Citations

Background: Lymphovenous anastomosis (LVA) is a microsurgical treatment for lymphedema of the lower extremity (LEL). This study systematically reviews the most recent data on outcomes of various LVA techniques for LEL in diverse patients. Methods: A comprehensive literature search was conducted in the Ovid MEDLINE, Ovid EMBASE, and Scopus databases to extract articles published through June 2021. Studies reporting data on objective postoperative improvement in lymphedema and/or subjective improvement in quality of life for patients with LEL were included. Extracted data comprised demographics, number of patients and lower limbs, duration of symptoms before LVA, surgical technique, duration of follow-up, and objective and subjective outcomes. Results: A total of 303 articles were identified and evaluated, of which 74 were ultimately deemed eligible for inclusion in this study, representing 6260 patients and 2554 lower limbs. The average patient age ranged from 22.6 to 76.14 years. The duration of lymphedema before LVA ranged from 12 months to 11.4 years. Objective rates of improvement in lymphedema ranged from 23.3% to 100%, with the greatest degree of improvement seen in patients with early-stage LEL. Conclusions: LVA is a safe and effective technique for the treatment of LEL of all stages. Several emerging techniques and variations may lead to improved patient outcomes.

Abstract Background Antispike monoclonal antibodies are recommended for early treatment of high-risk persons with mild to moderate coronavirus disease 2019 (COVID-19). However, clinical outcomes of their use during the severe acute respiratory syndrome coronavirus 2 Omicron wave are limited. Methods This is a descriptive retrospective study of high-risk adult patients who received treatment with sotrovimab (January 1–March 20, 2022) or bebtelovimab (March 21–April 30, 2022). The primary outcome was the proportion of patients who progressed to severe outcome within 30 days after receiving antispike-neutralizing monoclonal antibody infusion. Results A total of 3872 high-risk patients (median age, 62.7 years; 41.1% male) with mild to moderate COVID-19 received sotrovimab (n = 2182) or bebtelovimab (n = 1690). Among sotrovimab-treated patients, the most common comorbidities were an immunosuppressed condition (46.7%), hypertension (38.2%), and diabetes (21.2%). The rates of severe outcome, intensive care unit (ICU) admission, and mortality were 2.2%, 1.0%, and 0.4%, respectively, after sotrovimab infusion. Among bebtelovimab-treated patients, the most common comorbidities were hypertension (42.7%), diabetes (17.1%), and an immunosuppressed condition (17.0%). The rates of severe disease, ICU admission, and mortality were 1.3%, 0.5%, and 0.2%, respectively, after bebtelovimab infusion. Older age, immunosuppressed status, and several comorbidities were associated with severe disease progression, while COVID-19 vaccination was associated with lower risk. No anaphylaxis was reported during monoclonal antibody infusion. Conclusions This real-world analysis of a large cohort of high-risk patients demonstrates low rates of severe disease after treatment with sotrovimab during the era dominated by Omicron B.1.1.529 and after treatment with bebtelovimab during the era dominated by BA.2 and Omicron subvariants.

Background: Surgical and nonoperative management of anterior cruciate ligament (ACL) injuries seek to mitigate the risk of knee instability and secondary meniscal injury. However, the associated risk and timing of secondary meniscal tears have not been completely elucidated. Purpose: To compare risk and timing of secondary meniscal injury between patients receiving nonoperative management, delayed ACL reconstruction (ACLR), and early ACLR using a machine learning survival analysis. Study Design: Cohort study; Level of evidence, 3. Methods: A geographic database was used to identify and review records of patients with a diagnosis of ACL rupture between 1990 and 2016 with minimum 2-year follow-up. Patients undergoing ACLR were matched 1:1 with nonoperatively treated controls. Rate and time to secondary meniscal tear were compared using random survival forest algorithms; independent models were developed and internally validated for predicting injury-free duration in both cohorts. Performance was measured using out-of-bag c-statistic, calibration, and Brier score. Model interpretability was enhanced using global variable importance and partial dependence curves. Results: The study included 1369 patients who underwent ACLR and 294 patients who had nonoperative treatment. After matching, no significant differences in rates of secondary meniscal tear were found ( P = .09); subgroup analysis revealed the shortest periods of meniscal survival in patients undergoing delayed ACLR. The random survival forest algorithm achieved excellent predictive performance for the ACLR cohort, with an out-of-bag c-statistic of 0.80 and a Brier score of 0.11. Significant variables for risk of meniscal tear for the ACLR cohort included time to return to sports or activity ≤350 days, time to surgery ≥50 days, age at injury ≤40 years, and high-impact or rotational landing sports, whereas those in the nonoperative cohort model included time to RTS ≤200 days, visual analog scale pain score >3 at consultation, hypermobility, and noncontact sports. Conclusion: Delayed ACLR demonstrated the greatest long-term risk of meniscal injury compared with nonoperative treatment or early ACLR. Risk factors for decreased meniscal survival after ACLR included increased time to surgery, shorter time to return to sports or activity, older age at injury, and involvement in high-impact or rotational landing sports. Pending careful external validation, these models may be deployed in the clinical space to provide real-time insights and enhance decision making.

Background: Acute myocarditis is an inflammatory condition that may herald the onset of dilated cardiomyopathy (DCM) or arrhythmogenic cardiomyopathy (ACM). We investigated the frequency and clinical consequences of DCM and ACM genetic variants in a population-based cohort of patients with acute myocarditis. Methods: This was a population-based cohort of 336 consecutive patients with acute myocarditis enrolled in London and Maastricht. All participants underwent targeted DNA sequencing for well-characterized cardiomyopathy-associated genes with comparison to healthy controls (n=1053) sequenced on the same platform. Case ascertainment in England was assessed against national hospital admission data. The primary outcome was all-cause mortality. Results: Variants that would be considered pathogenic if found in a patient with DCM or ACM were identified in 8% of myocarditis cases compared with <1% of healthy controls ( P =0.0097). In the London cohort (n=230; median age, 33 years; 84% men), patients were representative of national myocarditis admissions (median age, 32 years; 71% men; 66% case ascertainment), and there was enrichment of rare truncating variants (tv) in ACM-associated genes (3.1% of cases versus 0.4% of controls; odds ratio, 8.2; P =0.001). This was driven predominantly by DSP -tv in patients with normal LV ejection fraction and ventricular arrhythmia. In Maastricht (n=106; median age, 54 years; 61% men), there was enrichment of rare truncating variants in DCM-associated genes, particularly TTN -tv, found in 7% (all with left ventricular ejection fraction <50%) compared with 1% in controls (odds ratio, 3.6; P =0.0116). Across both cohorts over a median of 5.0 years (interquartile range, 3.9–7.8 years), all-cause mortality was 5.4%. Two-thirds of deaths were cardiovascular, attributable to worsening heart failure (92%) or sudden cardiac death (8%). The 5-year mortality risk was 3.3% in genotype-negative patients versus 11.1% for genotype-positive patients ( P adjusted =0.08). Conclusions: We identified DCM- or ACM-associated genetic variants in 8% of patients with acute myocarditis. This was dominated by the identification of DSP -tv in those with normal left ventricular ejection fraction and TTN -tv in those with reduced left ventricular ejection fraction. Despite differences between cohorts, these variants have clinical implications for treatment, risk stratification, and family screening. Genetic counseling and testing should be considered in patients with acute myocarditis to help reassure the majority while improving the management of those with an underlying genetic variant.

The influence of pharmacotherapy regimens on surgical patient outcomes is increasingly appreciated in the era of enhanced recovery protocols and institutional focus on reducing postoperative complications. Specifics related to medication selection, dosing, frequency of administration, and duration of therapy are evolving to optimize pharmacotherapeutic regimens for many enhanced recovery protocolized elements. This review provides a summary of recent pharmacotherapeutic strategies, including those configured within electronic health record (EHR) applications and functionalities, that are associated with the minimization of the frequency and severity of postoperative complications (POCs), shortened hospital length of stay (LOS), reduced readmission rates, and cost or revenue impacts. Further, it will highlight preventive pharmacotherapy regimens that are correlated with improved patient preparation, especially those related to surgical site infection (SSI), venous thromboembolism (VTE), nausea and vomiting (PONV), postoperative ileus (POI), and emergence delirium (PoD) as well as less commonly encountered POCs such as acute kidney injury (AKI) and atrial fibrillation (AF). The importance of interprofessional collaboration in all periprocedural phases, focusing on medication management through shared responsibilities for drug therapy outcomes, will be emphasized. Finally, examples of collaborative care through shared mental models of drug stewardship and non-medical practice agreements to improve operative throughput, reduce operative stress, and increase patient satisfaction are illustrated.

Abstract The effectiveness of bebtelovimab in real-world settings has not been assessed. In this retrospective cohort study of 3607 high-risk patients, bebtelovimab was used more commonly than nirmatrelvir-ritonavir for treatment of coronavirus disease 2019 (COVID-19) among older patients, immunosuppressed patients, and those with multiple comorbid conditions. Despite its use in patients with multiple comorbid conditions, the rate of progression to severe disease after bebtelovimab (1.4% [95% confidence interval, 1.2%–1.7%]) was not significantly different from that for nirmatrelvir-ritonavir treatment (1.2% [.8%–1.5%]). Our findings support the emergency use authorization of bebtelovimab for treatment of COVID-19 during the Omicron epoch dominated by BA.2 and subvariants.

Background: Little is known about the benefits and outcomes of meniscal repair in patients older than 60 years. Purpose: To (1) report the clinical and radiographic outcomes of meniscal repair in patients aged ≥60 years and compare them with matched patients who underwent meniscectomy and (2) identify procedural failures. Study Design: Cohort study; Level of evidence, 2. Methods: We included 32 knees in 32 patients aged ≥60 years (20 female, 12 male; mean age, 64.5 ± 4.6 years) who underwent meniscal repair surgery at a single medical institution between 2010 and 2020. Patients were matched according to age, sex, body mass index, and meniscal tear type with a comparison cohort who underwent meniscectomy (n = 49 patients [49 knees]; 32 female, 17 male). For all patients, demographic information, clinical history, physical examination findings, treatment details, and radiographic images were reviewed and analyzed. At final follow-up (mean, 42.2 months; range, 13-128 months), patients completed the 2000 International Knee Documentation Committee (IKDC) Subjective Knee Evaluation Form, Knee injury and Osteoarthritis Outcome Score (KOOS), and Lysholm score. Clinical failure was defined as revision surgery and/or progression to total knee arthroplasty (TKA). A matched-pairs t test was used to analyze differences between the 2 treatment groups, and Kaplan-Meier analysis was used to determine the rates of knee osteoarthritis and progression to TKA. Results: The majority of patients had a medial meniscal tear (72.8%), whereas the lateral meniscus was torn in 27.2% of cases. Most tears were located in the meniscal root (56.8%), followed by the posterior horn (34.6%) and midbody (8.6%). At final follow-up, all outcome scores were higher in the repair group compared with the meniscectomy group (IKDC, 78.9 ± 13.4 vs 56.0 ± 15.4; KOOS, 86.6 ± 11.9 vs 61.7 ± 16.2; Lysholm, 88.3 ± 13.3 vs 68.7 ± 15.2, respectively; P < .001 for all). Clinical failure was observed in 22% of patients in the repair group. Conclusion: All clinical outcome scores were higher in the meniscal repair group compared with the matched meniscectomy group at final follow-up. The clinical failure rate of the repair group was 22%. These findings support meniscal repair in selected patients aged ≥60 years.

AbstractHospitals, payors, and patients increasingly expect us to report our outcomes in more detail and to justify our treatment decisions and costs. Although there are many stakeholders in surgical outcomes, physicians must take the lead role in defining how outcomes are assessed. Skull base lesions interact with surrounding anatomy to produce a complex spectrum of presentations and surgical challenges, requiring a wide variety of surgical approaches. Moreover, many skull base lesions are relatively rare. These factors and others often preclude the use of prospective randomized clinical trials, thus necessitating alternate methods of scientific inquiry. In this paper, we propose a roadmap for implementing a skull base registry, along with expected benefits and challenges.

AbstractObjectivesTo standardly assess and describe nailfold videocapillaroscopy (NVC) assessment in children and adolescents with juvenile rheumatic and musculoskeletal diseases (jRMD) vs healthy controls (HCs).Material and methodsIn consecutive jRMD children and matched HCs from 13 centres worldwide, 16 NVC images per patient were acquired locally and read centrally per international consensus standard evaluation of the EULAR Study Group on Microcirculation in Rheumatic Diseases. A total of 95 patients with JIA, 22 with JDM, 20 with childhood-onset SLE (cSLE), 13 with juvenile SSc (jSSc), 21 with localized scleroderma (lSc), 18 with MCTD and 20 with primary RP (PRP) were included. NVC differences between juvenile subgroups and HCs were calculated through multivariable regression analysis.ResultsA total of 6474 images were assessed from 413 subjects (mean age 12.1 years, 70.9% female). The quantitative NVC characteristics were significantly lower or higher in the following subgroups compared with HCs: for density: lower in jSSc, JDM, MCTD, cSLE and lSc; for dilations: higher in jSSc, MCTD and JDM; for abnormal shapes: higher in JDM and MCTD; for haemorrhages: higher in jSSc, MCTD, JDM and cSLE. The qualitative NVC assessment of JIA, lSc and PRP did not differ from HCs, whereas the cSLE and jSSc, MCTD, JDM and cSLE subgroups showed more non-specific and scleroderma patterns, respectively.ConclusionsThis analysis resulted from a pioneering registry of NVC in jRMD. The NVC assessment in jRMD differed significantly from HCs. Future prospective follow-up will further elucidate the role of NVC in jRMD.