Citations

Heart transplantation is a well-established treatment for end-stage heart failure, but many patients present in poor physical condition, complicating outcomes. The Impella 5.5 device, used in cardiogenic shock, may support pretransplant rehabilitation by stabilizing organ function and promoting functional improvement. This retrospective cohort study assessed the relationship between functional status, measured by standardized Activity Measure for Post-Acute Care Basic Mobility (AM-PAC) scores, and days alive outside the hospital within 30 days post-transplant (DAOH-30). Patients who received Impella 5.5 support before transplantation between January 2019 and October 2023 were included, excluding those without AM-PAC scores within 24 hours pretransplant. Among 65 patients, the median DAOH-30 was 15 days (interquartile range [IQR], 8–19). Higher pretransplant standardized AM-PAC scores correlate with increased DAOH-30 (adjusted coefficient 0.3; 95% confidence interval [CI] = 0.01–0.6; p = 0.04), as did AM-PAC score improvement during rehabilitation (adjusted coefficient 0.35; 95% CI = 0.01–0.6; p = 0.04). Extended rehabilitation was associated with greater functional gains. These findings suggest that better pretransplant functional status and rehabilitation-related improvements were associated with increased DAOH-30. The Impella 5.5 device facilitates rehabilitation and may enhance post-transplant outcomes. Further research should refine strategies to optimize rehabilitation and recovery in this high-risk population.

ABSTRACTBackgroundMicroplastics are emerging as environmental pollutants with potential neurotoxic effects, yet their association with neurological disabilities remains largely unexplored.MethodsIn this cross‐sectional study comprising 218 coastal counties in the United States, we compared the self‐reported prevalence of cognitive disability, mobility disability, self‐care disability, and independent living disability in counties with very high and low marine microplastic levels (MMLs). Unadjusted and adjusted prevalence ratios (PRs) were computed using population‐weighted quasi‐Poisson regression across three different models to examine the relationship between disability prevalence and MMLs.ResultsCounties exposed to very high marine microplastic levels had a higher mean prevalence of self‐reported cognitive disability (15.2% vs. 13.9%), mobility disability (14.1% vs. 12.3%), self‐care disability (4.2% vs. 3.6%), and independent living disability (8.5% vs. 7.7%) compared to those exposed to low levels (p < 0.001). Regression analyses revealed significantly elevated adjusted prevalence ratios (PRs) for cognitive (PR: 1.09 [95% CI: 1.06–1.12], p < 0.001), mobility (PR: 1.06 [1.03–1.10], p < 0.001), self‐care (PR: 1.16 [1.11–1.20], p < 0.001), and independent living disability (PR: 1.08 [1.05–1.12], p < 0.001) in counties with very high microplastic exposure compared to those with low exposure.ConclusionsThis study highlights a significant association between marine microplastic pollution and the self‐reported prevalence of cognitive, mobility, self‐care, and independent living disabilities at the county level. While merely associative, these findings emphasize the urgent need for further investigation into the individual‐level health impacts of microplastic exposure and underscore the importance of environmental interventions to mitigate potential risks.

Abstract Objectives To compare the efficacy and safety of antibiotic lock therapy (ALT) versus catheter removal in managing central vascular catheter–associated bloodstream infection (CVC-BSI). Methods We conducted a single-centre, retrospective cohort study of adult patients treated with ALT or catheter removal for management of CVC-BSI between 2018 and 2022. The primary outcome was a composite of 90 day microbiological relapse or recurrent BSI. Secondary outcomes included 30 day mortality, CVC-associated complications and Clostridioides difficile infection (CDI). Logistic regression with propensity score-adjustment was used to evaluate differences in outcomes and identify predictors of relapse. Results During the study period, 106 participants received ALT and 181 underwent catheter removal. Patients treated with ALT received shorter courses of systemic antimicrobials (11 versus 14 days; P &lt; 0.001) and had shorter hospital stays (4 versus 10 days; P &lt; 0.001). Median duration of catheter salvage in patients receiving ALT was 28 days (IQR 7–80). Primary composite outcome was similar between both groups, but ALT was associated with a significantly higher risk of microbiological relapse within 90 days (20% versus 7%; adjusted odds ratio 3.93, 95% CI 1.64–9.40; P = 0.002). No significant difference in 30 day mortality, CVC-related complications or CDI was observed. CoNS BSI was an independent predictor of microbiological relapse in patients treated with ALT (OR 2.28; P = 0.05). Conclusions Although ALT offers a non-invasive catheter salvage strategy, its association with higher relapse rates, particularly in CoNS BSI, suggests catheter removal should remain the preferred approach when feasible. ALT could be considered a short-term catheter salvage strategy for pathogens with low virulence when used with close surveillance.

SUMMARY Antibody and antigen detection assays continue to play a significant role in the diagnosis of dimorphic fungal pathogens, including Blastomyces dermatitidis complex, Coccidioides immitis/posadasii , Paracoccidioides species, Histoplasma species , Sporothrix species, and Talaromyces marneffei . The performance characteristics of serologic and antigen detection assays for these pathogens are variable, however, influenced by multiple factors, including sample type, disease presentation, patient immunostatus, and timing of specimen collection relative to symptom onset. As a result, there is a need for a centralized document summarizing the accuracy of currently available antibody and antigen detection assays for each of these agents, including discussion of individual assay nuances and caveats that should be considered by clinicians and laboratorians alike. In addition, this review provides expert recommendations for the utilization and interpretation of serologic and antigen detection assays for these dimorphic pathogens.

AbstractAimThere is increasing adoption of nonoperative management of rectal cancer; however, the extent to which trainees are proficient in nonoperative management is unclear. The aim of this work was to describe the exposure of recent colorectal resident graduates to nonoperative management, their comfort level in assessing clinical responses and their comfort in performing rectal cancer surgeries.MethodThis was an online survey of Accreditation Council for Graduate Medical Education‐certified colorectal surgery residency graduates of training programmes in 2020, 2021 and 2022 utilizing their respective WhatsApp class chat groups. Data on resident comfort in assessing complete or near complete clinical response as part of nonoperative management, adoption in practice and perceived effects on rectal cancer operative experience were collected.ResultsForty five graduates responded, with 83.3% exposed to nonoperative management in training. Eighty five per cent utilize nonoperative management in their own practices and 37.1% felt it had a negative impact on preparing them for rectal cancer surgeries. While 82.4% felt comfortable assessing a complete clinical response, only 61.8% felt comfortable assessing a near complete response. Residents who perceived a positive effect on their training felt more comfortable assessing a complete or near complete response.ConclusionMost recent graduates were exposed to nonoperative management in training and utilize it in practice, although many did not feel comfortable assessing a near complete response. A significant portion felt it had a negative impact on their experience and quantity of rectal cancer surgeries. This suggests a need to improve colorectal resident education in nonoperative management of rectal cancer while simultaneously preserving surgical experience for trainees.

Purpose To evaluate which patient factors are associated with specific metrics of poor access to care in patients with a rotator cuff tear (RCT). Methods The All of Us Database was utilized to form a cohort of patients with RCT between May 2018 and May 2023. Patients with a diagnosis of RCT using Systematized Nomenclature of Medicine clinical terms were included. The association of RCT diagnosis and patient‐specific factors on self‐reported outcomes of “delayed care,” “could not afford care,” “skipped medication,” and “have not seen provider in more than 1 year” were analyzed. Statistical tests performed were univariate regression and multivariable logistic regression. Results In total, 4,265 patients with RCT who completed the access to care survey were included. In the RCT cohort, 26.7% reported delayed care, 24.9% reported an inability to afford care, 12.1% reported skipped medications, and 1.7% reported not seeing a provider in more than 1 year. Multivariable analysis of patient treatment and demographic features revealed younger age, female sex, lower income, poor physical health, and poor mental health to be strongly associated with higher reported rates of delayed care, inability to afford care, and skipped medications. History of rotator cuff repair, marital status, and sexual orientation were not associated with reported poor access to care. Conclusions A quarter of patients with rotator cuff tears report delays in overall medical care and inability to afford care. Among patients diagnosed with RCT, patients of younger age, female sex, low income, and poor physical and mental health have higher odds of decreased access to health care. Clinical Relevance Health care disparities and access to care are topics that should be investigated to reduce them.

Abstract Aims We explored the manifestations of individual weight loss (WL) response to long-term lifestyle interventions on cardiometabolic risk. Methods and results We pooled data from three large long-term lifestyle WL-intervention trials: 24-month DIRECT (ClinicalTrials.gov: NCT00160108; n = 322; 87% adherence), 18-month CENTRAL (ClinicalTrials.gov: NCT01530724; n = 278; 86% adherence), and 18-month DIRECT PLUS (ClinicalTrials.gov: NCT03020186; n = 294; 89% adherence). We analyzed longitudinal changes in cardiometabolic risk markers, including anthropometrics, blood biomarkers, and magnetic-resonance-imaging-assessed fat depots, and measured DNA-methylation, proteomics, and metabolomics. Among trial completers (n = 761, mean age = 50.4 years; 89% men, baseline body-mass-index = 30.1 kg/m2), mean WL was −3.3 kg (−3.5%). We classified participants as Successful-WL (36%) with relative-WL &gt; 5%, WL-Resistant (28%) who did not lose or gained weight, and Moderate-WL (36%) with WL between 0% and 5%. Successful-WL achieved the greatest improvements in multiple health indicators. However, the WL-Resistant also showed some significant improvements, with increased high-density-lipoprotein-cholesterol (HDLc) and decreased leptin and visceral fat (P &lt; 0.05 vs. baseline). Overall, each 1 kg sustained lifestyle-induced WL was associated with improvements in lipid markers and insulin resistance [HDLc (+1.44%), triglycerides (−1.37%), insulin (−2.46%), HOMA-IR (−2.71%), leptin (−2.79%)] and intrahepatic-fat regression (−0.49 absolute-units)] and modest but significant change in systolic and diastolic blood pressures (−0.26% and −0.36%). We identified 12 significant methylation sites that are associated with Successful-WL (FDR &lt; 0.05; AUC = 0.73). Conclusion While only ∼one-third of individuals achieved long-term WL, the Moderate-WL and WL-Resistant individuals could benefit improvements in visceral adiposity and cardiometabolic risk by shifting towards a healthy lifestyle pattern, beyond WL. Site-specific DNA methylation may predict an individual's likelihood of successful WL. Registration NCT00160108, NCT01530724, NCT03020186.

BACKGROUND AND OBJECTIVES: Despite many publications about cavernous malformations (CMs), controversy remains regarding diagnostic and management strategies. To update evidence-based guidelines for the clinical management of brain and spinal cord CMs. METHODS: The Alliance to Cure CMs, the patient support group in the United States advocating on behalf of patients and research in CM, convened a multidisciplinary writing group comprising expert CM clinicians to help summarize the existing literature related to the clinical care of CM, focusing on 5 topics: (1) epidemiology and natural history, (2) genetic testing and counseling, (3) diagnostic criteria and imaging standards, (4) neurosurgical considerations, and (5) neurological considerations. Building on prior evidence-based recommendations reflecting literature review through October 2014, the group conducted a systematic review of the more recent literature, identified references for mandatory citation, rated evidence, developed recommendations, and established consensus according to a prespecified protocol. Finally, the writing group outlined remaining knowledge gaps and controversies to guide future research. RESULTS: From 2672 publications published between October 1, 2014, and March 15, 2023, and meeting key word criteria, 234 were selected based on prearticulated criteria for mandatory consideration in evidence-based recommendations. Topic authors used these and other supporting references to summarize current knowledge and arrive at 53 management recommendations, with unanimous consensus based on a Delphi process. These were rated by class (strength of recommendation) and level (quality of evidence) per the American Heart Association/American Stroke Association criteria. Eighteen recommendations were class 1 (34%), class 2 in 31 (58%), and class 3 in 4 (8%). Three were level A (6%), 19 (36%) were level B, and 31 (58%) were level C. CONCLUSION: Current evidence supports prior and new recommendations for the management of CMs, but many reflect moderate classes and low levels, mandating further research to better inform clinical practice.