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Same-Day Discharge After Left Bundle Area Pacing
No full textBackground: Left bundle area pacing (LBAP) has emerged as an area that appears to be an attractive alternative to other forms of physiological pacing owing to its ease and favorable pacing parameters. Same-day discharge after conventional pacemakers, implantable cardioverter defibrillators, and more recently leadless pacemakers have become routine, especially after the COVID-19 pandemic. With the advent of LBAP, the safety and feasibility of same-day discharge remain unclear.
Methods: This is a retrospective, observational case series of consecutive, sequential patients undergoing LBAP at Baystate Medical Center, an academic teaching hospital. We included all patients who underwent LBAP and were discharged on the same day of procedure completion. Safety parameters included any procedure-related complications including pneumothorax, cardiac tamponade, septal perforation, and lead dislodgement. Pacemaker parameters included pacing threshold, R-wave amplitude, and lead impedance pre-discharge the following day of implantation and up to 6 months of follow-up.
Results: A total of 11 patients were included in our analysis, the average age was 70.3 ± 6.74 years. The most common indication for pacemaker insertion was AV block (73%). No complications were seen in any of the patients. The average time between the procedure and discharge was 5.6 hours. Pacemaker and lead parameters were stable after 6 months of follow-up.
Conclusions: In this case series, we find that same-day discharge after LBAP for any indication is a safe and feasible option. As this mode of pacing becomes increasingly more common, larger prospective studies evaluating the safety and feasibility of early discharge after LBAP will be needed
NPM 1 Mutations in AML-The Landscape in 2023
No full textAcute myeloid leukemia (AML) represents 80% of acute leukemia in adults and is characterized by clonal expansion of hematopoietic stem cells secondary to genomic mutations, rendering a selective growth advantage to the mutant clones. NPM1mut is found in around 30% of AML and clinically presents with leukocytosis, high blast percentage and extramedullary involvement. Considered as a gate-keeper mutation, NPM1mut appears to be a first hit in the process of leukemogenesis and development of overt leukemia. Commonly associated with other mutations (e.g., FLT 3, DNMT3A, TET2, SF3B1), NPM1 mutation in AML has an important role in diagnosis, prognosis, treatment and post-treatment monitoring. Several novel therapies targeting NPM1 are being developed in various clinical phases with demonstration of efficacy. In this review, we summarize the pathophysiology of the NPM1 gene mutation in AML, clinical implications and the novel targeted therapies to date.
Keywords: CAR-T cells; XPO1 inhibitors; acute myeloid leukemia (AML); arsenic trioxide; exportin 1; menin inhibitors; minimal residual disease (MRD); nucleophosmin (NPM1) mutation
HCV serostatus and injection sharing practices among those who obtain syringes from pharmacies and directly and indirectly from syringe services programs in rural New England
No full textBackground: Among people who inject drugs (PWID), obtaining syringes via syringe services programs (SSPs) and pharmacies reduces injection sharing practices associated with hepatitis C virus (HCV). Whether indirect use of SSPs via secondary exchange confers a similar benefit remains unknown, particularly in rural settings. We compared HCV serostatus and injection sharing practices by primary syringe source among a sample of rural PWID.
Methods: Data are from a cross-sectional study of adults who use drugs recruited from eleven rural counties in New Hampshire, Vermont, and Massachusetts using respondent-driven sampling (2018-2019). Study staff performed HCV antibody testing. An audio computer-assisted self-interview assessed sociodemographic characteristics, past 30-day injection practices, and past 30-day primary syringe source. Primary syringe source was classified as direct SSP, pharmacy, indirect SSP (secondary exchange), or other (friend/acquaintance, street seller, partner/relative, found them). Mixed effects modified Poisson models assessed the association of primary syringe source with HCV seroprevalence and injection sharing practices.
Results: Among 397 PWID, the most common primary syringe source was other (33%), then pharmacies (27%), SSPs (22%), and secondary exchange (18%). In multivariable models, compared with those obtaining most syringes from other sources, those obtaining most syringes from pharmacies had a lower HCV seroprevalence [adjusted prevalence ratio (APR):0.85, 95% confidence interval (CI) 0.73-0.9985]; however, the upper bound of the 95% CI was close to 1.0. Compared with those obtaining most syringes from other sources, PWID obtaining most syringes directly from SSPs or pharmacies were less likely to report borrowing used syringes [APR(SSP):0.60, 95% CI 0.43-0.85 and APR(Pharmacies):0.70, 95% CI 0.52-0.93], borrowing used injection equipment [APR(SSP):0.59, 95% CI 0.50-0.69 and APR (Pharmacies):0.81, 95% CI 0.68-0.98], and backloading [APR(SSP):0.65, 95% CI 0.48-0.88 and APR(Pharmacies):0.78, 95% CI 0.67-0.91]. Potential inverse associations between obtaining most syringes via secondary exchange and injection sharing practices did not reach the threshold for statistical significance.
Conclusions: PWID in rural New England largely relied on informal syringe sources (i.e., secondary exchange or sources besides SSPs/pharmacies). Those obtaining most syringes from an SSP or pharmacy were less likely to share injection equipment/syringes and had a lower HCV seroprevalence, which suggests using these sources reduces the risk of new HCV infections or serves as proxy for past injection behavior.
Keywords: Hepatitis C virus; Pharmacy; Rural; Secondary exchange; Syringe services programs
Total and subgenomic RNA viral load in patients infected with SARS-CoV-2 Alpha, Delta, and Omicron variants
No full textBackground: SARS-CoV-2 genomic and subgenomic RNA levels are frequently used as a correlate of infectiousness. The impact of host factors and SARS-CoV-2 lineage on RNA viral load is unclear.
Methods: Total nucleocapsid (N) and subgenomic N (sgN) RNA levels were measured by RT-qPCR in specimens from 3,204 individuals hospitalized with COVID-19 at 21 hospitals. RT-qPCR cycle threshold (Ct) values were used to estimate RNA viral load. The impact of time of sampling, SARS-CoV-2 variant, age, comorbidities, vaccination, and immune status on N and sgN Ct values were evaluated using multiple linear regression.
Results: Ct values at presentation for N (mean ±standard deviation) were 24.14±4.53 for non-variants of concern, 25.15±4.33 for Alpha, 25.31±4.50 for Delta, and 26.26±4.42 for Omicron. N and sgN RNA levels varied with time since symptom onset and infecting variant but not with age, comorbidity, immune status, or vaccination. When normalized to total N RNA, sgN levels were similar across all variants.
Conclusions: RNA viral loads were similar among hospitalized adults, irrespective of infecting variant and known risk factors for severe COVID-19. Total N and subgenomic RNA N viral loads were highly correlated, suggesting that subgenomic RNA measurements adds little information for the purposes of estimating infectivity.
Keywords: SARS-CoV-2; subgenomic RNA; variants of concern; viral load
Characterization and Management of Type II and Complex Endoleaks after Fenestrated/Branched Endovascular Aneurysm Repair
No full textIntroduction: Endoleaks are more common after fenestrated/branched endovascular aneurysm repair (F/B-EVAR) than infrarenal EVAR secondary to the length of aortic coverage and number of component junctions. While reports have focused on type I and III endoleaks, less is known regarding type II endoleaks following F/B-EVAR. We hypothesized that type II endoleaks are common, and often complex (associated with additional endoleak types), given the potential for multiple inflow and outflow sources. We sought to describe the incidence and complexity of type II endoleaks after F/B-EVAR.
Methods: F/B-EVAR data prospectively collected at a single institution in an investigational device exemption clinical trial (G130210) were retrospectively analyzed (2014-2021). Endoleaks were characterized by type, time to detection, and management. Primary endoleaks were defined as those present on completion imaging or at first postoperative imaging; secondary were those on subsequent imaging. Recurrent endoleaks were those that developed after a successfully resolved endoleak. Reinterventions were considered for type I or III endoleaks, or any endoleak associated with sac growth \u3e5mm. Technical success, defined as absence of flow in the aneurysm sac at procedure conclusion as well as methods of intervention were captured.
Results: Among 335 consecutive F/B-EVARs (mean±SD follow-up 2.5±1.5 years), 125 patients (37%) experienced 166 endoleaks (81 primary, 72 secondary, 13 recurrent). Of these 125 patients, 50 (40% of patients) underwent 71 interventions for 60 endoleaks. Type II endoleaks were the most frequent (n=100, 60%), with 20 identified during the index procedure, 12 (60%) of which resolved prior to 30-day follow-up. Of the 100 type II endoleaks, 20 (20%; 12 primary, 5 secondary, 3 recurrent) were associated with sac growth; 15 (75%) of those with associated sac growth underwent intervention. At intervention, 6 (40%) were reclassified as complex, with concomitant type I or type III endoleak. Initial technical success for endoleak treatment was 96% (68 of 71). There were 13 recurrences, all of which were associated with complex endoleaks.
Conclusions: Nearly half of the patients who underwent F/B-EVAR experienced an endoleak. The majority were classified as type II, with nearly a fifth associated with sac expansion. Interventions for type II endoleak frequently led to reclassification as complex, with a concomitant type I or III endoleak not appreciated on CTA and/or duplex. Further study is needed to determine if the primary treatment goal for complex aneurysm repair is sac stability or sac regression, as this would inform both the importance of properly classifying endoleaks noninvasively and the intervention threshold for managing type II endoleaks.
Keywords: NESVS 2022 Annual Meeting; endoleak; fenestrated branched endovascular aneurysm repair; thoracoabdominal aneurysm; type II endoleak
Invited Commentary: Persistence Pays Off- Pursuing NED Status in Hepatoblastoma Improves Survival: An Observational Study by Fleming A, et al
No full textPrognostic Language in Critical Neurologic Illness: A Multicenter Mixed-Methods Study
No full textBackground and objectives: There are no evidence-based guidelines for discussing prognosis in critical neurologic illness, but in general, experts recommend that clinicians communicate prognosis using estimates, such as numerical or qualitative expressions of risk. Little is known about how real-world clinicians communicate prognosis in critical neurologic illness. Our primary objective was to characterize prognostic language clinicians used in critical neurologic illness. We additionally explored whether prognostic language differed between prognostic domains (e.g., survival, cognition).
Methods: We conducted a multi-center cross-sectional mixed-methods study analyzing de-identified transcripts of audio-recorded clinician-family meetings for patients with neurologic illness requiring intensive care (e.g., intracerebral hemorrhage, traumatic brain injury, severe stroke) from seven U.S.
Centers: Two coders assigned prognostic language type and domain of prognosis to each clinician prognostic statement. Prognostic language was coded as probabilistic (estimating the likelihood of an outcome occurring, e.g., 80% survive ; She\u27ll probably survive ) or non-probabilistic (characterizing outcomes without offering likelihood; e.g., She may not survive ). We applied univariate and multivariable binomial logistic regression to examine independent associations between prognostic language and domain of prognosis.
Results: We analyzed 43 clinician-family meetings for 39 patients with 78 surrogates and 27 clinicians. Clinicians made 512 statements about survival (median 0/meeting [IQR 0;2]), physical function (median 2[IQR 0;7]), cognition (median 2[IQR 0;6]) and overall recovery (median 2[IQR 1;4]). Most statements were non-probabilistic (316/512 [62%]), 10/512(2%) of prognostic statements offered numeric estimates, and 21% (9/43) of family meetings only contained nonprobabilistic language. Compared to statements about cognition, statements about survival (OR 2.50[95% CI 1.01, 6.18]; p=0.048) and physical function (OR 3.22[1.77, 5.86]; p\u3c0.001) were more frequently probabilistic. Statements about physical function were less likely to be uncertainty-based than statements about cognition (OR 0.34 [95% CI 0.17-0.66]; p=0.002).
Discussion: Clinicians preferred not to use estimates (either numeric or qualitative) when discussing critical neurologic illness prognosis, especially when they discussed cognitive outcomes. These findings may inform interventions to improve prognostic communication in critical neurologic illness
Individualizing methadone treatment with split dosing: An underutilized tool
No full textMethadone\u27s long half-life typically allows for once daily dosing. However, a growing body of evidence and clinical experience shows that some patients may benefit from twice-daily ( split ) dosing to produce more stable symptoms and minimize side effects, independent of serum peak-to-trough levels. Concerns regarding split dosing typically center on diversion and poor adherence and must be taken seriously. However, policy changes during COVID-19 demonstrate that the rigidity historically applied to methadone may be unnecessarily stringent. Given clinical advances and policy updates, we believe clinicians should weigh the risks and benefits of this underutilized tool for select patients, as we await the evidence-based recommendations our patients deserve.
Keywords: COVID-19; Methadone; Opioid treatment program; Split dosing
ASSESSMENT OF PATIENT SATISFACTION WITH HOME VERSUS OFFICE INDWELLING CATHETER REMOVAL PLACED FOR URINARY RETENTION AFTER FEMALE PELVIC FLOOR SURGERY: A RANDOMIZED CONTROLLED TRIAL
No full textObjectives: To assess patient satisfaction with location of indwelling catheter removal placed for urinary retention after urogynecologic surgery.
Materials and methods: All adult women who were diagnosed with urinary retention requiring post-operative indwelling catheter insertion after undergoing surgery for urinary incontinence and/or pelvic organ prolapse were eligible for this randomized controlled study. They were randomly assigned to catheter removal at home or in the office. Those who were randomized to home removal were taught how to remove the catheter prior to discharge, and discharged home with written instructions, a voiding hat, and 10 mL syringe. All patients had their catheter removed 2-4 days after discharge. Those patients who were allocated to home removal were contacted in the afternoon by the office nurse. Subjects who graded their force of urine stream 5, on a scale of 0-10, were considered to have safely passed their voiding trial. For patients randomized to the office removal group, the voiding trial consisted of retrograde filling the bladder to maximum they could tolerate up to 300 mL. Urinating \u3e50% of instilled volume was considered successful. Those who were unsuccessful in either group had catheter reinsertion or self-catheterization training in the office. Primary study outcome was patient satisfaction, measured based on patients\u27 response to a question How satisfied were you with the overall removal process of the catheter? . A visual analogue scale was created to assess patient satisfaction and 4 secondary outcomes. A sample size of 40 participants per group were needed to detect a 10 mm difference in satisfaction between groups on the visual analogue scale. This calculation provided 80% power and an alpha of 0.05. Final number accounted for 10% loss to follow up. We compared the baseline characteristics including urodynamic parameters, relevant perioperative indices, and patient satisfaction between the groups.
Results: Of the 78 women enrolled in the study, 38 (48.7%) removed their catheter at home and 40 (51.3%) had an office visit for catheter removal. Median and interquartile range (IQR) for age, vaginal parity, and body mass index (BMI) were 60 (49-72) years, 2 (2-3), and 28 (24-32) kg/m2, respectively, in the overall sample. Groups did not differ significantly in age, vaginal parity, body mass index, prior surgical history, or type of concomitant procedures. Patient satisfaction was comparable between the groups, with a median score (IQR) of 95 (87-100) in the home catheter removal group and 95 (80-98) in the office catheter removal group (p=0.52). Voiding trial pass rate was similar between women who underwent home (83.8%) versus office (72.5%) catheter removal (p=0.23). No participants in either group had to emergently come into the office or hospital due to inadequate voiding afterwards. Within 30 days post operatively, a lower proportion of women in the home catheter removal group (8.3%) had urinary tract infection, compared to patients in the office catheter removal group (26.3%) (p=0.04).
Conclusion: In women with urinary retention after urogynecologic surgery, there is no difference in satisfaction with regards to location of indwelling catheter removal when comparing home and office.
Keywords: bladder emptying; self-catheter removal; urinary retention; voiding difficulty; voiding trial
Frontofacial Features of Unilateral Lambdoid Craniosynostosis: A Multicenter Assessment
No full textUnilateral lambdoid craniosynostosis is differentiated from deformational plagiocephaly primarily by assessing the cranium from posterior and bird\u27s-eye views. Findings include posterior displacement of the ipsilateral ear, ipsilateral occipitomastoid bossing, ipsilateral occipitoparietal flattening, contralateral parietal bossing, and contralateral frontal bossing. Diagnosis based off facial morphology may be an easier approach because the face is less obstructed by hair and head-coverings, and can easily be assessed when supine. However, frontofacial characteristics of unilateral lambdoid craniosynostosis are not well described.
Methods: A retrospective cohort review of patients with isolated, unilateral lambdoid craniosynostosis from the Children\u27s Hospital of Pittsburgh and the Children\u27s Hospital of Philadelphia was performed. Preoperative frontal and profile photographs were reviewed for salient characteristics.
Results: Nineteen patients met inclusion criteria. Eleven patients had left lambdoid craniosynostosis, and eight had right lambdoid craniosynostosis. All patients were nonsyndromic. Patients demonstrated contralateral parietal bossing and greater visibility of the ipsilateral ear. Contralateral frontal bossing was mild. The orbits were tall and turricephaly was present in varying severity. Facial scoliosis as a C-shaped deformity was present in varying severity. The nasal root and chin pointed to the contralateral side.
Conclusions: The combination of greater visibility of the ipsilateral ear, contralateral parietal bossing, and C-shaped convex ipsilateral facial scoliosis are hallmark frontofacial features of unilateral lambdoid craniosynostosis. Although the ipsilateral ear is more posterior, the greater visibility may be attributed to lateral displacement from the mastoid bulge. Evaluation of long-term postoperative results is needed to assess if this pathognomonic facial morphology is corrected following posterior vault reconstruction