create the UIATS. For internal and blinded external validation, 30 representative cases of patients with UIAs were used to test the level of agreement (5 point Likert Scale) with treatment recommendations based on the UIATS. Results: The final UIATS system was designed in three domains (patient-, aneurysm - and treatment-related), comprising 13 different categories and 29 different features (Figure 1). Mean agreement based on Likert scores (5 indicating strong agreement and 1 indicating strong disagreement) was 4·2 for both reviewer cohorts, whereas mean agreement per case was 4·2 (panel members) and 4·5 (external reviewers) (p=0·017, Mann-Whitney-U Test). Conclusion: The final version of UIATS system was internally and externally validated by a large multidisciplinary group of neurovascular specialists, which suggests that the UIATS reflects contemporary decision-making regarding management of a patient with an UIA. The UIATS may aid clinicians in deciding on the appropriate management for an UIA.

Background and Objective Hyperdense middle cerebral artery (HDMCA) sign is an early sign seen on CT head after acute ischemic stroke indicating acute arterial thrombosis. We aimed to measure HDMCA sign objectively. Methods We conducted a retrospective analysis of prospectively collected data from 151 cases of acute ischemic stroke eligible for IV rt-PA by time criteria, admitted to Mayo Clinic from March, 2002 through June, 2011. Admission CT Head was studied to identify HDMCA sign. All patients had either 24 hour CT head or MRI head to confirm the stroke in the same vessel territory. MCA was measured in Hounsfield units and was compared to the contralateral MCA. Receiver Operating Characteristic (ROC) curve analysis was performed to calculate sensitivity and specificity. Results Mean admission NIHSS score was 11±7. HDMCA sign was seen in 93 (62%) patients. ROC curve analysis for ipsilateral MCA Hounsfield units had an area under the curve 0.88 (p<0.001, CI 0.83-0.94) which showed 50 HU or more had 48% sensitivity and 98% specificity. Ratio of ipsilateral to contralateral MCA HU had an area under the curve 0.94 (p<0.001, CI 0.90-0.98) which showed ratio of 1.23 had 67% sensitivity and 98% specificity. A combination of either ipsilateral HU more than equal to 50 or a ratio of ipsilateral to contralateral MCA HU more than equal to 1.23 had 77% sensitivity, 95% specificity, 96% positive predictive value and 72% negative predictive value. Conclusion A combination of ipsilateral HU more than equal to 50 or a ratio of ipsilateral to contralateral MCA HU more than equal to 1.23 can objectively identify HDMCA sign with good sensitivity and high specificity.

Background and Objective Hyperdense MCA (HDMCA) sign is an early sign seen on CT head after acute ischemic stroke indicating acute arterial thrombosis. It has been reported as a predictor of stroke morbidity and mortality. The relationship of size of hyperdense middle cerebral artery (MCA) sign with stroke volume and functional outcome has not been sufficiently studied. Methods We did a retrospective analysis of prospectively collected data from 206 cases of acute ischemic stroke eligible for IV rt-PA by time criteria, admitted to Mayo Clinic from March, 2002 through June, 2011. Admission CT Head was studied to identify HDMCA sign which was further subcategorized according to size. CT head at 24 hours after intravenous tissue plasminogen activator was used to calculate Alberta Stroke Program Early CT Score (ASPECTS) to measure ischemic damage area. Functional outcome was assessed using the modified Rankin score at 3 months and dichotomized into less than equal to 2 (good outcome) and more than 2 (bad outcome). Univariate analysis including t-test, Chi-square, and Fisher Exact test was used when appropriate. Results Mean admission NIHSS score was 11±7. HDMCA sign was seen in 99 (48%) patients: 100% MCA occlusion (7) 76-100% M1 (17), 50-75% M1 (17), less than 50% M1 (6), MCA dot sign (23), sylvian dot sign (21) and sylvian MCA sign, defined as any sylvian MCA occlusion bigger than a dot (8). Univariate analysis showed statistically significant associations between our HDMCA classification and ASPECTS at 24 hours (p<0.001) and modified Rankin score at 3 months (p<0.001). Smaller infarctions (ASPECTS >8) were observed more often with lower MCA clot burden; MCA dot (48%), less than 50% MCA (80%), sylvian dot (57%) and sylvian MCA (38%), 50-75% M1 (6%), 75-100% M1 (0%) and 100% MCA (0%). Good outcome (mRS≤2 at 3 months) was seen more often with lower MCA clot burden; MCA dot (52%), less than 50% MCA (67%), sylvian dot (67%) and sylvian MCA (63%). Conversely, larger HDMCA size was associated with poor outcome (mRS>2); 50-75% M1 (100%), 75-100% (88%) and 100% MCA (100%). Conclusion The size of the HDMCA sign size is an important predictor of ischemic stroke mortality and morbidity. HDMCA should be measured upon admission as it may help refine prognostication and identify patients who could benefit from endovascular rescue therapy after intravenous thrombolysis.