Citations

INTRODUCTION: Prophylactic pancreatic stent placement (PSP) is effective for preventing pancreatitis after endoscopic retrograde cholangiopancreatography (ERCP) in high-risk cases, but the optimal technical approach to this intervention remains uncertain. METHODS: In this secondary analysis of 787 clinical trial patients who underwent successful stent placement, we studied the impact of (i) whether pancreatic wire access was achieved for the sole purpose of PSP or naturally during the conduct of the case, (ii) the amount of effort expended on PSP, (iii) stent length, (iv) stent diameter, and (v) guidewire caliber. We used logistic regression models to examine the adjusted association between each technical factor and post-ERCP pancreatitis (PEP). RESULTS: Ninety-one of the 787 patients experienced PEP. There was no clear association between PEP and whether pancreatic wire access was achieved for the sole purpose of PSP (vs occurring naturally; odds ratio [OR] 0.82, 95% confidence interval [CI] 0.37–1.84), whether substantial effort expended on stent placement (vs nonsubstantial effort; OR 1.58, 95% CI 0.73–3.45), stent length (>5 vs ≤5 cm; OR 1.01, 95% CI 0.63–1.61), stent diameter (≥5 vs <5 Fr; OR 1.13, 95% CI 0.65–1.96), or guidewire caliber (0.035 vs 0.025 in; 0.83, 95% CI 0.49–1.41). DISCUSSION: The 5 modifiable technical factors studied in this secondary analysis of large-scale randomized trial data did not appear to have a strong impact on the benefit of prophylactic PSP in preventing PEP after high-risk ERCP. Within the limitations of post hoc subgroup analysis, these findings may have important implications in procedural decision making and suggest that the benefit of PSP is robust to variations in technical approach.

Mobile health (mHealth) technology has assumed a pervasive role in healthcare and society. By capturing real-time features related to spine health, mHealth assessments have the potential to transform multiple aspects of spine care. Yet mHealth applications may not be familiar to many spine surgeons and other spine clinicians. Consequently, the objective of this narrative review is to provide an overview of the technology, analytical considerations, and applications of mHealth tools for evaluating spine surgery patients. Reflecting their near-ubiquitous role in society, smartphones are the most commonly available form of mHealth technology and can provide measures related to activity, sleep, and even social interaction. By comparison, wearable devices can provide more detailed mobility and physiological measures, although capabilities vary substantially by device. To date, mHealth evaluations in spine surgery patients have focused on the use of activity measures, particularly step counts, in an attempt to objectively quantify spine health. However, the correlation between step counts and patient-reported disease severity is inconsistent, and further work is needed to define the mobility metrics most relevant to spine surgery patients. mHealth assessments may also support a variety of other applications that have been studied less frequently, including those that prevent postoperative complications, predict surgical outcomes, and serve as motivational aids to patients. These areas represent key opportunities for future investigations. To maximize the potential of mHealth evaluations, several barriers must be overcome, including technical challenges, privacy and regulatory concerns, and questions related to reimbursement. Despite those obstacles, mHealth technology has the potential to transform many aspects of spine surgery research and practice, and its applications will only continue to grow in the years ahead.

Liver transplantation (LT) is a life‐saving treatment for patients with acute liver failure (ALF). Currently, there are few detailed data regarding long‐term outcomes after LT for ALF. We combined prospective data from the Acute Liver Failure Study Group (ALFSG) Registry with those of the Scientific Registry of Transplant Recipients (SRTR) to assess outcomes among consecutive patients with ALF listed for LT. Cohort analysis of detailed pretransplantation data for patients listed for LT for ALF in the ALFSG Registry between January 1998 and October 2018 matched with transplantation‐related data from the SRTR. Primary outcomes were 1‐ and 3‐year post‐LT patient survival. Secondary outcome was receipt of LT; independent associations with successful receipt of LT were determined using multivariable logistic regression. Of 624 patients with ALF listed for LT, 398 (64%) underwent LT, 100 (16%) died without LT, and 126 (20%) recovered spontaneously. Among LT recipients, etiologies included seronegative/indeterminate (22%), drug‐induced liver injury (18%), acetaminophen overdose (APAP; 16%), and viral hepatitis (15%). The 1‐ and 3‐year post‐LT patient survival rates were 91% and 90%, respectively. Comparing those dying on the waiting list versus with those who received LT, the former had more severe multiorgan failure, reflected by increased vasopressor use (65% vs. 22%), mechanical ventilation (84% vs. 57%), and renal replacement therapy (57% vs. 30%; p < 0.0001 for all). After adjusting for relevant covariates, age (adjusted odds ratio [aOR] 1.02, 95% confidence interval [CI] 1.00–1.04), APAP etiology (aOR 2.72, 95% CI 1.42–5.23), requirement for vasopressors (aOR 4.19, 95% CI 2.44–7.20), Grade III/IV hepatic encephalopathy (aOR 2.47, 95% CI 1.29–4.72), and Model for End‐Stage Liver Disease (MELD) scores (aOR 1.05, 95% CI 1.02–1.09; p < 0.05 for all) were independently associated with death without receipt of LT. Post‐LT outcomes for ALF are excellent in this cohort of very ill patients. The development of multiorgan failure while on the transplantation list and APAP ALF etiology were associated with a lower likelihood of successful receipt of LT.