Citations

Body positioning exerts profound physiological effects in critically ill patients, influencing respiratory mechanics, ventilation-perfusion matching, hemodynamics, and overall clinical outcomes. Transitioning from an upright to a recumbent position alters thoracoabdominal pressure relationships, reduces ribcage contribution to tidal ventilation, and shifts ventilatory load to the diaphragm. These changes decrease functional residual capacity and promote airway closure in dependent lung regions, predisposing patients to atelectasis—an effect further amplified by intra-abdominal pathology or diaphragmatic weakness. Positioning also reshapes pulmonary perfusion and ventilation, which impact cardiopulmonary hemodynamics. These physiologic principles translate to important therapeutic applications across disease states. In ARDS, prone positioning improves oxygenation via a number of mechanisms, reduces ventilator-induced lung injury, and confers substantial mortality benefit. Prone position may also improve air flow distribution in COPD and enhance venous return in select cardiac physiologies. Conversely, conditions such as ascites, morbid obesity, and hepatopulmonary syndrome exemplify pathologic interactions between abdominal pressure, lung volumes, and posture, often requiring tailored positioning strategies to optimize respiratory performance. Overall, body positioning represents a potent, underutilized intervention in critical care. Understanding the mechanistic foundations of position-dependent changes in ventilation, perfusion, and pleural pressure can help clinicians strategically leverage positioning to improve patient outcomes across a spectrum of pulmonary and systemic illnesses.

Background Long-term corticosteroid (LTC) use is a known risk factor for adverse outcomes after various surgical procedures. However, the impact of LTC use on surgical complications after TSA remains underexplored. This study aims to assess the influence of LTC use on 90-day and 5-year complications following TSA. Methods A retrospective cohort study utilizing the PearlDiver database was conducted. Patients undergoing primary TSA with a minimum 5-year follow-up were included. LTC users were propensity-matched 1:10 with controls based on demographic variables and comorbidities. Postoperative complications within 90 days of surgery and long-term complications within 5 years were compared between groups. Multivariable logistic regressions were used to compare complications controlling for demographic variables and comorbidities. Results In a matched cohort of 556 LTC users to 4942 controls, corticosteroid users exhibited a 2.91-fold higher risk of pneumonia (95% CI: 1.69–4.80, p < 0.001) and a 2.19-fold higher risk of venous thromboembolism (VTE) (95% CI: 1.30–3.51, p = 0.001) within 90 days following TSA. No significant differences in 5-year surgical outcomes were observed. Discussion LTC users are at a heightened risk for 90-day medical complications, including pneumonia and VTE following TSA. However, their 5-year risk of surgical complications was comparable to patients without LTC use.

Abstract Background The tumor, node, metastasis (TNM) classification at pathological evaluation determines prognosis following cancer treatment. For rectal cancer patients undergoing neoadjuvant therapy, whether ypTNM likely confers different prognosis than pTNM. We compared survival outcomes of patients classified by ypTNM vs pTNM staging. Methods Patients with resected locoregional rectal cancer from the National Cancer Database who underwent upfront surgery (pTNM) and had ≥5 years follow-up (2010-2017) were compared with those receiving neoadjuvant therapy followed by surgery (ypTNM). To address treatment selection bias, analyses were stratified by receipt of guideline-concordant care. Overall survival (OS) was compared using Kaplan-Meier and multivariable Cox regression analyses. Results Of 50 436 patients (median age = 60; 61.4% male), 11 732 (23.3%) underwent upfront surgery and 38 704 (76.7%) received neoadjuvant therapy; 78.8% of the upfront surgery group received guideline-concordant care. In analyses stratified by guideline-concordant care, overall survival was similar for stage 0-I (hazard ratio [HR] = 1.05; 95% CI = 0.96 to 1.15) but significantly worse for ypTNM vs pTNM in stage II (HR = 1.50; 95% CI = 1.27 to 1.77; 5-year OS = 75.6% vs 83.2%) and stage III (HR = 1.60; 95% CI = 1.46 to 1.75; 5-year OS = 67.0% vs 78.2%). Multivariable analysis confirmed ypTNM was associated with worse survival at each stage (stage 0-I: HR = 1.14, P = .004; stage II: HR = 1.49, P &lt; .001; stage III: HR = 1.60, P &lt; .001). Conclusion Stage for stage, ypTNM classification is associated with worse survival than pTNM classification, with increasing difference at higher stages. Future staging systems and management guidelines should account for these differences to optimize prognostication and stratification for clinical trials and surveillance strategies.

Abstract Recurrent Clostridioides difficile infection (CDI) is a clinical syndrome, a trial end point, and a surveillance construct. Epidemiologic and administrative datasets count repeat positive tests or coded episodes, but conflate colonization or test of cure with recurrence. Trials operationalize recurrent CDI with symptoms and testing, but have variable follow-up. Clinically, recurrent CDI requires response, and recurrent illness requires excluding postinfection bowel dysfunction and mimics. Relapse and reinfection remain difficult to distinguish without strain typing, which is more relevant for research. We propose a pragmatic lens: explicitly name the definition used, match it to the decision, and adjudicate clinical recurrence before escalating therapy.

Abstract Introduction Despite regulatory mandates for advanced therapy (AT) washout periods of up to 5 drug half-lives before enrolling patients in inflammatory bowel disease (IBD) trials, the evidence base for these requirements is largely empirical, and whether shorter intervals independently increase the risk of serious infections in real-world practice remains unknown. Methods Using the OptumLabs Data Warehouse, we identified adult patients with IBD who initiated a new AT (tumor necrosis factor antagonists, vedolizumab, interleukin (IL)-12/23 or IL-23 antagonists, or Janus kinase inhibitors) between 2018 and 2023 using a class-specific new-user design. We examined whether exposure to AT within the preceding 12 months (vs no exposure to AT within that window) and timing of discontinuation (≤1 month, 1-&lt;3 months, or 3-12 months) were associated with risk of serious infections using multivariable Cox proportional hazards regression. Results Among 21 564 AT initiators (47 ± 18 years; 52% female; 57% Crohn’s disease), 7490 (34.7%) had AT exposure within the preceding 12 months. Over a mean follow-up of 1.6 ± 0.9 y, 1955 (9.1%) experienced a serious infection. Prior AT exposure was associated with higher infection risk (hazard ratio [HR]: 1.19, 95% confidence interval [CI]: 1.07-1.33), consistent in inverse probability of treatment-weighted analyses (HR, 1.20 [1.06-1.37]). Among patients with prior exposure, timing of discontinuation was not associated with infection risk (HR, 1.17 [0.95-1.43] for ≤1 month vs 3-12 months; HR, 1.01 [0.83-1.22] for 1-&lt;3 months), with no dose–response relationship on continuous modeling. Discussion AT exposure within the preceding 12 months is associated with modestly higher risk of serious infection after initiating a new AT in IBD, but timing of discontinuation does not independently influence this risk.

Abstract Background Data describing the incidence and clinical outcomes of respiratory syncytial virus (RSV) infection among patients with inflammatory bowel disease (IBD) are limited. Methods We conducted a nationwide retrospective cohort study using the Veterans Health Administration (VHA) database. Adults with IBD were identified using a previously validated algorithm and matched 1:2 to non-IBD controls using propensity score matching. Laboratory-confirmed RSV infections that occurred between January 1, 2021, and December 31, 2024, were identified using standardized laboratory codes and confirmed by manual chart adjudication. Primary outcomes included RSV incidence and hospitalizations. Secondary outcomes included intensive care unit (ICU) admission and patient outcomes stratified by IBD medication class. Results After propensity score matching, 52 740 IBD patients and 104 997 non-IBD controls were included. Infection with RSV occurred in 219 patients with IBD and 426 non-IBD patients. Incidence rates of RSV were similar between cohorts across all years in our study period. Hospitalization related to RSV occurred in 18.26% of IBD-RSV patients compared with 13.15% of non-IBD patients (P = .08). ICU admission was rare in both groups (&lt;1%). Among patients with IBD, RSV-related hospitalization did not differ significantly by medication class, when comparing biologic therapy (8.93%) with 5-aminosalicylic acid monotherapy (17.58%) (P = .15). Conclusions In this nationwide cohort, patients with IBD, with predominantly lower exposure to advanced therapies, did not have higher rates of RSV infection or worse clinical outcomes compared with matched non-IBD controls. RSV outcomes were similar across IBD medication classes. These findings support current vaccination recommendations and provide reassurance regarding RSV risk among patients with IBD.

Background Gastro-oesophageal reflux disease (GORD) occurs in most (∼75%) patients with systemic sclerosis (SSc) and significantly impacts quality of life. Current recommendations lack depth and therefore our aim was to produce practical, consensus-based recommendations for refractory SSc-related GORD. Methods An international, multidisciplinary steering board (SB) was assembled (n=19) consisting of clinicians (rheumatologists, gastroenterologists, gastrointestinal surgeons), an expert methodologist and patient representation. After reviewing the latest definitions of GORD and refractory GORD in the published literature, the SB collectively devised a practical definition of SSc refractory-GORD. Initial recommendations were drafted/agreed on by the SB based on review of the existing guidelines, published literature and expert opinion. Two online voting rounds were conducted to determine whether items should be accepted, with >75% and >60% SB agreement required for first and second rounds, respectively. Results There was a good response/completion rate for the initial (74%) and final (84%) voting rounds. The SB agreed on all 36 draft recommendations. The majority (n=34) were approved in the first round. Recommendations were organised according to the following categories: general approach to management (n=5), assessment (n=6), non-pharmacological (n=2) and pharmacological (n=10) management, endoscopic and surgical treatment (n=3), and special circumstances including refractory GORD and SSc-interstitial lung disease (n=3), myositis and SSc connective tissue disease-overlap (n=3) and perilung transplant (n=4). Conclusion The group of experts has drafted extended and practical recommendations for the management of SSc refractory-GORD. The necessity of a structured approach and a patient assessment is highlighted in order to provide a multidisciplinary approach to the tailored choice of the treatment. Our work also has also identified significant unmet needs and has provided a research agenda to advance the field.

Shear wave elastography generates shear waves with an acoustic radiation force to obtain estimates of the shear wave speed. Shear wave elastography often utilizes time-of-flight calculations that apply cross-correlations or time-to-peak methods to obtain estimates of the shear wave speed in the time-domain. However, these time-domain methods fail to consider the effect of dispersion caused by the shear viscosity, which can introduce substantial errors into estimates of the shear wave speed. To solve this problem, a new viscoelastic method for estimating shear wave parameters in the time-domain is introduced. The performance of the new method, which is applied to shear wave particle velocity waveforms, is established by evaluating a simulated three-dimensional viscoelastic Green's function model for shear waves in the time-domain. Results show that the new viscoelastic time-domain method is applicable to locations outside of the push beam region at the focal depth and throughout a two-dimensional plane. The results also indicate that estimates of the shear wave speed are either comparable to or significantly improved relative to values obtained from cross-correlations while simultaneously providing estimates of the shear viscosity in the time-domain.