Citations

INTRODUCTION: Hepatitis B virus (HBV) vaccination is recommended in patients with inflammatory bowel disease (IBD). Although the 2-dose Heplisav-B vaccine has proven effective, more than 20% of patients with IBD do not seroconvert. We prospectively evaluated the effectiveness of a third Heplisav-B dose in patients with IBD lacking HBV immunity despite 2-dose vaccination. METHODS: Adults with IBD who had received 2-dose Heplisav-B vaccination between 2018 and 2023 were identified. Seroconversion was defined as hepatitis B surface antibody (HBsAb) ≥ 10 IU/L measured at ≥4 weeks after vaccination. Patients who did not seroconvert were prospectively offered a third Heplisav-B dose, followed by repeat HBsAb measurement. Demographic, clinical, medication, and vaccination data were compared between those who did and did not seroconvert. RESULTS: Of 192 patients identified, 71.9% (138/192) seroconverted after 2-dose Heplisav-B vaccination. The 54 patients (28.1%) who did not seroconvert were more likely to be male, have diabetes, chronic kidney disease, or elevated Charlson Comorbidity Index. Of the 54 patients, 30 (55.6%) elected to receive a third Heplisav-B dose, with 56.7% (17/30) achieving seroconversion (median HBsAb titer 376 IU/L, IQR 47–1,000 IU/L) despite a median intervaccination time of 416 days (IQR 90.8–667.8). No differences were noted between patients who did vs did not seroconvert after third-dose vaccination. DISCUSSION: In patients with IBD lacking HBV immunity despite 2-dose Heplisav-B vaccination, administration of a third dose resulted in a 56.7% seroconversion rate. Our results suggest that administration of an additional Heplisav-B dose may be an effective strategy in patients lacking immunity despite primary 2-dose vaccination.

Introduction: Differential diagnoses of a pediatric neck mass are extensive, ranging across benign, malignant, congenital and infectious causes. Limited access to imaging in low-resource settings increases the complexity of narrowing this list to appropriately diagnose and treat neck masses. This occasionally allows neck masses to grow unchecked, increasing the morbidity of their presence and eventual excision. The goal of this report is to describe nuances in the diagnosis and treatment of pediatric neck masses in resource-limited settings through a case report of a neck mass in a pediatric patient. Patient presentation: A 10-year-old girl in Harare, Zimbabwe, presented for surgical management of a midline neck mass that appeared 4 years prior to presentation for definitive treatment. A myriad of barriers delayed her care, allowing the mass to grow into her floor of mouth, displacing her tongue and leading to speech and feeding difficulties. Management and outcome: At presentation to the tertiary care facility, she received a pre-operative ultrasound showing a well-circumscribed, echogenic mass. Her neck mass was surgically excised through a transoral approach. Permanent pathology was consistent with a dermoid cyst. Conclusion: At 1-month postoperative follow-up, the patient had experienced no complications and had a complete resolution of her functional symptoms and appearance. Contribution: We present a case that can illuminate the utility of ultrasound in the diagnosis of pediatric neck masses. Additionally, we facilitate an important discussion on transoral versus transcervical approach for midline neck masses with the decision hinging on size, location, surgeon preference and comfort and consideration of cosmesis.

OBJECTIVE This study was conducted to investigate the impact of antiplatelet administration in the periprocedural period on the occurrence of thromboembolic complications (TECs) in patients undergoing treatment using the Woven EndoBridge (WEB) device for intracranial wide-necked bifurcation aneurysms. The primary objective was to assess whether the use of antiplatelets in the pre- and postprocedural phases reduces the likelihood of developing TECs, considering various covariates. METHODS A retrospective multicenter observational study was conducted within the WorldWideWEB Consortium and comprised 38 academic centers with endovascular treatment capabilities. Univariable and multivariable logistic regression analyses were performed to determine the association between antiplatelet use and TECs, adjusting for covariates. Missing predictor data were addressed using multiple imputation. RESULTS The study comprised two cohorts: one addressing general thromboembolic events and consisting of 1412 patients, among whom 103 experienced TECs, and another focusing on symptomatic thromboembolic events and comprising 1395 patients, of whom 50 experienced symptomatic TECs. Preprocedural antiplatelet use was associated with a reduced likelihood of overall TECs (OR 0.32, 95% CI 0.19–0.53, p < 0.001) and symptomatic TECs (OR 0.49, 95% CI 0.25–0.95, p = 0.036), whereas postprocedural antiplatelet use showed no significant association with TECs. The study also revealed additional predictors of TECs, including stent use (overall: OR 4.96, 95% CI 2.38–10.3, p < 0.001; symptomatic: OR 3.24, 95% CI 1.26–8.36, p = 0.015), WEB single-layer sphere (SLS) type (overall: OR 0.18, 95% CI 0.04–0.74, p = 0.017), and posterior circulation aneurysm location (symptomatic: OR 18.43, 95% CI 1.48–230, p = 0.024). CONCLUSIONS The findings of this study suggest that the preprocedural administration of antiplatelets is associated with a reduced likelihood of TECs in patients undergoing treatment with the WEB device for wide-necked bifurcation aneurysms. However, postprocedural antiplatelet use did not show a significant impact on TEC occurrence.

PURPOSE Immune checkpoint inhibitors (ICIs) have revolutionized cancer treatment, yet their use is associated with immune-related adverse events (irAEs). Estimating the prevalence and patient impact of these irAEs in the real-world data setting is critical for characterizing the benefit/risk profile of ICI therapies beyond the clinical trial population. Diagnosis codes, such as International Classification of Diseases codes, do not comprehensively illustrate a patient's care journey and offer no insight into drug-irAE causality. This study aims to capture the relationship between ICIs and irAEs more accurately by using augmented curation (AC), a natural language processing–based innovation, on unstructured data in electronic health records. METHODS In a cohort of 9,290 patients treated with ICIs at Mayo Clinic from 2005 to 2021, we compared the prevalence of irAEs using diagnosis codes and AC models, which classify drug-irAE pairs in clinical notes with implied textual causality. Four illustrative irAEs with high patient impact—myocarditis, encephalitis, pneumonitis, and severe cutaneous adverse reactions, abbreviated as MEPS—were analyzed using corticosteroid administration and ICI discontinuation as proxies of severity. RESULTS For MEPS, only 70% (n = 118) of patients found by AC were also identified by diagnosis codes. Using AC models, patients with MEPS received corticosteroids for their respective irAE 82% of the time and permanently discontinued the ICI because of the irAE 35.9% (n = 115) of the time. CONCLUSION Overall, AC models enabled more accurate identification and assessment of patient impact of ICI-induced irAEs not found using diagnosis codes, demonstrating a novel and more efficient strategy to assess real-world clinical outcomes in patients treated with ICIs.

BACKGROUND AND OBJECTIVES: Predicting functional outcomes after surgical management of ruptured aneurysms is essential. This study sought to validate the modified Southwestern Aneurysm Severity Index (mSASI), which predicts functional outcomes 1 year after treatment. METHODS: The surgical arm of a randomized controlled trial, the Barrow Ruptured Aneurysm Trial, was used to validate the mSASI model. mSASI scores incorporating the Hunt and Hess scale, Non-Neurological American Society of Anesthesiologists Physical Classification Status, imaging findings, and other modifiers were assigned and evaluated against the Glasgow Outcome Scale (GOS) score at 1 year. The model's performance was assessed for discrimination and calibration. Similar evaluations were constructed using the modified Rankin Scale (mRS) as the 1-year functional outcome measurement. Long-term outcomes (3, 6, 10 years) were also evaluated. RESULTS: Of 280 clinical trial patients treated surgically, 242 met the inclusion criteria. The mean age was 54.1 ± 12.9 years; 31% were men. Favorable GOS score (4-5) and mRS score (0-2) at 1 year were observed in 73.6% and 66.1% of patients, respectively. The mSASI model predicted unfavorable GOS score at 1 year with fair to good discrimination (area under the curve = 0.75, 95% CI = 0.68-0.82) and accurate calibration (R 2 = 0.98). Similar results were obtained when mRS was used as the outcome measure (area under the curve = 0.75, 95% CI = 0.68-0.82; R 2 = 0.95). CONCLUSION: The mSASI model was externally validated in our cohort to predict functional outcomes using the GOS or mRS scores 1 year after surgery. This index may be used for prognosticating outcomes of patients undergoing surgery for ruptured aneurysms at short-term and long-term intervals.

Abstract Background: The three delays model, identifies three key stages to delays in care that can contribute to adverse outcomes: decision-making to seek care, accessing healthcare facilities, and receiving appropriate medical care. However, the application of this model in otolaryngology-head and neck surgery (OHNS) and in a human conflict environment has not been examined. This study aims to explore the impact of each delay type within the OHNS population in post-war Mekelle, Ethiopia. By investigating these delays, the study seeks to uncover strategies for reducing delays and improving outcomes in the management of OHNS pathology for this and similar environments. Methods: This study was conducted during a 3-week short term OHNS surgical trip in Mekele, Ethiopia, following a 2 year war. A total of 105 patients attending the OHNS clinic were identified and given verbal interviews and semi-structured questionnaires. The three delays model was applied to analyze the data collected, focusing on the following aspects: 1) decision to seek care, 2) reaching care, and 3) receiving care. Results: A total of 105 patients were included in the analysis, with 100% (105/105) experiencing type 1 delays (decision to seek care), 75% experiencing type 2 delays (75/105) and an additional 77% (77/105) facing type 3 delays (receiving appropriate care after reaching health care facility). More than half of the patients encountered delays in all three types. Various factors contributed to type 3 delays, including multiple delays at the time of admission, drug shortages, non-availability of skilled staff, and incompetence. Cost of transportation emerged as the primary factor contributing to type 2 delays. Conclusion: The findings provide valuable insights into the specific delays experienced by patients seeking OHNS services in a post-war setting and inform potential strategies for improving healthcare delivery in similar contexts.

Introduction: Studies have demonstrated an association between hyperkalemia and increased mortality in patients with myocardial infarction, but limited data exist regarding hyperkalemia and associated death among unselected cardiac intensive care unit (CICU) patients. Hypothesis: Hyperkalemia is associated with mortality in CICU patients. Methods: Historical cohort of 9,681 CICU patients admitted from January 2007 to December 2015 with serum potassium measured on admission. Hyperkalemia was defined as admission potassium >=5.0 mEq/L, normokalemia as admission potassium 3.5-4.9 mEq/L, and hypokalemia as admission potassium <3.5 mEq/L. Multivariate logistic regression was used to determine predictors of hospital mortality. Post-discharge survival was assessed using Kaplan-Meier analysis and Cox proportional hazards models. Results: Mean age was 67±15 years with 3,629 (36%) females and hospital mortality of 9%. Hyperkalemia occurred in 1,187 (12.3%), and hypokalemia occurred in 719 (7.4%). Compared to normokalemic patients, both hyperkalemic patients (unadjusted OR 2.85, 95% CI 2.40-3.39; P<.001) and hypokalemic patients (unadjusted OR 2.31, 95% CI 1.85-2.88; P<.001) were at increased risk of hospital mortality. After adjustment for illness severity and renal function, only hyperkalemic patients were at increased risk of hospital death (adjusted OR 1.35, 95% CI 1.07-1.69; p = 0.01), while hypokalemic patients were not (P = NS). Among hospital survivors, hyperkalemic patients had lower post-discharge survival by Kaplan-Meier analysis (P <0.001), while hypokalemic patients had similar survival compared to normokalemic patients (p = NS). After adjustment for illness severity and renal function, hospital survivors with hyperkalemia were at increased risk for post-discharge mortality compared with normokalemic patients (adjusted HR 1.16, 95% CI 1.05-1.28; p=.003). Conclusions: Hyperkalemia on CICU admission is associated with higher hospital and post-discharge mortality, independent of renal function and illness severity. This emphasizes the importance of potassium abnormalities as a risk predictor in patients admitted to the CICU.