Citations

Objective: To address whether kidney transplant (KTx) candidates, ages 60+, should accept a high Kidney Donor Profile Index (KDPI) kidney and differences when considering a high (>85%) versus low (<85%) KDPI KTx. Background: To date, there is limited survival data to guide decision-making for patients aged ≥60 years who are faced with the choice of accepting a high KDPI kidney or remaining on the waitlist. Methods: Propensity-matched cohort study using data from United Network on Organ Sharing (2014–2021). Cox proportional hazard models and competing risk models allowed comparison of (1) patient survival on the waitlist or after KTx and (2) patient and graft survival after KTx for the second comparison between matched groups, stratified by age groups: 60 to 65, 66 to 70, and 71+. Results: Receiving a >85% KDPI kidney versus remaining on the waitlist was associated with reduced mortality [Hazard Ratio (HR): 0.68, 95% CI: 0.59–0.80, P < 0.001] overall and across the 2 oldest age groups: 66 to 70 (HR: 0.57, 95% CI: 0.44–0.73, P < 0.001) and 71+ (HR: 0.59, 95% CI: 0.44–0.83, P < 0.001). Those aged 60 to 65 did not experience a survival benefit (HR: 0.86, 95% CI: 0.67–1.11, P = 0.259). Patients ages 60+ receiving a >85% or ≤85% KDPI kidney experience comparable survival rates. Conclusions: Our study revealed a survival advantage linked to receiving a lower-quality KTx than remaining on the waitlist in the overall sample and for those 66+. Graft failure and survival were independent of the organ quality.

Background: Disparities in postoperative nausea and vomiting and its prophylaxis may exist based on race, ethnicity, and socioeconomic status. The objective was to evaluate whether patients from racial and ethnic minority groups and patients from lower socioeconomic status backgrounds received less appropriate postoperative nausea and vomiting prophylaxis and experienced higher rates of postoperative and postdischarge nausea and vomiting. Methods: This retrospective cohort study included 23,333 adults who underwent major surgeries (total knee arthroplasty, cholecystectomy, hysterectomy, and prostatectomy) from 2017 to 2022 in a single, multistate hospital system. Outcomes included prophylactic antiemetic administration according to consensus guidelines, as well as the occurrence of postoperative and postdischarge nausea and vomiting, with predictors being patient race and ethnicity, payor type, and community-level socioeconomic status. Results: About 45% (n = 10,407) of patients received guideline-recommended postoperative nausea and vomiting prophylaxis. Regression models showed statistically significant differences in appropriate postoperative nausea and vomiting prophylaxis by race and ethnicity, as well as community-level socioeconomic status, with Black (odds ratio, 0.76; 95% CI, 0.63 to 0.92) and Hispanic (odds ratio, 0.82; 95% CI, 0.70 to 0.96) patients having lower odds of receiving appropriate antiemetic prophylaxis compared to non-Hispanic White patients. Approximately 11% of patients (n = 2,522) experienced postoperative nausea and vomiting in the postanesthesia care unit, and about 19.5% of patients (n = 4,540) experienced postdischarge nausea and vomiting. No significant differences in postoperative nausea and vomiting were observed in the postanesthesia care unit among different groups; however, Black, Hispanic, other races and ethnicities, and patients with Medicaid had higher odds of postdischarge nausea and vomiting. Conclusions: The study identified differences in appropriate postoperative nausea and vomiting prophylaxis by race and ethnicity, as well as community-level socioeconomic status. There were no differences in postoperative nausea and vomiting by the predictors, but there were higher odds of postdischarge nausea and vomiting by race and ethnicity and payor. This study underscores the importance of data stratification in quality measures to identify disparities in perioperative care; it can lead to changes in perioperative anesthetic management. Further research should explore these associations in a broader cohort and address potential confounding sources.

ABSTRACTIntroductionThis study examined simultaneous pancreas–kidney transplant (SPKt) in Black and White patients to identify disparities in transplantation, days on the waitlist, and reasons for SPKt waitlist removal.MethodsUsing the United Network for Organ Sharing Standard Transplant Analysis and Research file, patients between January 1, 2009, and May 31, 2021, were included. Three cohorts (overall, SPKt recipients only, and those not transplanted) were selected using propensity score matching. Conditional logistic regression was used for categorical outcomes. Days on the waitlist were compared using negative binomial regression.ResultsBlack patients had increased odds of receiving a SPKt (OR, 1.25 [95% CI, 1.11–1.40], p < 0.001). White patients had increased odds of receiving a kidney‐only transplant (OR 0.48 [95% CI, 0.38–0.61], p < 0.001), and specifically increased odds of receiving a living donor kidney (OR 0.34 [0.25–0.45], p < 0.001).ConclusionThis study found that Black patients are more likely to receive a SPKt. Results suggest that there are opportunities for additional inquiry related to patient removal from the waitlist, particularly considering White patients received or accepted more kidney‐only transplants and were more likely to receive a living donor kidney‐only transplant.

BACKGROUND: Venous thromboembolism occurs in approximately 2% of patients undergoing abdominal and pelvic surgery for cancers of the colon, rectum, and anus and is considered preventable. The American Society of Colon and Rectal Surgeons recommends extended prophylaxis in high-risk patients, but there is low adherence to the guidelines. OBJECTIVE: This study aims to analyze the impact of venous thromboembolism risk-guided prophylaxis in patients undergoing elective abdominal and pelvic surgeries for colorectal and anal cancers from 2016 to 2021. DESIGN: This was a retrospective analysis. SETTING: The study was conducted at a multisite tertiary referral academic health care system. PATIENTS: Patients who underwent elective abdominal or pelvic surgery for colon, rectal, or anal cancer. MAIN OUTCOME MEASURES: Receipt of Caprini-guided venous thromboembolism prophylaxis, 90-day postoperative rate of deep vein thrombosis, pulmonary embolism, venous thromboembolism, and bleeding events. RESULTS: A total of 3504 patients underwent elective operations, of whom 2224 (63%) received appropriate thromboprophylaxis in the inpatient setting. In the postdischarged cohort of 2769 patients, only 2% received appropriate thromboprophylaxis and no thromboembolic events were observed. In the group receiving inappropriate thromboprophylaxis, at 90 days postdischarge, the deep vein thrombosis, pulmonary embolism, and venous thromboembolism rates were 0.60%, 0.40%, and 0.88%, respectively. Postoperative bleeding was not different between the 2 groups. LIMITATIONS: Limitations to our study include its retrospective nature, use of aggregated electronic medical records, and single health care system experience. CONCLUSION: Most patients in our health care system undergoing abdominal or pelvic surgery for cancers of the colon, rectum, and anus were discharged without appropriate Caprini-guided venous thromboembolism prophylaxis. Risk-guided prophylaxis was associated with decreased rates of inhospital and postdischarge venous thromboembolism without increased bleeding complications. See Video Abstract. MARGEN DE MEJORA: EL IMPACTO DE LA TROMBOPROFILAXIS RECOMENDADA POR LAS DIRECTRICES EN PACIENTES SOMETIDOS A CIRUGÍA ABDOMINAL POR CÁNCER COLORRECTAL Y ANAL EN UN CENTRO DE REFERENCIA TERCIARIO ANTECEDENTES: El tromboembolismo venoso ocurre en aproximadamente el 2% de los pacientes sometidos a cirugía abdominal y pélvica por cánceres de colon, recto y ano, y se considera prevenible. La Sociedad Estadounidense de Cirujanos de Colon y Recto recomienda una profilaxis prolongada en pacientes de alto riesgo, pero el cumplimiento de las directrices es bajo. OBJETIVO: Este estudio tiene como objetivo analizar el impacto de la profilaxis guiada por el riesgo de tromboembolismo venoso (TEV) en pacientes sometidos a cirugías abdominales y pélvicas electivas por cáncer colorrectal y anal entre 2016 y 2021. DISEÑO: Este fue un análisis retrospectivo. AJUSTE: El estudio se llevó a cabo en un sistema de salud académico de referencia terciaria de múltiples sitios. PACIENTES: Pacientes sometidos a cirugía abdominal o pélvica electiva por cáncer de colon, recto o ano. PRINCIPALES MEDIDAS DE RESULTADO: Recepción de profilaxis de tromboembolismo venoso guiada por Caprini, tasa postoperatoria de 90 días de trombosis venosa profunda, embolia pulmonar, tromboembolismo venoso y eventos de sangrado. RESULTADOS: Un total de 3.504 pacientes se sometieron a operaciones electivas, de los cuales 2.224 (63%) recibieron tromboprofilaxis adecuada en el ámbito hospitalario. En el cohorte de 2.769 pacientes después del alta, solo el 2% recibió tromboprofilaxis adecuada en la que no se observaron eventos tromboembólicos. En el grupo que recibió tromboprofilaxis inadecuada, a los 90 días después del alta, las tasas de trombosis venosa profunda, embolia pulmonar y tromboembolia venosa fueron del 0,60%, 0,40% y 0,88%, respectivamente. El sangrado posoperatorio no fue diferente entre los dos grupos. LIMITACIONES: Las limitaciones de nuestro estudio incluyen su naturaleza retrospectiva, el uso de registros médicos electrónicos agregados y la experiencia de un solo sistema de atención médica. CONCLUSIÓN: La mayoría de los pacientes en nuestro sistema de salud sometidos a cirugía abdominal o pélvica por cánceres de colon, recto y ano fueron dados de alta sin una profilaxis adecuada de TEV guiada por Caprini. La profilaxis guiada por el riesgo se asoció con menores tasas de tromboembolismo venoso hospitalario y dado de alta sin un aumento de las complicaciones de sangrado. (Traducción—Dr. Aurian Garcia Gonzalez)

ObjectiveThe aim was to determine the utilization of Caprini guideline‐indicated venous thromboembolism (VTE) prophylaxis and impact on VTE and bleeding outcomes in otolaryngology (ORL) surgery patients.MethodsElective ORL surgeries performed between 2016 and 2021 were retrospectively identified. Logistic regression models were used to examine the association between patient characteristics and receiving appropriate prophylaxis, inpatient, 30‐ and 90‐day VTE and bleeding events.ResultsA total of 4955 elective ORL surgeries were analyzed. Thirty percent of the inpatient cohort and 2% of the discharged cohort received appropriate risk‐stratified VTE prophylaxis. In those who did not receive appropriate prophylaxis, overall inpatient VTE was 3.5‐fold higher (0.73% vs. 0.20%, p = 0.015), and all PE occurred in this cohort (0.47% vs. 0.00%, p = 0.005). All 30‐ and 90‐day discharged VTE events occurred in those not receiving appropriate prophylaxis. Inpatient, 30‐ and 90‐day discharged bleeding rates were 2.10%, 0.13%, and 0.33%, respectively. Although inpatient bleeding was significantly higher in those receiving appropriate prophylaxis, all 30‐ and 90‐day post‐discharge bleeding events occurred in patients not receiving appropriate prophylaxis. On regression analysis, Caprini score was significantly positively associated with likelihood of receiving appropriate inpatient prophylaxis (odds ratio [OR] 1.05, confidence interval [CI] 1.03–1.07) but was negatively associated in the discharge cohort (OR 0.43, CI 0.36–0.51). Receipt of appropriate prophylaxis was associated with reduced odds of inpatient VTE (OR 0.24, CI 0.06–0.69), but not with risk of bleeding.ConclusionAlthough Caprini VTE risk‐stratified prophylaxis has a positive impact in reducing inpatient and post‐discharge VTE, it must be balanced against the risk of inpatient postoperative bleeding.Level of Evidence3 Laryngoscope, 134:1169–1182, 2024

Introduction Acute stroke patients presenting with large vessel occlusion secondary to intracranial atherosclerosis (ICAS‐LVO) may require rescue therapy (RT) in addition to mechanical thrombectomy (MT) to achieve and maintain successful recanalization. We performed a systematic review and meta‐analysis of comparative studies that reported outcomes of RT in ICAS‐LVO patients to evaluate its safety and efficacy. Methods Databases searched include PubMed, CINAHL Complete, and Scopus from database date of inception through August 17, 2021. We included comparative studies that reported the outcomes of ICAS‐LVO RT compared to outcomes of ICAS‐LVO patients who did not undergo RT or to those presenting with embolic LVO patients (non‐ICAS LVO). Meta‐analysis using the random effects model was used to combine estimates reporting odds ratios (OR) and 95% confidence intervals (CI). Results Total of 9 nonrandomized studies were included: 5 studies in ICAS‐LVO RT vs. ICAS‐LVO non‐RT analysis and 5 ICAS‐LVO RT vs. non‐ICAS LVO analysis. Rescue treatments included intra‐arterial antiplatelets, angioplasty, stenting or combination of treatments. Compared to non‐RT ICAS LVO, RT was associated with increased favorable 90‐day outcome (OR 3.19, 95% CI 1.91‐5.32, I2 14%) and decreased 90‐day mortality (OR 0.35, 95% CI 0.16‐0.76, I2 21%) (Figure 1). In the analysis of ICAS LVO vs embolic LVO, the incidence of favorable 90‐day outcome and 90‐day mortality did not differ between the ICAS‐LVO RT and non‐ICAS LVO (OR 0.97, 95% CI 0.58‐1.64, I2 50%) and (OR 1.22, 95% CI 0.90‐1.66, I2 0%), respectively. Conclusions Rescue treatment is associated with better outcomes in ICAS‐LVO patients. The outcomes of ICAS‐LVO patients who receive RT may be comparable to embolic LVO patients (non‐ICAS LVO).

A biliary stricture is an abnormal narrowing in the ductal drainage system of the liver that can result in clinically and physiologically relevant obstruction to the flow of bile. The most common and ominous etiology is malignancy, underscoring the importance of a high index of suspicion in the evaluation of this condition. The goals of care in patients with a biliary stricture are confirming or excluding malignancy (diagnosis) and reestablishing flow of bile to the duodenum (drainage); the approach to diagnosis and drainage varies according to anatomic location (extrahepatic vs perihilar). For extrahepatic strictures, endoscopic ultrasound-guided tissue acquisition is highly accurate and has become the diagnostic mainstay. In contrast, the diagnosis of perihilar strictures remains a challenge. Similarly, the drainage of extrahepatic strictures tends to be more straightforward and safer and less controversial than that of perihilar strictures. Recent evidence has provided some clarity in multiple important areas pertaining to biliary strictures, whereas several remaining controversies require additional research. The goal of this guideline is to provide practicing clinicians with the most evidence-based guidance on the approach to patients with extrahepatic and perihilar strictures, focusing on diagnosis and drainage.

Abstract Coronavirus disease 2019 (COVID-19) infection is associated with risk of persistent neurocognitive and neuropsychiatric complications, termed “long COVID”. It is unclear whether the neuropsychological manifestations of COVID-19 present as a uniform syndrome or as distinct neurophenotypes with differing risk factors and recovery outcomes. We examined post-acute neuropsychological profiles following SARS-CoV-2 infection in 205 patients recruited from inpatient and outpatient populations, using an unsupervised machine learning cluster analysis, with objective and subjective measures as input features. This resulted in three distinct post-COVID clusters. In the largest cluster (69%), cognitive functions were within normal limits, although mild subjective attention and memory complaints were reported. Vaccination was associated with membership in this “normal cognition” phenotype. Cognitive impairment was present in the remaining 31% of the sample but clustered into two differentially impaired groups. In 16% of participants, memory deficits, slowed processing speed, and fatigue were predominant. Risk factors for membership in the “memory-speed impaired” neurophenotype included anosmia and more severe COVID-19 infection. In the remaining 15% of participants, executive dysfunction was predominant. Risk factors for membership in this milder “dysexecutive” neurophenotype included disease-nonspecific factors such as neighborhood deprivation and obesity. Recovery outcomes at 6-month follow-up differed across neurophenotypes, with the normal cognition group showing improvement in verbal memory and psychomotor speed, the dysexecutive group showing improvement in cognitive flexibility, and the memory-speed impaired group showing no objective improvement and relatively worse functional outcomes compared to the other two clusters. These results indicate that there are multiple post-acute neurophenotypes of long COVID, with different etiological pathways and recovery outcomes. This information may inform phenotype-specific approaches to treatment.