Citations

Hazardous alcohol use remains a major contributor to acute and chronic liver disease, while alcohol-associated liver disease (ALD) is a leading indication for liver transplantation. In recent years, embedded, interprofessional ALD clinics have improved access to alcohol use disorder care within hepatology and liver transplantation, but more work is needed to meet this challenge. The literature is lacking regarding scaling procedures to provide services for increasingly large ill patient populations. This article begins to fill this gap by describing “expanded ALD care”: broad, innovative, longitudinal, interprofessional care delivery strategies surpassing standalone clinics. Drawing from analogous patient populations served by collaborative models in primary care and comprehensive eating disorder treatment, the expanded ALD care framework proposes practical strategies toward specific innovations: equipoise between biomedical and psychosocial care elements, increased clinician number and reach, long-term patient relationships, harm reduction and palliative care, outreach to external agencies and clinicians, and enhanced support for patients and families. The article also defines attributes of innovative healthcare systems that support expanded ALD care.

Objective: Reverse hybrid coronary revascularization (RHCR) is the integration of percutaneous coronary intervention (PCI) followed by sternal-sparing coronary artery bypass grafting in patients with multivessel coronary artery disease (CAD). We sought to review our RHCR experience over a 10-year period using PCI first followed by robotic totally endoscopic coronary artery bypass (TECAB). Methods: We reviewed the indications and outcomes in patients who underwent RHCR (PCI with drug-eluting stents first, followed by TECAB). Results: From July 2013 to August 2024, 882 robotic TECAB procedures were performed at our institution. Of these, 60 patients underwent RHCR. The mean age of the patients was 66.7 ± 10 years, and 74% were male patients. The target vessel stented was the right coronary artery in 52 patients (87%), circumflex coronary artery in 10 patients (17%), and diagonal in 4 patients (7%). The average time from PCI to TECAB was 3.8 ± 1.64 months. A total of 35 patients (58%) underwent multivessel grafting, with 74% bilateral internal thoracic artery (ITA) use. The mean operative time was 253 ± 88 min, and the mean hospital length of stay was 2 ± 0.76 days. There were no conversions, perioperative strokes, or myocardial infarctions. At mean follow-up of 34 ± 27 months, cardiac-related mortality occurred in 1 patient. Freedom from major adverse cardiac or cerebrovascular events including repeat revascularization was 93%. Conclusions: RHCR is safe and feasible in selected patients with multivessel CAD. In experienced hands, stenting first followed by robotic TECAB with left ITA or bilateral ITA grafts resulted in excellent early and midterm outcomes. Further studies are warranted.

BACKGROUND: Mortality due to ischemic heart disease (IHD) has declined in countries with high socioeconomic development. Whether these declines extend to other settings, and whether socioeconomic development influences IHD mortality among men and women differently, is unknown. METHODS: We obtained annual data on sex-specific IHD mortality rates for countries/territories in the GBD study (Global Burden of Disease) from 1980 to 2021. The sociodemographic index (SI), a measure of socioeconomic development, was retrieved for each country/territory. Age-adjusted IHD mortality rates were modeled as a smooth function of sex, year, and SI. RESULTS: From 1980 to 2021, IHD mortality rates did not decrease in low SI settings for men or women. In contrast, mortality rates relative to 1980 declined by >25% in average SI settings (age-adjusted mortality per 100 000, 153–107 for women and 218–161 for men) and >50% in high SI settings (age-adjusted mortality per 100 000, 162–69 for women and 258–114 for men). Comparing the 20th versus 80th percentile of SI in 2021 (corresponding to lower versus higher socioeconomic development), mortality rates were 81% higher for men and 111% higher for women living in socioeconomically deprived settings ( P for difference by sex: 0.01), although absolute differences were larger in men. The association of low SI with higher IHD mortality was especially pronounced for mortality attributable to environmental/occupational risk factors (eg, particulate matter air pollution, lead exposure, and extremes of temperature), with mortality rates being 174% higher among women and 199% higher among men. CONCLUSIONS: Across the past 4 decades, low socioeconomic development was associated with no improvement in IHD mortality rates for men or women, in contrast to the large reductions observed in settings with high socioeconomic development. In contemporary settings, socioeconomic deprivation is associated with larger relative excess mortality in women and larger absolute excess mortality in men.

Abstract Purpose: Soft-tissue sarcomas are rare malignancies with poor prognosis and limited systemic treatment options. We conducted a phase II study to assess the efficacy and safety of trabectedin and olaparib in patients with advanced disease. Patients and Methods: Patients with soft-tissue sarcoma who received ≥1 prior therapy were recruited into two cohorts. Cohort 1 included leiomyosarcoma and liposarcoma; cohort 2 included other histologies. All patients received trabectedin (1.1 mg/m2 24-hour infusion every 21 days) and olaparib (150 mg twice daily continuously). The study was conducted using a Simon minimax two-stage design with a primary endpoint of objective response (OR) rate per RECIST 1.1. Results: Twenty-nine (cohort 1, 16; cohort 2, 13) patients enrolled; one patient in cohort 2 was not evaluable. There were no confirmed ORs in cohort 1; the best response was stable disease in 12 (75%) patients and progressive disease in four (25%). Two partial responses were observed in cohort 2 (n = 12). The most common adverse events were fatigue (75%), neutropenia (75%), anemia (68%), and thrombocytopenia (68%). The median progression-free survival and overall survival for all patients were 3.5 (95% confidence interval, 3.3–8.2) and 13.2 months (95% confidence interval, 10.3–20.9), respectively. Next-generation sequencing of 17 tumors revealed multiple abnormalities, most commonly in TP53, RB1, and ATRX. Conclusions: Trabectedin plus olaparib conferred high rates of toxicity and failed to demonstrate ORs in leiomyosarcoma and liposarcoma. Preliminary evidence of clinical benefit in two patients in cohort 2 suggests potential value of either or both drugs in other sarcomas.

Problem definition: We study how to leverage patient-specific information to improve a hospital’s operational efficiency. We use abdominal surgery as the clinical setting and study the heterogeneous effects of surgical volume on surgery duration. We develop a framework for using patient-specific information by addressing three important questions: (1) Is the effect of surgical volume heterogeneous across patients with different features? (2) If so, how could patient-specific information that captures the heterogeneous effects of surgical volume on surgery duration be generated? (3) What is the value of patient-specific information in helping a hospital improve its operational efficiency? Methodology/results: Using an instrumental variable approach to address potential endogeneity issues, we first use a regression model to show that the average effect of surgical volume on surgery duration is significant. Then, we use a regression model with interaction terms to show that the effect of surgical volume is heterogeneous. After that, we apply an instrumental variable forest approach to obtain patient-specific volume effects. Finally, we use patient-specific volume effects and an optimization model to assess the potential value of patient-specific information in improving a hospital’s operational efficiency. We find the that total duration of surgeries could be reduced by 2.5%–8.9% if patient-specific volume effects are considered. Managerial implications: This study provides a framework for understanding treatment effect heterogeneity and using patient-specific information to improve a hospital’s operational efficiency. We provide empirical evidence that the effect of surgical volume is heterogeneous and address the challenges of estimating heterogeneous effects for different patients. Our framework can help hospital administrators to better match patients with surgeons, improving a hospital’s operational efficiency. Supplemental Material: The online appendix is available at https://doi.org/10.1287/msom.2023.0019 .

Abstract Background Primary aldosteronism (PA), a primary adrenal disorder leading to excessive aldosterone production by one or both adrenal glands, is a common cause of hypertension. It is associated with an increased risk of cardiovascular complications compared with primary hypertension. Despite effective methods for diagnosing and treating PA, it remains markedly underdiagnosed and undertreated. Objective To develop an updated guideline that provides a practical, clinical approach to identifying and managing PA to improve diagnosis rates and encourage targeted treatment. Methods The Guideline Development Panel (GDP), composed of a multidisciplinary panel of clinical experts and experts in systemic review methodology, used the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach to define 10 questions related to the diagnosis and treatment of PA. Systematic reviews were conducted for each question. The GDP used the GRADE Evidence to Decision (EtD) framework to consider contextual factors, such as stakeholder values and preferences, costs and required resources, cost-effectiveness, acceptability, feasibility, and the potential impact on health equity. Results We suggest that all individuals with hypertension be screened for PA by measuring aldosterone and renin and determining the aldosterone to renin ratio, and that subsequent clinical care be guided by the results. We suggest that individuals with PA receive PA-specific therapy, either medical or surgical. In individuals who screen positive for PA, we suggest (1) commencement of PA-specific medical therapy in individuals who do not desire or are not candidates for surgery and in situations where the probability of lateralizing PA (excess aldosterone produced by one adrenal) is low based on screening results; and (2) aldosterone suppression testing in situations when screening results indicate an intermediate probability for lateralizing PA and individualized decision making confirms a desire to pursue eligibility for surgical therapy. In those who test positive by aldosterone suppression testing, and in those in whom screening results show a high probability of lateralizing PA (obviating the need for aldosterone suppression testing), we suggest adrenal lateralization with computed tomography scanning and adrenal venous sampling prior to deciding the treatment approach (medical vs surgical). In all individuals with PA and an adrenal adenoma, we suggest performing a 1-mg overnight dexamethasone suppression test. We suggest the use of mineralocorticoid receptor antagonists (MRAs) over epithelial sodium-channel (ENaC) inhibitors in the medical treatment of PA. We suggest the use of spironolactone over other MRAs, given its lower cost and greater availability; however, all MRAs, when titrated to equivalent potencies, are anticipated to have similar efficacy in treating PA. Thus, MRAs with greater mineralocorticoid receptor specificity and fewer androgen/progesterone receptor-mediated side effects may be preferred in some situations. In individuals receiving MRA therapy, we suggest monitoring renin and, in those whose hypertension remains uncontrolled and renin is suppressed, titrating the MRA to increase renin. Conclusion These recommendations provide a practical framework for the diagnosis and treatment of PA. They are based on currently available literature and take into consideration outcomes that are important to key stakeholders. The goal is to increase identification of individuals with PA and, by initiating PA-specific medical or surgical therapy, improve blood pressure control and reduce PA-associated adverse cardiovascular events. The guidelines also highlight important knowledge gaps in PA diagnosis and management.

Abstract Goals/Purpose To address the complex problems arising from contemporary aesthetic procedures, specifically focusing on the occurrence of antibiotic-resistant non-tuberculosis mycobacterium (NTM) infections following autologous fat grafting and the development of full-thickness burns due to the use of Renuvion for skin tightening. The study underscores the critical need for stringent aseptic techniques, updated sterilization practices, and thorough understanding of new cosmetic technologies to prevent severe complications. Methods/Technique A 45-year-old otherwise healthy female underwent autologous fat grafting to the face and neck tightening with Renuvion in 2023 at an outside aesthetic clinic to address premature facial and cervical ageing. Post-operatively, her course was complicated by multiple midface abscesses from fat grafting and third-degree burns to the neck from Renuvion. She initially sought treatment at a local community hospital, where aspiration was performed which revealed a Mycobacterium fortuitum infection. Despite debridement and antibiotics for the abscesses and xenograft application for her cervical burns, her symptoms persisted, prompting presentation to our tertiary care center. On arrival to our facility, the patient exhibited multiple dermal and subcutaneous abscesses in the premaxillary soft tissues. Broad-spectrum antibiotics were initiated, and she underwent surgical incision and drainage. Cultures identified a multiple resistant Mycobacterium fortuitum complex. Following infectious disease consultation, she commenced a 10-month course of IV antibiotic therapy involving three drugs. Despite this, in 2024, she experienced on-going facial drainage, necessitating further debridement and antibiotic therapy. Results/Complications The patient’s condition was complicated by the discovery of a multiply resistant Mycobacterium fortuitum complex. The infection's resistance to standard antibiotics required an extended and rigorous 10-month treatment regimen involving a combination of macrolide, aminoglycoside, and other antibiotics as well as surgical debridement. Despite aggressive treatment, persistent facial drainage necessitated further surgical intervention. The chronic and recurring nature of the infection significantly increased morbidity and highlighted the need for a multidisciplinary approach to optimize patient outcomes. Additionally, the use of Renuvion led to full-thickness burns, a complication not previously reported in the literature per extensive review. Conclusion This case report and literature review highlights the increasing complexities and potential complications associated with modern aesthetic procedures, specifically antibiotic resistant NTM infections following autologous fat grafting and full thickness burns in the setting of liposuction and Renuvion skin tightening. It underscores the necessity for meticulous aseptic technique, thorough knowledge of equipment, and adherence to modern sterilization protocols to mitigate the risk of infection. Additionally, the development of thermal injuries with Renuvion emphasizes the need for increased reporting to enable proper training and caution with its application. This case report is limited by the inability to definitively identify the source or etiology of the mycobacterium infection and the specific method that led to the full thickness burn, which highlights the need for further investigation and reporting in these areas. This case report is intended to stimulate discussion, investing, and reporting to ultimately improve safety standards in cosmetic surgery and stresses the importance for patients to seek out board-certified and qualified plastic surgeons, as their expertise and adherence to the highest safety standards can significantly reduce the risk of complications such as these.

Abstract Goals/Purpose This study aims to examine the sentiment and polarization of social media content regarding transgender care. We seek to quantitatively analyze social media posts related to transgender care using sentiment analysis, assessing the extent of positive or negative bias in online discussions about transgender healthcare. By establishing a baseline understanding of how online misinformation may impact public perceptions of transgender care, we highlight the importance of addressing online extremism in healthcare as a public health concern. This research represents the first large-scale natural language processing (NLP) analysis of online sentiment towards transgender care, utilizing sentiment analysis to minimize bias and provide quantitative insights into the impact of online rhetoric on public perception and patient care. Methods/Technique The lead author mined X for posts that mentioned transgender surgery (TG) and gender affirming surgery (GAS) from January 2018 to December 2023. Two different NLP models then analyzed the posts. The first was a binary model that characterized each post as positive or negative. The latter was an emotion-based model that scored each post about seven emotions – fear, sadness, anger, disgust, neutral, surprise, and joy. Posts were then classified by their highest-scoring emotion. An exponential regression analysis within the Python language was performed to study the trend in annual X post volume related to gender surgery. To determine whether there were statistically significant differences in sentiment between transgender (TG) and gender-affirming surgery (GAS) topics, independent two-sample t-tests were conducted for both positive and negative sentiments for each year within the study period. Results/Complications In total, there were 81,264 posts related to gender surgery included in our analysis. In 2018 there were 2,093 posts, compared to 2023 where there were 40,258 posts – a roughly 20-fold increase in annual post volume. In our exponential regression model, annual post volume demonstrated a strong positive trend R2 = 0.939, p = 0.001, Figure 1). Most of the posts were classified as ‘negative’ (63,192 posts, 78%). Mean scores for both GAS and TG posts trended towards more negative and less positive sentiments over the study period (Figure 2). When comparing annual TG to GAS posts, those that mentioned TG were significantly more negative and less positive in every year studied (p < 0.05). Conclusion Our analysis of social media posts related to gender-affirming surgery (GAS) and transgender (TG) care reveals a significant increase in online discourse over the past five years. The volume of posts grew exponentially from 2,093 in 2018 to 40,258 in 2023, representing a 20-fold increase. This rise in online discussion reflects the growing public interest and controversy surrounding transgender healthcare.The sentiment analysis revealed a trend toward increasingly negative rhetoric. A substantial majority (78%) of the posts were classified as negative, indicating a prevalence of critical or hostile attitudes towards GAS and TG care on social media platforms. The mean sentiment scores for both GAS and TG-related posts showed a consistent shift toward more negative and less positive sentiments over time. Notably, posts specifically mentioning transgender individuals or issues consistently displayed more negative and less positive sentiments compared to general GAS-related posts across all years studied. This finding suggests that transgender-specific topics are subject to particularly intense scrutiny and criticism online.These results highlight the urgent need for strategies to address misinformation and negative rhetoric surrounding transgender healthcare on social media platforms. The increasing volume and negativity of online discussions may contribute to a hostile environment for transgender individuals seeking care and for healthcare providers offering these services. Future research should focus on developing effective interventions to counter this trend and promote more balanced, informed discussions of transgender healthcare issues online.

Cardiac tumors, though rare, present significant diagnostic and therapeutic challenges due to their heterogeneous nature and anatomical complexity. This narrative review synthesizes current evidence on prevalence, diagnostic modalities, and management strategies for primary and metastatic cardiac tumors. Echocardiography, cardiac MRI, and CT remain cornerstone imaging tools for differentiating tumors from non-neoplastic masses, while advances in PET/CT and tissue characterization techniques refine staging and treatment planning. Surgical resection with clear margins (R0) is critical for resectable tumors, particularly benign myxomas, though malignant tumors like sarcomas require multimodal approaches combining surgery, radiotherapy, and systemic therapies. Emerging strategies such as heart autotransplantation and staged resections offer promise for complex cases, while oligometastatic disease management highlights the role of stereotactic radiotherapy and immunotherapy. Key challenges include standardizing resection margins, optimizing neoadjuvant therapies, and addressing high recurrence rates in malignancies. Future directions emphasize integrating AI-driven imaging analysis, molecular biomarkers, and genomic profiling to personalize therapies, alongside global registries to enhance data on rare tumors. Equitable access to advanced diagnostics and multidisciplinary collaboration are essential to improve outcomes. This review underscores the need for standardized guidelines, technological innovation, and patient-centered research to address gaps in cardiac oncology.