Citations

Abstract Background Patients with inflammatory bowel disease (IBD) often experience symptoms refractory to available treatments, prompting the use of alternative therapies like cannabis. Previous studies have shown cannabis users require higher levels of sedation for procedures. The anti-inflammatory effects of cannabis have been studied with mixed conclusions. We aimed to investigate if patients with IBD who reported cannabis use required more resources for endoscopic procedures and were more likely to have endoscopic inflammation. Methods This is a retrospective case–control study of adult patients with IBD between November 2018 and November 2022 at a tertiary academic medical center undergoing endoscopic evaluation of acute complaints related to IBD. Cases were matched for age, sex, and body mass index. Results There were 124 patients with IBD with 62 patients reporting cannabis use and 62 patients without reported cannabis use. There was a significant difference in endoscopy duration (P < .001) and endoscopic inflammation (P = .044) between groups. There was no significant difference in recovery room length of stay (P = .15), IBD treatment during time of endoscopy (P = .84), stricture (P = .53), propofol dose administered when adjusted for procedure duration (P = .082), or endoscopic duration between cannabis users with and without endoscopic inflammation (P = .194). Conclusions IBD cannabis users had longer endoscopic durations and were more likely to exhibit inflammation on endoscopic evaluation compared to cannabis non-users. Our study underscores the importance of medication reconciliation for more accurate resource allocation. Additionally, federal expansion of cannabis research is needed for randomized control trials to fulfill the presently unmet need for data on patient outcomes.

Importance SARS-CoV-2 infection has been linked to neurotoxic effects and cognitive deficits. Objective To determine whether decreases in cognitive function were accelerated after SARS-CoV-2 infection compared with individuals not infected. Design, Setting, and Participants Multicenter, prospective cohort study from 2016 to 2022 among 3525 participants alive on March 1, 2020, and enrolled in The Atherosclerosis Risk in Communities (ARIC) study and the Collaborative Cohort of Cohorts for COVID-19 Research study who completed a prepandemic cognitive assessment and a pandemic-era assessment of SARS-CoV-2 infection. Final analyses performed in November 2024. Exposure SARS-CoV-2 infection determined via self-report of a positive SARS-CoV-2 test or health care professional diagnosis of COVID-19, a positive SARS-CoV-2 antinucleocapsid antibody response, or presence of an administrative code for COVID-19 on medical records. Main outcomes and measures A neuropsychological battery assessed multiple cognitive domains, and a cocalibrated confirmatory factor analysis generated factor scores for global cognitive function. The primary outcome was the rate of excess change in cognitive function. Results The 3525 eligible participants had a mean (SD) age of 80.8 (4.7) years, 2085 (59.1%) were female, 752 (21.4%) were Black, and 2773 (78.6%) were White. SARS-CoV-2 infection was detected among 307 participants (8.7%), 103 of whom (33.6%) were hospitalized. Among uninfected participants, the mean annualized change in cognitive function was −0.09 (95% CI, −0.13 to −0.04). Compared with this rate, change was faster (β = −0.06; 95% CI, −0.09 to −0.02) among participants hospitalized for infection, but not different from participants who were infected but not hospitalized (β = 0.00; 95% CI, −0.02 to 0.03). The association among participants hospitalized for infection was evident in the cognitive domains of memory and executive function, but not language. Conclusions and relevance This cohort study of older participants found accelerated decreases in cognition among individuals hospitalized for SARS-CoV-2 infection, but not nonhospitalized infection, in comparison with individuals not yet infected.

Abstract Background Pneumocystis jirovecii pneumonia (PCP) is increasingly seen in patients who are non-HIV immunocompromised hosts, yet modern risk factors and outcomes are poorly recognized and defined. Methods A retrospective review was conducted of adult patients who met criteria for proven or probable PCP from 2017 to 2024 across a large academic multicenter health system. The primary outcome was mortality among cohorts, defined by etiology of immunosuppression through univariate and age-adjusted logistic regression. Secondary analyses included trends in annual diagnoses and testing patterns. Results A total of 701 patients met criteria for inclusion, representing one of the largest clinically characterized cohorts of PCP to date. The median age was 65 years (IQR, 54–73) and 62% were male. The most common risk groups were hematologic malignancy (32.2%), solid tumor cancers receiving chemotherapy (22.4%), and autoimmune disease with immunosuppression (17.7%). Annual PCP diagnoses increased at a rate of 15.8% (95% CI, 8.9%–23.2%) in parallel with increased testing. Only 5.4% of patients were receiving prophylaxis at the time of diagnosis. Overall mortality was 20% (95% CI, 17%–23%) and highest in cirrhosis (adjusted odds ratio, 6.24; 95% CI, 2.84–13.69; P < .001). Conclusions PCP in the current era affects a broad range of patients who are immunocompromised, with high associated mortality and low rates of prophylaxis. Patients with solid tumors and those with cirrhosis are at particularly high risk of mortality. These findings highlight the need to reassess and redefine PCP prophylaxis guidelines in specific populations and our understanding of who is at risk.

Abstract Aims While intentional weight loss achieved through cardiometabolic medications has been associated with robust salutary effects in heart failure (HF) with preserved ejection fraction (HFpEF), the clinical significance of unintentional weight loss in this setting remains unclear. Methods and results This retrospective cohort study included 434 overweight or obese patients with invasively proven HFpEF (67 ± 11 years, 236 female), without weight-reducing therapies or known malignancy, who underwent invasive hemodynamic cardiopulmonary testing and long-term clinical follow-up. The annualized weight change from index to final evaluation for the tertiles was: −21.1 to −1.8 kg/year (tertile 1); −1.8 to 0 kg/year (tertile 2); and 0 to +17.0 kg/year (tertile 3). Patients in tertile 1 had subtle abnormalities in ventilatory control at baseline, but there were no other significant differences between groups across a vast array of haemodynamic and metabolic parameters, both at rest and during exercise. Baseline weight was directly correlated with right and left heart filling pressures (r = 0.23–0.34, p < 0.001), but annualized weight change showed no correlation with any baseline haemodynamic measurements (all p > 0.05). Over a median follow-up of 4.7 years (interquartile range 2.3–6.5), patients in tertile 1 had higher risk of all-cause death (hazard ratio [HR] 3.36, 95% confidence interval [CI] 1.77–6.39, p < 0.001), all-cause death or HF hospitalization (HR 2.49, 95% CI 1.53–4.04, p < 0.001) and cardiac death or HF hospitalization (HR 2.28, 95% CI 1.28–4.07, p = 0.005) compared with those in tertile 2 or 3. These findings were consistent after multivariable adjustment. Conclusions Unintentional weight loss is associated with worse prognosis in patients with HFpEF and overweight or obesity, even as haemodynamics, exercise capacity, and gas exchange are not different from patients with stable or increasing weight. These data underline important and fundamental differences between therapeutic and unintended weight loss in HFpEF.

ABSTRACT Background This medical center migrated from alcohol to sotradecol foam sclerotherapy (SFS) because of perceived improved efficacy in managing symptomatic kidney and liver cysts. We report technical aspects, change in short- and long-term cyst volumes, patient-reported outcomes, safety and applications of the technique. Methods In this retrospective observational study, cases from January 2017 to December 2021 had TKCV/TLCV (per Targeted Kidney or Liver or Cyst analysis) segmented using a deep-learning algorithm and cyst segmentation software (pre-, post-procedure and longitudinally). TKCV/TLCV % change were evaluated using the one-sample Wilcoxon signed rank test. For analyses involving changes in cyst volumes, the median % change in cyst volume per patient was assessed. Longitudinal changes in cyst volumes were assessed using linear mixed models. Changes in quality of life (QOL) [Linear Analog Self-Assessment (LASA), Polycystic Liver Disease Quality of life Questionnaire (PLD-Q) and 12-item short-form (SF12)] were also assessed. Results There were 102 SFS sessions (38 kidney, 58 liver, 6 combined liver/kidney cysts) performed on 77 unique individuals included for analysis. Median [interquartile range (IQR)] % reductions in TKCV were –92.0% (IQR –98.2%, –82.7%, P < .001) and for TLCV were –83.1% (IQR –93.5%, –52.9%, P < .001). Among patients with multiple kidney procedures (n = 7), median % reduction in TKCV was –94.3% (IQR –96.6%, –92.4%, P = .023). For patients with multiple liver procedures (n = 11), median % reduction in TLCV was –63.3% (IQR –85.2%, –28.3%, P = .004). Results were similar among the four patients undergoing multi-stage procedures (n = 1 kidney, n = 3 liver). When measured longitudinally, both liver and kidney cyst volumes declined to levels near 0 mL by 1 year follow-up and remained stable several years later. LASA physical domain and PLD-Q QOL scores improved post-SFS procedure. Conclusion SFS led to substantial long-term reductions in TKCV/TLCV and improved QOL. SFS can augment cyst volume reduction in addition to tolvaptan (kidney cysts) and octreotide (liver cysts). In some individuals with large symptomatic cysts, multiple SFS procedures were safe and effective in reducing TLCV/TKCV and improving symptoms.

ABSTRACT Purpose The natural history of biochemical recurrence (BCR) after radical prostatectomy (RP) remains understudied, with limited long‐term data from large cohorts inclusive of both salvage radiotherapy (SRT)‐treated and untreated patients. Herein, we sought to evaluate the outcomes of patients with BCR and the impact of SRT on disease progression. Materials and Methods Patients undergoing RP who developed BCR (PSA ≥ 0.20 ng/mL) were included. Patients with BCR treated with SRT were compared to untreated patients using risk‐set matching with time‐dependent propensity scores. The primary outcome was metastases, analyzed using Kaplan–Meier and Cox models. The number needed to treat (NNT) with SRT to prevent progression was derived at 5 and 15 years. Results Among 6881 patients with BCR, 2109 received SRT. At a median follow‐up of 10.2 years, 1147 patients developed metastases. The median PSA at the time of SRT was 0.50 ng/mL. After 1:1 propensity score matching (2109 patients per cohort), SRT significantly reduced the risk of metastases at 5 (12.7% vs. 19.3%, p < 0.0001) and 15 years (28.6% vs. 31.5%, p < 0.001). On multivariable analysis, SRT independently reduced metastasis risk (HR 0.75, 95% CI 0.63–0.90, p = 0.002), translating to NNT of 23 and 15 at 5 and 15 years, respectively. Interaction analyses between SRT and nodal status ( p = 0.04) showed greater metastasis risk reduction in pN+ (HR 0.41, 95% CI 0.22–0.77, p = 0.005) compared to pN− disease (HR 0.81, 95% CI 0.67–0.97, p = 0.02). Conclusions Most patients with BCR post‐RP do not progress to metastasis. For those who do progress, SRT inarguably improves the oncologic outcomes in the BCR setting. However, careful patient selection and shared decision making should be encouraged in order to limit overtreatment and side effects.

The translation of AI-generated brain metastases (BM) segmentation into clinical practice relies heavily on diverse, high-quality annotated medical imaging datasets. The BraTS-METS 2023 challenge has gained momentum for testing and benchmarking algorithms using rigorously annotated internationally compiled real-world datasets. This study presents the results of the segmentation challenge and characterizes the challenging cases that impacted the performance of the winning algorithms. Untreated brain metastases on standard anatomic MRI sequences (T1, T2, FLAIR, T1PG) from eight contributed international datasets were annotated in stepwise method: published UNET algorithms, student, neuroradiologist, final approver neuroradiologist. Segmentations were ranked based on lesion-wise Dice and Hausdorff distance (HD95) scores. False positives (FP) and false negatives (FN) were rigorously penalized, receiving a score of 0 for Dice and a fixed penalty of 374 for HD95. The mean scores for the teams were calculated. Eight datasets comprising 1303 studies were annotated, with 402 studies (3076 lesions) released on Synapse as publicly available datasets to challenge competitors. Additionally, 31 studies (139 lesions) were held out for validation, and 59 studies (218 lesions) were used for testing. Segmentation accuracy was measured as rank across subjects, with the winning team achieving a LesionWise mean score of 7.9. The Dice score for the winning team was 0.65 ± 0.25. Common errors among the leading teams included false negatives for small lesions and misregistration of masks in space. The Dice scores and lesion detection rates of all algorithms diminished with decreasing tumor size, particularly for tumors smaller than 100 mm3. In conclusion, algorithms for BM segmentation require further refinement to balance high sensitivity in lesion detection with the minimization of false positives and negatives. The BraTS-METS 2023 challenge successfully curated well- annotated, diverse datasets and identified common errors, facilitating the translation of BM segmentation across varied environments and providing the tools for future development of personalized volumetric reports to patients undergoing BM treatment.

Background The Midclavicle Block achieves balanced methylene blue spread across both anterosuperior and posteroinferior periosteal surfaces in cadavers with intact clavicles. Objective To evaluate the anatomical distribution pattern of the Midclavicle Block in cadaveric specimens with midshaft clavicle fractures, with a focus on periosteal coverage and involvement of the fracture site. Methods An anatomical study was conducted on 10 cadavers (20 clavicular regions). A midshaft clavicle fracture model was created, and the Midclavicle Block technique was applied under ultrasound guidance. A methylene blue solution was injected, and dissections were performed to evaluate dye spread primarily in the deep muscular and the clavicular plane, including the fracture site. Probabilistic maps of dye distribution were generated. Results The anatomical dissection in the deep muscular plane revealed consistent staining of the fracture site in all specimens, along with the subclavius muscle and the clavipectoral fascia, while the pectoralis minor muscle remained unaffected in every case. As the dissection progressed toward the infraclavicular brachial plexus plane, no staining of the plexus was observed, with dye spread restricted to the subclavius muscle and adjacent clavipectoral fascia. The mean staining of the anterosuperior and posteroinferior periosteal surfaces was 55.5% (95% CI: 50.6% to 60.4%) and 53.8% (95% CI: 49.5% to 58.1%), respectively. The highest dye concentration was observed in the middle third of the clavicle, corresponding to the fracture zone. Conclusion The Midclavicle Block resulted in effective periosteal coverage and targeted fracture site staining. Clinical studies are needed to confirm its in vivo efficacy, given the limitations inherent to cadaveric specimens.

Background: Autonomic dysfunction is common after spinal cord injury (SCI). There are currently limited tools to comprehensively characterize its deficits. While individual established autonomic tests have a long history and sound scientific background, translating these autonomic testing results to inform clinical understanding is a major barrier. Objectives: To assess a strategic battery of autonomic tests to characterize and act as a biomarker of autonomic regulation for individuals with SCI and to develop a novel graphical representation of these data to facilitate understanding of autonomic dysfunction after SCI. Methods: We outline a battery of six laboratory autonomic tests that were curated to collectively describe the ability of individuals with SCI to inhibit and recruit sympathetic activity through the injured spinal cord. Heart rate/blood pressure variability, bolus phenylephrine, hand and foot cold pressor, Valsalva maneuver, and bladder pressor are herein described. Incorporating normative control data for 30 uninjured individuals completing this testing battery, we further demonstrate the utility of a composite biomarker, comparing these control results to 11 individuals with SCI. Results: Results demonstrate strong normality of data with testing psychometrics, suggesting stable reproducibility with repeat testing. Even in this preliminary sample of individuals with SCI, clear differences begin to emerge compared to uninjured norms. This illustrates the ability of this collective testing battery to characterize autonomic regulation after SCI. To aid in clinical translation, we further present a graphical representation, an autonomic phenotype , which serves as a snapshot of how normal or abnormal sympathetic inhibition and recruitment of activation may be after SCI. Conclusion: Utilizing these autonomic phenotypes, three example cases of individuals with SCI highlight evidence of varied degrees of autonomically complete SCI. Together, this represents a key advancement in our understanding of autonomic function after SCI.