Citations

Background: Patients with decompensated cirrhosis experience frequent hospitalizations, yet evidence supporting remote post-discharge care remains limited. This study assessed the impact of cirrhosis-specific Remote Patient Management (CiRPM) program following hospitalization for acutely decompensated (AD) cirrhosis. Methods: Adults hospitalized for AD cirrhosis were included in a three-cohort observational study comparing CiRPM (2021-2024) with contemporary (C-control) and historical controls (H-control, 2018-2019). CiRPM enabled vital-sign and symptom transmission with 24/7 virtual nursing support. Subgroup analyses were conducted by disease etiology, CLIF-C AD score, and decompensation type. IPTW was used to adjust for confounding, and time-to-event outcomes were analyzed using Cox proportional hazards models. Results: Among 430 patients (156 CiRPM, 152 H-control, 122 C-control), mean age was 59 years, 65% had alcohol-associated liver disease (ALD), CLIF-C AD score of 56. CiRPM was associated with lower 90-day liver-related readmissions versus C-control (39% vs. 58%; HR 0.57, p =0.01) and a similar trend versus H-control (39% vs. 52%; HR 0.67, p =0.07). Associations were stronger among patients with CLIF-C AD ≥60 (HR 0.43 vs. H-control, p =0.005; HR 0.51 vs. C-control, p =0.02). Among ALD patients, fewer fluid-related readmissions (OR 0.40 and 0.37; both p <0.001) and recurrent hospitalizations (OR 0.51; p =0.001 and p =0.002) were observed in the CiRPM group. In non-ALD patients, hepatic encephalopathy readmissions were lower (OR 0.29, p =0.004; OR 0.36, p =0.02). Mortality did not differ across groups. Conclusion: CiRPM enrollment was associated with fewer liver-related hospitalizations, particularly among patients with ALD and CLIF-C AD ≥60, supporting targeted remote management as a scalable post-discharge strategy for this high-risk population.

Background: Lumbar laminectomy and fusion may be complicated by cerebrospinal fluid (CSF) leaks. Beta-2 transferrin (B2T) is a diagnostic marker for CSF that has been mostly studied in the context of cranial CSF leak, but its accuracy in diagnosing spinal leaks is less certain. Case Description: A 59-year-old male with chronic back pain and lumbar stenosis underwent a multi-level laminectomy and fusion with a watertight repair of incidental durotomy. Postoperatively, he developed a non-healing surgical wound and persistent high drain output with fluid testing positive for B2T. However, the patient had no clinical symptoms or signs of CSF leak and repeated wound exploration showed no leak. The wound became infected and, due to poor healing, the patient underwent a secondary closure with a negative pressure treatment dressing. Multiple intraoperative dressing changes did not disclose a CSF leak despite the fact that a repeat B2T in the wound fluid remained positive. Conclusions: This report describes a case of false-positive B2T in a patient after lumbar spine surgery. This case highlights the fact that a positive B2T measured in spinal wound fluid may not be diagnostic of a CSF leak. Possible sources of false-positive B2T laboratory results are discussed in this paper.

Abstract INTRODUCTION Combining Alzheimer's disease blood biomarkers may improve prediction of amyloid positivity (A+) compared with single biomarkers. METHODS Logistic regression models using plasma phosphorylated tau 217 (p‐tau217), amyloid beta (Aβ) 42, and Aβ40 were developed in cognitively impaired (CI) participants from Mayo Clinic Rochester (MCR) and validated in Alzheimer's Disease Neuroimaging Initiative (ADNI) and Mayo Clinic Florida (MCF) cohorts. Performance was measured by area under the curve (AUC) and Probability of Amyloid Positivity Score (PAPS). RESULTS Plasma p‐tau217 alone showed high AUC (95% confidence intervals) across cohorts MCR, 0.928 (0.900–0.953); ADNI, 0.938 (0.915–0.959); MCF, 0.935 (0.893–0.970). Adding Aβ42 to regression models yielded marginal model improvement MCR, 0.940 (0.915–0.963); ADNI, 0.945 (0.922–0.965); MCF, 0.960 (0.925–0.986). Utilization of two cutpoints (≥ 90% sensitivity and specificity), yielded ≤ 10% intermediate results for p‐tau217, and ≤ 8% for p‐tau217+Aβ42. Addition of Aβ40 did not improve models’ performance. DISCUSSION An immunoassay‐based p‐tau217 PAPS model accurately predicted amyloid positivity across independent CI cohorts and achieved confirmatory‐test performance with two cutpoints. The added value of Aβ42 was modest and cohort dependent, supporting the potential of use of p‐tau217–based PAPS in clinical workflows.

BACKGROUND AND OBJECTIVES: Surgery for cervical spondylotic myelopathy improves quality of life but remains expensive. We conducted a cost-effectiveness analysis of patients treated with anterior cervical diskectomy/fusion (ACDF), posterior cervical decompression/fusion (PCDF), and laminoplasty (LP) in the Cervical Spondylotic Myelopathy Surgical (CSM-S) Trial, a randomized trial comparing surgical approaches for cervical spondylotic myelopathy. METHODS: In the trial, patients were randomized (2:3) to anterior (ACDF) or posterior surgery (LP or PCDF, at surgeon's discretion). A cost-effectiveness analysis was performed from a societal perspective with a 1-year time horizon, including only US patients as-treated. Cumulative costs were estimated using patient data on utilization and lost productivity using a human capital approach. Direct costs were calculated using 2022 Medicare rates for professional fees and cost-to-charge ratios for hospital services. Quality-adjusted life-years (QALYs) were calculated from patient responses to the EuroQol-5-Dimensions instrument at baseline and 3, 6, and 12 months postoperatively. Incremental cost-effectiveness ratio analysis was performed with bootstrapping to address uncertainty. RESULTS: Of 163 total patients enrolled in the CSM-S Trial, 153 from the United States (mean age, 62 years; 80 (52%) female) were included as-treated (ACDF = 61, PCDF = 64, LP = 28) in a cost-effectiveness analysis. Economic data were not available for 9 patients. The remaining 144 patients treated (ACDF = 55, PCDF = 61, LP = 28) had cost data through a 1-year follow-up. Mean hospitalization costs were higher after PCDF than ACDF and LP ($33 410 vs $26 468 vs $25 550; P < .001). Mean total costs were higher after PCDF than ACDF and LP ($62 383 vs $53 074 vs $47 426; P = .017). LP yielded greater QALY gains than ACDF (0.792 vs 0.732; P = .08) and PCDF (0.792 vs 0.698; P = .01). At a willingness-to-pay threshold of $150 000/QALY-gained, the probability that LP was cost-effective compared with PCDF was 99.7% and the probability compared with ACDF was 96%. CONCLUSION: In the CSM-S Trial, LP yielded greater 1-year quality-of-life improvements at lower costs than PCDF and ACDF.

Chimeric antigen receptor T-cell (CAR-T) and CD20xCD3 bispecific antibody (BsAb) therapies are both effective for relapsed/refractory (R/R) follicular lymphoma (FL), but comparative real-world survival outcomes and time toxicity have not been characterized. We performed a multicenter retrospective study of 228 patients with R/R FL treated with standard-of-care CAR-T (n = 141) or BsAb (n = 87) across 17 U.S. academic centers in the third-line or later setting. Progression-free survival (PFS) and overall survival (OS) were stratified by 2 or ≥3 prior lines of therapy (LOT2 or LOT3+), including propensity matching. Time toxicity was measured by physical health care contact days. Median PFS was not reached (NR) with CAR-T and 581 days with BsAb in the LOT2 cohort (p &lt; .0001), and was NR with CAR-T and 584 days with BsAb in the LOT3+ cohort (p = .0064). CAR-T recipients were younger (p &lt; .0001) and had better performance status (p = .007) but were more refractory to prior LOT (p = .017). PFS advantages of CAR-T were independent of these differences. OS did not differ between treatment groups. CAR-T had significantly greater time toxicity over the first year, with higher mean contact days than BsAb in both the LOT2 (58 vs 44) and LOT3+ (69 vs 49) cohorts. In this large multicenter cohort of patients with R/R FL, CAR-T was associated with superior PFS but greater time toxicity compared with BsAb therapy. These findings provide real-world outcomes data and time toxicity benchmarks to support treatment sequencing decision-making in R/R FL.

Objective During open chondral defect preparation, audible debridement sound changes mark the transition from deep cartilage to the calcified cartilage layer. We developed a novel curette microphone to characterize these audio feature differences during arthroscopic defect preparation. Design A piezoelectric curette microphone was used to transmit and record debridement sound from 12 defect preparations (6 deep cartilage, 6 CCL) using human osteochondral allograft remnants. Live audio from the device was used to stop each debridement at the intended level, which was verified histologically. Spectrograms and power-spectral density plots were used to describe the audible transition from deep cartilage to CCL. We compared 22 audio features describing loudness, frequency, and complexity between the two tissue levels. Results Curette strokes against the deep cartilage were louder, higher frequency, and more acoustically complex than strokes against the CCL (p < 0.001). Cartilage debridement generated acoustically complex frequency bands above 2.5 kHz that diminished upon reaching the CCL. Debridement of the CCL produced a simpler audio profile that was predominant below 350 Hz. Conclusion The novel curette microphone presented here transmits high-fidelity debridement audio that can be used to accurately distinguish tissue depth based on the distinct audio profiles of the deep cartilage and CCL.

Abstract Background The T6 neurological level of spinal cord injury (SCI) is classically taught as differentiating who is and is not at risk for autonomic dysreflexia (AD); yet the reliability of this metric has rarely been tested. Objectives To determine how often individuals with SCI above and below the T6 neurological level of injury (NLI) experience symptomatic AD, quantify AD in the autonomic physiology laboratory, and describe underlying mechanisms that clinically manifest. Design Cross‐sectional. Setting Academic medical center. Participants 138 individuals with/without SCI. Interventions Not applicable. Main Outcome Measures Symptoms of AD were quantified using the validated Autonomic Dysfunction Following SCI‐AD survey. Deep autonomic physiology characterization was further completed ( n = 34 uninjured controls, n = 28 individuals with SCI) to identify underlying AD mechanisms. Continuous blood pressure, heart rate, regional vascular resistance in the arm/leg, and pre/posttest catecholamines were recorded. Vascular responsiveness and baroreflex sensitivity were assessed with intravenous phenylephrine boluses. Foot cold pressor and bladder pressor tests served as below level mild noxious stimuli to elicit controlled AD. Results AD symptoms were, as expected, significantly higher after SCI compared to uninjured controls ( p < .001). Symptomatic AD was identified in 77% of individuals with SCI at/above T6, compared to 38% with injuries below T6. McNemar's statistic indicated the T6 neurological level poorly differentiated who developed symptomatic AD ( p = .039). During laboratory testing, 57% of those with SCI at/above T6 experienced AD, as did 57% of those with injuries below T6 ( p = .33). Physiologically, AD in individuals with SCI below T6 can be due to heightened vascular responsiveness and poor baroreflex sensitivity, leading to minimal compensatory bradycardia. Conclusions Symptomatic and objective AD occurs in those with SCI above and below the T6 NLI threshold. As such, targeted autonomic testing must translate to the bedside to accurately quantify AD risk. In the interim, though the T6 threshold has become cannon in many patient and resident education materials regarding AD risk, evidence suggests clinical care should avoid using this strict cutoff.

Abstract Positron emission tomography (PET)-based molecular imaging is a clinically important tool for the evaluation of dementia and other neurodegenerative disorders, using radiotracers that target specific molecular and pathophysiological processes. Fluorodeoxyglucose brain PET has historically supported neurodegenerative disorder evaluation through detection of characteristic patterns of regional glucose hypometabolism. In recent years, the molecular imaging of protein aggregates has taken on an increasingly important role. This is evident with the widespread clinical adoption of amyloid PET and early use of tau PET to provide diagnostic and prognostic information for patients with suspected Alzheimer’s disease. Additional classes of radiotracers relevant to neurodegenerative diseases are under active investigation, including those targeting neuroinflammation, synaptic density, and α-synuclein aggregates. We review the major classes of PET radiotracers for neurodegenerative diseases, describing their molecular mechanisms, diagnostic performance, and their current and emerging clinical roles in dementia evaluation. Case examples for clinically used tracers illustrate imaging features relevant to diagnosis and characterization of prognosis and treatment effect. Finally, we discuss early developments and current challenges in the development of theranostic approaches and novel radiotracers for neurodegenerative diseases.

Background: Iliopsoas impingement (IPI) is a known cause of persistent anterior hip pain following total hip arthroplasty (THA). Management of IPI has often relied on an 8-mm anterior acetabular overhang threshold to guide operative treatment, favoring acetabular revision for greater overhang and iliopsoas tenotomy for lesser overhang. These thresholds were initially established on the basis of the outcomes of open tenotomy, and now, with an improved understanding of IPI and the advent of arthroscopic iliopsoas fractional lengthening (IPFL), a review of the 8-mm threshold is warranted. Methods: A retrospective review was performed to identify patients who underwent arthroscopic IPFL following primary THA between 2017 and 2024, with a minimum follow-up of 1 year. Acetabular overhang was measured for all patients using cross-table lateral radiographs, and patients were stratified into <8-mm and ≥8-mm cohorts. Patient-reported outcome measures, reoperations, revisions, and complications were collected and analyzed on the basis of both the classic 8-mm threshold and continuous statistical methods. Results: We evaluated 86 hips undergoing IPFL. There were 83 patients (30 men and 53 women), with a mean age of 63.0 ± 11.2 years; with regard to race, 80 patients were White, 1 patient was Black or African American, and 2 patients listed other race or chose not to disclose. The acetabular overhang was <8 mm for 67 hips and ≥8 mm for 19 hips. The mean follow-up was 2.5 ± 1.6 years (range, 1 to 7.5 years). When comparing patients with <8-mm and ≥8-mm acetabular overhang, we observed no significant differences (p > 0.06) in the preoperative and postoperative visual analog scale (VAS) pain scores, modified Harris hip score, Single Assessment Numeric Evaluation (SANE) score, Tegner activity level, subjective groin pain improvement, subjective hip flexion strength improvement, and overall satisfaction. Reoperation (2.9% compared with 10.5%; p = 0.210) and acetabular revision rates (1.5% compared with 5%; p = 0.387) were not significantly different between the <8-mm and ≥8-mm overhang groups. Conclusions: Arthroscopic IPFL provided satisfactory outcomes for patients with IPI, independent of the magnitude of acetabular overhang. IPFL should be considered for first-line surgical management of IPI refractory to nonoperative management, even in the setting of substantial acetabular overhang, given positive outcomes and low rates of subsequent acetabular revision. Level of Evidence: Therapeutic Level IV . See Instructions for Authors for a complete description of levels of evidence.