Citations

The use of temporary mechanical circulatory support in refractory heart failure cardiogenic shock (HFCS) has risen, leading to potential complications. Post-Cardiac Injury Syndrome (PCIS) from Impella insertion is rare but may result from subclavian artery manipulation and aortic irritation. We report the first case of pericarditis (PCIS) caused by Impella 5.5 insertion in an HFCS patient awaiting heart transplantation. The patient developed chest pain, tachycardia, and hypotension post-Impella insertion. Laboratory results and electrocardiograms confirmed PCIS. Treatment with Ibuprofen and Colchicine was successful. He received a heart transplant 14 days later. This case emphasizes recognizing iatrogenic pericarditis after Impella insertion and the need to avoid additional myocardial strain.

Background: Diabetic patients experience carpal tunnel syndrome (CTS) at high rates, have increased symptom severity, and experience prolonged recovery after carpal tunnel release (CTR). This study assessed the association of glucagon-like peptide-1 receptor agonist (GLP-1) therapy with postoperative outcomes after CTR in type II diabetic patients with CTS. Methods: Using the PearlDiver database, 25 229 diabetic patients with CTS who underwent CTR and were prescribed GLP-1 therapy were identified and exact matched to 25 229 controls based on age, sex, Elixhauser comorbidity index, tobacco use, obesity, hypothyroidism, and body mass index where available. Demographic variables and comorbidities were compared between groups using Kruskal-Wallis analyses for continuous variables and chi-square tests for categorical variables. Bivariate logistic regression analysis was conducted for 90-day outcomes and 2-year CTR revision. Results: Patients on GLP-1 therapy had decreased risk of 90-day medical complications (odds ratio [OR] = 0.90; 95% confidence interval [CI], 0.84-0.96) and hospital readmission (OR = 0.85; 95% CI, 0.77-0.94) of 0.5% and 0.4%, respectively, compared with controls. No significant differences were found in 90-day surgical complications or 2-year revision rates between cohorts. There were no cases of aspiration pneumonia. The GLP-1 cohort had increased odds of higher 90-day total costs of care (OR = 2.42; 95% CI, 1.88-3.15). Conclusions: GLP-1 therapy is associated with reduced risk of 90-day medical complications and hospital readmission following CTR in diabetic patients, suggesting these medications may optimize comorbidity profiles via glucose control preoperatively. Future studies may examine whether GLP-1 therapy is associated with minimum clinically important difference in patient-reported outcome measures for CTS in diabetic patients.

Background: In recent years, there has been an increased push for diversity in orthopaedics at the residency level. There has also been a noticeable shift away from foot and ankle fellowship, with many fellowship positions open throughout the country annually. With the increase in osteopathic and female orthopaedic applications to orthopaedic surgery residency, we hypothesized that this would be reflected in the foot and ankle fellowship applications in the last decade. Methods: The San Franscisco Match data from 2012 to 2023 were analyzed for degree type and from 2013 to 2023 for gender. There were 1082 applicants for adult foot and ankle fellowships from 2012 to 2023, 74 osteopathic applicants (11.4%), and 573 allopathic applicants (88.6%). There were 126 female applicants (21.3%) and 465 male applicants (78.7%). The 435 international graduates were excluded from this analysis. The degree type, gender, number of applicants, and number of applicants matched into orthopaedic foot and ankle fellowship was reviewed. Results: The number of osteopathic applicants and female applications did not change significantly over the study period. There was a statistically significant decrease in the number of allopathic applicants ( P = .003) and a significant decrease in the number of male applicants to foot and ankle fellowship ( P = .00004). The match rate for allopathic, osteopathic, and male applicants all statistically increased over the study periods, whereas the female applicant match rate remained stable. Programs tended to rank their matched allopathic residents higher, whereas osteopathic applicants’ position in the fellowship program rank list remained steady. Female and male applicants matched at programs higher on their rank lists, whereas programs match applicants lower on theirs. Conclusion: More orthopaedic foot and ankle surgeons are needed nationwide. Understanding recent trends in applicant demographics and match outcomes may help inform strategies to increase interest and participation in this subspecialty. Level of Evidence: IV, cross-sectional study.

BACKGROUND: Heart failure (HF) is a heterogeneous syndrome with high mortality. The need for a new taxonomy of HF is recognized; up to now, such phenomapping efforts have primarily used clinical data. Proteomics offers potential for more precise phenotypic identification and mechanistic insights. However, few phenomapping studies have used this approach, and all have focused on targeted cardiovascular proteomics panels and a restricted HF ejection fraction group. METHODS: We measured over 7000 plasma proteins in a population-based cohort of 1351 patients with HF, used k-means clustering to identify distinct phenogroups, and compared their clinical characteristics and all-cause mortality. RESULTS: Three proteomics-defined phenogroups were identified, with substantial differences in survival (phenogroup 1 5-year survival probability, 65% [95% CI, 61%–68%]; phenogroup 2, 45% [40%–51%]; phenogroup 3, 26% [22%–30%]), independent of clinical characteristics. Phenogroups also exhibited differences in several measures suggesting poorer health, including NT-proBNP (N-terminal pro-B-type natriuretic peptide), kidney function, and Meta-Analysis Global Group in Chronic Heart Failure scores, but did not differ by ejection fraction or New York Heart Association class. CONCLUSIONS: Our study demonstrates that molecular phenomapping can stratify patients with HF into distinct subgroups that go beyond predefined clinical classifications.

BACKGROUND: The Harmony transcatheter pulmonary valve (TPV) is designed to treat severe pulmonary regurgitation in the native or surgically repaired right ventricular (RV) outflow tract. Early outcomes after TPV replacement with the Harmony valve have been positive, but longer-term data are limited. METHODS: The study included patients who received a commercially available TPV22 or TPV25 device as part of the nonrandomized, prospective Native Outflow Tract Early Feasibility Study, Harmony Pivotal Trial, and Continued Access Study. Patients completed at least 3 years of follow-up, and outcomes to 5 years were reported when available. RESULTS: Eighty-nine patients were catheterized, and 86 were successfully implanted with a Harmony TPV. Median duration of follow-up was 5 (range 0–6) years in the TPV22 group and 3 (1–4) years in the TPV25 group. At 3 years, all patients with a TPV22 and 96% of those with a TPV25 had ≤mild pulmonary regurgitation. By magnetic resonance imaging, significant improvements from preimplant to 2 years were observed in RV end-diastolic volume index, RV to left ventricular end-diastolic volume ratio, and effective RV stroke volume (all P <0.001). SF-36 quality-of-life scores improved after Harmony implantation and were sustained over 3 years. Early cases of ventricular tachycardia resolved, and there were no new arrhythmias. Adverse events up to 5 years included 3 deaths unrelated to the device or procedure, 2 cases of endocarditis that were treated (1 medically, 1 transcatheter debulking of a vegetation) and resolved, 6 patients with RV outflow tract obstruction or thrombosis resulting in valve-in valve procedures, and 1 major stent fracture resulting in surgical explant. CONCLUSIONS: At 3 to 5 years, Harmony TPV replacement resulted in sustained valve competence, beneficial cardiac remodeling, and improved quality of life. Continued monitoring is needed to assess long-term outcomes and valve performance. REGISTRATION: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT01762124; NCT02979587.

Objectives/Hypothesis: Botulinum neurotoxin type-A (BoNT-A) injection into the true vocal cords is an effective treatment for restoring vocal functionality in adductor spasmodic dysphonia (AdSD). The Glasgow Benefit Inventory was developed to measure quality of life change following any otolaryngologic intervention and was recently revised to a 5-factor subdomain (GBI-5F) questionnaire to improve clinical utility. The study aim was to utilize the GBI-5F to measure patient-reported quality of life change in AdSD patients following BoNT-A injection. Methods: The GBI-5F questionnaire was administered to patients diagnosed with AdSD who received a BoNT-A vocal cord injection between December 2022 and May 2023. All patients had received multiple prior injections. GBI-5F subdomains and demographics were analyzed to identify areas for patient-reported improvement. Results: Sixty-six patients completed the GBI-5F. There were 52 (78.7%) females and average age was 69.4 years. The median total benefit score was +40.0 (interquartile range [IQR], 20.0). Median subdomain scores were +83.3 (IQR, 50.0) for quality of life, +50.0 (IQR, 50.0) for self-confidence, +33.3 (IQR, 33.3) for social involvement, +16.7 (IQR, 50.0) for support, and 0.0 (IQR, 16.7) for general health. Differences in the individual subdomain scores were statistically significant ( P < .0001). No significant differences were found in the total GBI-5F score or any subdomain according to sex or presence of vocal tremor (all P > .05). A moderately positive correlation was noted between median total score and percent functional improvement (r = 0.46, P < .001). Conclusion: Botulinum injection therapy for AdSD provides overall benefit to patients as measured by the GBI-5F, with particular improvement observed for perceived quality of life, self-confidence, and social involvement. Sex, presence/absence of vocal tremor, and age do not appear to modify benefit, though degree of functional improvement is positively correlated with total score.

Objective Mechanical thrombectomy (MT) is well-established for the treatment of acute ischemic stroke (AIS) from large vessel occlusion (LVO), with growing data supporting the expansion to distal and medium vessel occlusions (DMVO). Despite successful recanalization in DMVO, certain patients still experience poor long-term clinical outcomes, prompting our study to comprehensively explore pre-MT factors influencing outcome despite excellent recanalization (final modified Thrombolysis in Cerebral Infarction [mTICI] score ≥2c). Methods We retrospectively examined data from patients who consecutively underwent MT for a primary middle cerebral artery (MCA) DMVO across 37 centers in North America, Asia, and Europe. We identified baseline clinical and imaging factors associated with poor clinical outcome (defined as a modified Rankin Scale [mRS] score of 3–6) at 3 months, despite excellent recanalization using a multivariable model. Results Between September 2017 and July 2021, 623 patients achieved mTICI > 2b and they were included in our study. Among them, 198 (32%) experienced a poor clinical outcome (mRS 3–6). Predictors of poor clinical outcome included higher age (OR 1.05 [1.03–1.07], p < 0.001), higher NIHSS at admission (OR 1.12 [1.08–1.15], p < 0.001), higher baseline mRS (OR 1.77 [0.96–3.26], p = 0.067), and diabetes (OR 1.59 [1.01–2.48], p = 0.044). Higher ASPECTS was associated with a decreased risk of poor clinical outcome (OR 0.82 [0.71–0.94], p = 0.006). Conclusion Older age, diabetes, higher baseline mRS, and NIHSS were associated with poor clinical outcome in MCA DMVO despite excellent recanalization. Conversely, a higher ASPECTS decreased the probability of such an outcome.

Abstract Alcohol misuse among women has risen compared to men. Women experience barriers to engaging in patient-centered comparative effectiveness research (CER) that, in turn, limits the evidence base for addressing alcohol misuse in this population. In this manuscript, we describe WomenWise, a community-partnered project and outline how we co-developed community focused CER training curriculum and collaboratively planned future partnered learning sessions (PLSs) with Community Advisory Board (CAB) feedback. Through this approach we aim to empower women to contribute to future patient-centered CER and enhance the stakeholder capacity for future patient-centered research.

Objective To explore if observations on nasopharyngoscopy influence the surgical procedure selected for the management of velopharyngeal insufficiency (VPI). Design Cross-sectional survey. Participants Seventeen surgeons with experience treating VPI. Interventions Review of twenty-four nasopharyngoscopy videos with a combination of velopharyngeal closure patterns and gap sizes. Main Outcome Measures Surgical procedure was selected after watching a nasopharyngoscopy video. Chi-square tests were used to evaluate if, for each surgeon, procedure selection varied based on closure pattern and gap size combination. Variable importance scores were obtained from a random forest analysis to quantify contribution of nasopharyngoscopy observations on procedure selection. Results Four procedures accounted for 86% of all surgeries selected: Furlow double-opposing Z-Plasty (33%), palatal lengthening using buccal myomucosal flaps (20%), pharyngeal flap (19%), and sphincter pharyngoplasty (14%). Four surgeons (23.5%) significantly varied their surgical selection when different closure pattern and gap size combinations were shown on nasopharyngoscopy. Ten surgeons (58%) selected the same procedure in ≥ 50% of the 24 nasopharyngoscopy videos. Individual surgeon preference was the strongest predictor of surgical selection, accounting for 57.9% of surgical selection variance. Velopharyngeal gap size accounted for 36.5% of the variance in surgical selection, yet the specific surgeries selected based on gap size varied widely across surgeons. Closure pattern was a weak predictor, contributing 5.6% to surgical selection variance. Conclusions Nasopharyngoscopy findings influence VPI surgical procedure selection in a highly individualized, surgeon-specific manner. Among factors observed on nasopharyngoscopy, velopharyngeal gap size has a much larger influence on procedure selection than closure pattern.

Abstract Background The radiation oncology clinical practice involves many steps relying on the dynamic interplay of abundant text data. Large language models have displayed remarkable capabilities in processing complex text information. But their direct applications in specific fields like radiation oncology remain underexplored. Purpose This study aims to investigate whether fine‐tuning LLMs with domain knowledge can improve the performance on Task (1) treatment regimen generation, Task (2) treatment modality selection (photon, proton, electron, or brachytherapy), and Task (3) ICD‐10 code prediction in radiation oncology. Methods Data for 15 724 patient cases were extracted. Cases where patients had a single diagnostic record, and a clearly identifiable primary treatment plan were selected for preprocessing and manual annotation to have 7903 cases of the patient diagnosis, treatment plan, treatment modality, and ICD‐10 code. Each case was used to construct a pair consisting of patient diagnostics details and an answer (treatment regimen, treatment modality, or ICD‐10 code, respectively) for the supervised fine‐tuning of these three tasks. Open source LLaMA2‐7B and Mistral‐7B models were utilized for the fine‐tuning with the Low‐Rank Approximations method. Accuracy and ROUGE‐1 score were reported for the fine‐tuned models and original models. Clinical evaluation was performed on Task (1) by radiation oncologists, while precision, recall, and F‐1 score were evaluated for Task (2) and (3). One‐sided Wilcoxon signed‐rank tests were used to statistically analyze the results. Results Fine‐tuned LLMs outperformed original LLMs across all tasks with p value ≤ 0.001. Clinical evaluation demonstrated that over 60% of the fine‐tuned LLMs‐generated treatment regimens were clinically acceptable. Precision, recall, and F1‐score showed improved performance of fine‐tuned LLMs. Conclusion Fine‐tuned LLMs demonstrated statistically significant improvements over original LLMs upon three clinically important tasks in radiation oncology. This study explored the feasibility of applying fine‐tuned LLMs in radiation oncology, inspiring further development of utilizing LLMs to assist with radiation oncology tasks.