Citations

Introduction: Treatment of cutaneous warts with intralesional vitamin D3 has demonstrated promising results in over 35 studies with methodological limitations. Methods: We conducted a randomized, double-blind, placebo-controlled trial in our primary care procedure clinic of intralesional vitamin D3 12 000 IU vs placebo in cutaneous warts every 4 weeks up to 3 times. Warts were assessed 4, 8, 12, and 24 weeks after the initial injection. The primary outcome was complete wart resolution. Reduction in wart size was a secondary outcome. Results: Between October 2020 and April 2023, we enrolled 77 participants with 1 or more cutaneous warts (41 and 36 in vitamin D3 and placebo groups, respectively) with untreated (32%) and recalcitrant (69%) warts. At 24 weeks, the index wart had resolved in 12 (30%) of vitamin D3 and 10 (31%) placebo participants. Treatment with vitamin D3 had no effect on wart surface area in an adjusted model nor wart resolution in analysis adjusted for baseline wart size, multiple warts, and the vehicle (OR 0.31 [95% CI] 0.01-10.3; P = 0.51). Conclusions: These results demonstrate a lack of benefit of intralesional vitamin D3 in cutaneous warts. ( ClinicalTrials.gov number NCT04278573)

Background: Flexor pollicis longus (FPL) palsy following both-bone forearm fracture (BBFF) is a rare complication. Methods: A retrospective review of acute BBFF treated with open reduction internal fixation by a single surgeon from 2005 to 2023 was performed. Injury and surgical characteristics of patients with documented FPL palsy were reviewed. In addition, 10 cadaveric dissections were performed to evaluate the anatomy of the anterior interosseous nerve (AIN) and its branches. The distance of these branches from palpable elbow landmarks and variability in branching pattern were evaluated. Results: Twenty-nine patients underwent surgery for acute BBFF. Of these, 5 (17%) had evidence of an FPL palsy either at the time of injury presentation (n = 2) or immediately following surgery (n = 3). All patients with FPL palsy sustained fractures in the middle one-third of the radius. All palsies resolved after an average of 33 days of observation. In cadaveric dissections, the average distance from the lateral epicondyle to the AIN takeoff and branch to the FPL was 5.5 and 7.6 cm, respectively. The AIN takeoff and branch to the FPL were never less than 4 and 7 cm from the lateral epicondyle, respectively. Conclusion: Flexor pollicis longus palsy following BBFF can occur at the time of injury or following surgery. All FPL palsies involved midshaft radial fractures and were likely neurapraxia. The etiology of FPL palsy remains unclear, but cadaveric dissection suggests the FPL motor branch may be at risk from mid-to-proximal radius fracture fragments or excessive traction during surgery.

Abstract Post-translational modifications (PTM) of tau are implicated in Alzheimer disease (AD) progression and are established biomarkers in cerebrospinal fluid and plasma; however, the labor-intensive nature of conventional proteomics limits their investigation in histology-specific contexts. We describe the findings of an artificial intelligence-guided laser capture microdissection (LCM) pipeline for harvesting neurofibrillary tangles (NFTs) by maturation level into pretangles (pre-NFTs), mature tangles (iNFTs), and ghost tangles (eNFTs) using 38 cases obtained from 2 independent biobanks. We evaluated the performance characteristics of proprietary machine learning algorithms for the subclassification of these NFT categories in anti-pTau217-stained whole slide images of entorhinal cortex, hippocampus, frontal, and parietal cortex sections. Overall precision/recall/F1 scores were highest for Classifier A (0.6/0.46/0.5). The best performing algorithm was used to guide LCM capture and inform NFT enrichment. Targeted proteomics on tau signature peptides (pTau181, pTau217, and TauMTBR) was performed on approximately 1250 NFT collections. The results demonstrated that their abundance increased from pretangles to mature tangles (∼2-11-fold increase), and that this was followed by a sharp reduction in ghost tangles (∼3-116-fold decrease), with pTau217 showing the most drastic change. Pathologist-trained NFT classifiers represent an objective albeit imperfect means to enrich specific morphologic forms permitting coupled LCM-MS (mass spectrometry) to investigate AD-associated PTM.

ABSTRACT Background Prompt detection and intervention are crucial for improving outcomes in acute invasive fungal rhinosinusitis (AIFS). Diagnostic prediction models assist in risk‐stratification, but their accuracy requires testing through external validation. This study aims to validate a previously published diagnostic prediction model for AIFS in an independent cohort. Methods A retrospective chart review was conducted at a tertiary care center (2008–2023) to identify patients with an otolaryngology consult for suspected AIFS. Of 65 patients identified, 11 (16.9%) were diagnosed with AIFS based on histopathology. Risk was calculated using Yin et al.’s predictive model. Predictive performance was assessed by calibration and discrimination. Results Patients had significantly higher rates of diabetes (46.2% vs. 26.1%, p = 0.002), long‐term steroid use (60% vs. 28.2%, p < 0.0001), and solid organ transplantation (38.5% vs. 8.5%, p < 0.001), compared with the development cohort, with conversely lower rates of hematologic malignancy (29.2% vs. 58.7, p < 0.001) and neutropenia (19.4% vs. 41%, p = 0.001). Despite these differences, both the three‐variable (C‐index: 0.844; 95% CI, 0.736–0.952) and four‐variable models (C‐index: 0.963; 95% CI, 0.919–1) showed adequate discrimination. Both models exhibited slight overprediction of risk, with a calibration‐in‐the‐large predicted risk of 24.1% (95% CI, 13.68–34.46) for the three‐variable model and 24.2% (95% CI, 13.76–34.57) for the four‐variable model. Calibration plots confirmed overprediction. Conclusion The AIFS diagnostic model demonstrates acceptable discrimination and calibration on external validation, with generalizability to patients with different comorbidities. Larger studies are recommended to further test the model's predictive performance and clinical applicability.

Background Although telehealth cardiac rehabilitation (CR) may improve access, there are concerns about its long‐term effectiveness and impact on equity as compared with in‐person CR. Our objective was to tailor a patient‐centered telehealth CR program for diverse populations. Methods CR patients and caregivers were recruited between January and September 2023 from 4 US academic medical centers. Participants engaged in human‐centered design sessions to iteratively refine a telehealth CR program. Sessions had planned topics, but there was variation across sites to account for site‐specific needs and participant feedback. Sessions were qualitatively analyzed using rapid template analysis with preselected behavioral science constructs and other emergent codes. Results The study included 21 participants (71% aged ≥60 years, 48% women, 62% non‐Hispanic White individuals; 90% CR patients, 10% CR caregivers). Participants thought that telehealth CR could be helpful for personalized support at home and convenience but recognized that technology is not always easy to use. Some expressed concerns about the safety of telehealth CR, especially at the beginning, and desired monitoring through a mobile device or video observation of exercise. Safety protocols and technology training were developed, which addressed concerns about telehealth CR. Opportunities for social support with telehealth CR were also desired. From these findings, an implementation toolkit was developed, including a graphic program description, safety plan, home exercise plan for during and after CR, and scripts for technology training and individual and group telehealth visits. Conclusions A patient‐centered telehealth CR program and implementation toolkit were systematically tailored to address the needs of diverse populations.

AbstractElectronic patient-reported outcome measures (ePROMs) can improve care for people with cancer, but effectiveness hinges on well-supported integration in clinical settings.We evaluated clinician use of specific clinical decision support (CDS) tools in the electronic health record (EHR) designed to facilitate timely, clinically appropriate responses to ePROM scores for six symptoms commonly experienced by cancer patients.The parent pragmatic trial, which took place at Mayo Clinic (Rochester, Minnesota, United States) and its affiliated community health care system between March 2019 and January 2023, evaluated the population-level effectiveness and implementation of an ePROM surveillance and EHR-facilitated collaborative care symptom management intervention. The present evaluation used a case study approach with four data sources: (1) clinician interactions with CDS tools abstracted from the EHR; (2) clinician notes identified with an institution-specific textual search tool; (3) qualitative interviews and group discussions with care teams; and (4) administrative records reviewed to identify training and outreach to care teams.EHR metrics showed very low adoption of CDS tools including alerts and symptom-specific order sets, despite educational outreach and information technology support provided to clinical care teams. Qualitative findings revealed that CDS use was not easy to integrate into busy clinical workflows and highlighted clinician perceptions that the collaborative care intervention provided additional patient support that reduced clinicians' need to utilize CDS tools. They also highlight the importance of contextual factors, including institutional priorities and EHR changes.This pragmatic clinical trial case study found limited adoption of EHR CDS tools that had been developed to increase clinicians' awareness of and responses to ePROM data. Findings suggest the need to align clinician and organizational implementation strategies, simplify CDS tools to fit practice expectations, and identify and address contextual factors that could undercut strategies like education and peer support. This may be especially important for teams who aim to iteratively evaluate and refine CDS and implementation strategies for multicomponent interventions or introduce new strategies that are responsive to barriers while maintaining scalability.

Surgical outcomes and perioperative factors associated with pediatric cranioplasty remain incompletely understood. The authors queried the National Surgical Quality Improvement Program-Pediatric (NSQIP-P) database to evaluate outcomes and intraoperative/postoperative blood transfusions in patients undergoing cranioplasty between 2019 and 2023. A total of 249 patients (mean age 9.1 ± 5.4 y) were included. Most cranioplasties (70.7%) utilized alloplastic materials compared with autologous. Blood transfusion was required in 24.1% of cases, predominantly on the day of surgery (86.7%). Multivariable analysis identified age (OR: 0.86 per year, 95% CI: 0.80–0.93, P < 0.001) and cranioplasty size >5 cm (versus ≤5 cm) (OR: 2.10, 95% CI: 1.01–4.50, P = 0.049) as predictors of transfusion. The 30-day unplanned readmission rate was 5.3% at a mean of 14.6 ± 7.9 days from surgery, most commonly for a surgical site infection (33.0%). The 30-day unplanned reoperation rate was 2.9%, at a mean of 10.2 ± 5.6 days. Autologous cranioplasty was not associated with higher odds of readmission (OR: 0.79, 95% CI: 0.25–2.13, P = 0.66) or reoperation (OR: 5.04, 95% CI: 0.96–36.99, P = 0.07) compared with alloplastic cranioplasty. Rates of readmission and reoperation following pediatric cranioplasty are comparable to other complex craniofacial procedures. Younger age and larger cranioplasty size are associated with higher rates of blood transfusion. Our results show that autologous reconstruction is not associated with higher short-term complication rates compared with alloplastic reconstruction, although future studies are still needed to further the understanding of the optimal cranioplasty material.

Spousal caregivers of persons living with serious illnesses experience significant emotional and social challenges related to their caregiving role. The purpose of this study was to gain a deeper understanding of how spousal caregivers perceive current and anticipated losses associated with caring for a partner living with advanced cancer. Spousal caregiver participants engaged in semistructured interviews about their caregiving experiences and subsequent changes that occurred in their lives. Caregivers experienced social changes, emotional energy investment, and relationship changes as sources of grief. Social changes involved a loss of freedom and increased isolation, while emotional energy investment manifested as suppressed emotions and fears about the future. Relationship changes encompassed both positive and negative shifts in communication and roles. Targeted interventions, such as support groups and counseling, are essential to mitigate the negative impacts of caregiving and improve the well-being of older adult spousal caregivers.

Abstract Rationale High-attenuation area (HAA) is a computed tomography (CT) tool that correlates with lung inflammation and fibrosis. Systemic molecular correlates of HAA (e.g., plasma proteins) may inform biological processes involved in interstitial lung disease. Objectives To identify plasma proteins that associate with HAA and correlate with a higher probability of developing new-onset fibrotic or subpleural interstitial lung abnormalities (ILAs). Methods Plasma protein levels were measured using a semiquantitative aptamer-based platform in MESA (the Multi-Ethnic Study of Atherosclerosis; N = 5,486) and SPIROMICS (Subpopulations and Intermediate Outcome Measures in COPD Study; N = 1,781). Linear regression models identified HAA-associated proteins after adjustment for demographic and socioeconomic factors, CT scanner parameters, study center, and batch. Associations of HAA-related proteins with new-onset fibrotic or subpleural ILAs were examined in MESA participants with ILA assessments on full-lung CT 10 years later. Immunohistochemical staining of select proteins was performed in lung tissue from pulmonary fibrosis cases. Measurements and Main Results There were 75 proteins detected that were significantly associated with HAA in MESA and SPIROMICS. Gene Ontology analysis of these proteins identified processes involved in immune cell chemotaxis and cellular growth and apoptosis. Seven proteins were associated with a higher probability of new-onset fibrotic or subpleural ILAs in MESA, and two of these, junctional adhesion molecule-like protein and GTP cyclohydrolase 1 feedback regulatory protein, stained in areas of fibrosis in lung tissue from patients with interstitial lung disease. Conclusions Plasma proteins associated with more HAA are involved in immune and cellular processes and associate with new-onset fibrotic-subpleural ILA.