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Value of Early Diagnosis and Treatment of Amyloidosis: A Pilot Study of Synovial Biopsy During Carpal Tunnel Release
No full textPURPOSE: The purpose of this study is to calculate the value of early diagnosis and treatment of transthyretin amyloidosis with tafamadis prior to the development of the symptoms of heart failure. In this pilot study of 51 patients, we present the validation of a published algorithm for the early identification of patients at risk for amyloidosis via tenosynovial biopsy during carpal tunnel release. In addition, by integrating clinical data from this pilot study with published predictive models, we aim to calculate the value of routine screening biopsies for transthyretin amyloidosis.
METHODS: Patients presenting for carpal tunnel release surgery had a tenosynovial biopsy collected at the time of surgery. Cost information was gathered from hospital records. In conjunction with published models, five incremental cost effectiveness ratio equations were generated to assess the value of these screening biopsies.
RESULTS: Of the 51 biopsied patients, six tested positive for amyloid, and one was started on tafamadis, a disease-modifying medication. Early diagnosis and treatment of patients with New York Heart Association class I (NYHA I) heart failure as opposed to NYHA IV results at a cost of 155,977.22/QALY. For treatment at NYHA class III compared with NYHA class IV, the cost is 50,000/QALY, early initiation of tafamadis does not represent a cost effective intervention. Routine biopsy of patients is not cost effective with the current cost of therapy and positivity rates of amyloidosis screening.
TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic IB
Effectiveness of the lymphatic microsurgical preventive healing approach for avoiding breast cancer-related arm lymphedema
No full textBACKGROUND: There is currently no proven surgical approach that prevents breast cancer related arm lymphedema (BCRAL). We hypothesized that the lymphatic microsurgical preventive healing approach (LyMPHA) during axillary lymph node dissection (ALND) could reduce BCRAL development.
STUDY DESIGN: We conducted a single-center retrospective cohort study of patients with breast cancer who underwent ALND with or without immediate LyMPHA between 2016 and 2022. Primary outcomes were development of BCRAL and quality of life measures within 4 years of surgery. Secondary outcomes were days to drain removal and postoperative complications. Kaplan-Meier analysis determined risk of BCRAL over time. Cox regression analysis was used to determine risk factors associated with development of BCRAL.
RESULTS: Of 187 patients who underwent ALND, 121 (64.7 %) received LyMPHA and 66 (35.3 %) underwent ALND only. The mean age was 56.4 ± 13.6 years. Patients who underwent LyMPHA had lower risk of lymphedema over time (p = 0.003), lower median percent functional impairment (4.7 % vs 11.6 %, p = 0.045), and shorter median drain duration (13.0 vs 15.0 days; p = 0.042). Regression analysis showed that those who received LyMPHA were half as likely to develop BCRAL (hazard ratio 0.53; 95 % CI 0.28-0.98; p = 0.043). Groups did not differ in the rate of postoperative complications. No other factors were associated with BCRAL, including age, body mass index, smoking status, or history of other cancer therapies.
CONCLUSION: Performing immediate lymphatic reconstruction with LyMPHA after ALND may prevent arm lymphedema and reduce morbidity in patients with breast cancer
Fibroids and Health Equity: Proceedings from the Society of Interventional Radiology Foundation Research Consensus Panel
No full textWhile known health care disparities among patients with fibroids exist, there is a lack of research on health equity in this specific population and how it affects patients seeking care and the treatment options offered or ultimately the selection they make. Subject matter experts from interventional radiology, obstetrics and gynecology, epidemiology, public health, and patient advocacy participated in a Society of Interventional Radiology Foundation Research Consensus Panel to discuss and to prioritize critical research topics focusing on health equity in patients with uterine fibroids. After topic presentations and discussion of research ideas, the panelists prioritized the following topics: (a) a prospective study evaluating whether the introduction of a standard educational program to patients with low health literacy regarding fibroids improves their scores on standardized patient-reported outcome measures; (b) evaluation of whether a digital-based technology can be effectively used to improve health education and awareness of fibroids; and (c) performance of surveys of patients to understand their barriers to accessing fibroid care and their motivations for selecting different fibroid treatments
Optimizing diagnosis in obstructed defecation syndrome: A review of imaging modalities
No full textObstructed defecation syndrome (ODS) is a complex defecatory disorder associated with pelvic floor dysfunction. It affects approximately 50% of women over the age of 50 and significantly impacts their quality of life. The causes of ODS include structural abnormalities such as rectocele, enterocele, intussusception, and pelvic floor descent, as well as functional disorders like anismus. Accurate diagnosis is crucial for effective management due to the high risk of treatment failure associated with inaccurate findings. Various imaging modalities are used to assess pelvic floor disorders, including fluoroscopic defecography (FD), magnetic resonance defecography (MRD), pelvic floor ultrasound (PFUS), and echodefecography (EDF). FD is the most commonly performed test worldwide, offering high accuracy in diagnosing pelvic floor disorders. It provides dynamic visualization of defecation mechanics but involves radiation exposure. MRD offers excellent soft tissue detail and multiplanar imaging without radiation, making it particularly useful for multicompartment disorders; however, it is associated with high procedural costs and limited availability. Both PFUS and EDF are minimally invasive and avoid radiation exposure. PFUS shows promise as a valuable screening tool that could help minimize the need for advanced imaging if findings are normal. EDF is also promising but requires specialized training and remains less widely available. This review evaluates the accuracy, advantages, and limitations of various diagnostic modalities for pelvic floor disorders, aiming to guide optimal clinical decision-making
Impact of Frailty on Physical Activity in the Postoperative Period After Liver Transplant Surgery: Pilot Study Using Fitbit Watch
No full textINTRODUCTION: Robust physical activity after liver transplant (LT) is an important determinant of long-term health. This pilot study aimed to evaluate whether a physical activity monitor (PAM) can be employed to monitor postoperative physical activity levels after LT.
METHODS: Adult patients undergoing LT were screened for inclusion. Several frailty tests, including the liver frailty index, were performed in the preoperative and postoperative periods. All patients were provided with Fitbit Inspire 2 watches to measure biophysical data and were instructed to wear them continuously for 30-60 postoperative days (POD).
RESULTS: Thirty-five patients were enrolled in the study. There was a negative linear correlation between age and the average daily steps during POD 1-30 and POD 31-60 after LT (r = -0.52, P = 0.001; r = -0.36, P = 0.044, respectively). In addition, longer hospital length of stay was negatively associated with daily steps during POD 1-30 and POD 31-60 (r = -0.43, P = 0.01; r = -0.50, P = 0.002, respectively). The majority of patients (89%) reported a medical benefit from using the PAM in the postoperative period.
CONCLUSION: This is the first study to demonstrate the feasibility and utility of providing wearable devices to measure patient physical activity after LT
Intraoperative cephalad migration of endovascular aortic repair endograft resulting in bilateral renal artery coverage
No full textMigration of an endovascular stent graft covering the renal arteries after endovascular aortic repair is a rare but serious complication. We present the case of a 73-year-old man who developed flank pain, oliguria, and a rise in serum creatinine to 4.09 mg/dL on postoperative day 2 following endovascular aortic repair for an infrarenal abdominal aortic aneurysm. The patient was then transferred to our hospital for further management. He was successfully treated with bilateral renal artery stenting through the brachial approach, adequately restoring renal artery perfusion more than 72 hours after his index procedure. The patient tolerated the procedure well and was discharged without significant complications. Follow-up demonstrated sustained renal recovery, with a stable serum creatinine of 1.13 mg/dL. This case presents a rare complication of excluder endograft deployment and highlights the need to be cognizant during limb cannulation and deployment
Oncological outcomes of open versus minimally invasive nephroureterectomy for locally advanced upper tract urothelial carcinoma
No full textINTRODUCTION & OBJECTIVES: It is currently recommended to perform open radical nephroureterectomy (oRNU) with bladder cuff excision in patients with locally advanced (cT3-4 or cN1-2) upper tract urothelial carcinoma (laUTUC). We tested the hypothesis that bladder recurrence-free survival (BRFS), metastasis-free survival (MFS), cancer-specific survival (CSS) and overall survival (OS) are not influenced by the surgical approach in patients with laUTUC using a large multicenter series.
MATERIAL & METHODS: This was a multicenter retrospective cohort study including 361 patients with preoperative cT3-4 cM0 or cN1-2 cM0 laUTUC treated with open or minimally invasive RNU from 1999 to 2019 at 21 academic centers in Europe, Asia, and the United States. Missing values of relevant baseline characteristics were estimated through multiple imputation of chained equations. Baseline patients\u27 heterogeneity was balanced using a 1:1 propensity score matching estimated using logistic regression. Uni- and multivariable Cox regression analyses for bladder recurrence, metastasis, cancer-specific death and overall death were performed according to clinical and pathological characteristics. Kaplan Meier (KM) estimates and log-rank test were used to compare BRFS, MFS, CSS and OS according to clinical and pathological features.
RESULTS: Median follow-up was 28 months. After propensity score matching, two cohorts of 115 laUTUC patients each with similar baseline and preoperative tumor characteristics were obtained. In the matched cohort, pT ≥ 3 stage was found in 84 (73%) and 67 (58.3%) patients in the oRNU and miRNU groups, respectively. Positive lymph nodes were detected in 27 (23.5%) and 32 (27.8%) patients in the oRNU and miRNU groups, respectively. In the multivariable regression analysis, pT ≥ 3 and positive lymph nodes were associated with an increased risk of metastasis (HR 3.22, 95% CI 1.26-8.23, and HR 4.03, 95% CI 2.05-7.89, respectively). The surgical approach (oRNU vs. mi RNU) did not influence oncological outcomes as shown by uni- and multivariable analyses as well as Kaplan-Meier estimates, regardless of pT stage.
CONCLUSIONS: The oncological outcomes of laUTUC for cT3-4 cM0 or cN1-2 cM0 disease are comparable whether RNU is performed via an open or minimally invasive approach. Therefore, the decision to opt for oRNU or miRNU should be guided by the surgeon\u27s expertise and the patient\u27s comorbidities, rather than concerns over long-term oncological outcomes associated with either surgical technique
Depression and depressive symptoms among people living with vitiligo: findings from the cross-sectional, population-based global VALIANT survey
No full textPURPOSE: Vitiligo often affects quality of life and psychosocial well-being. This analysis of the population-based global Vitiligo and Life Impact Among International Communities (VALIANT) study sought to understand the impact of vitiligo on depression and depressive symptoms from the patient perspective.
MATERIALS AND METHODS: The cross-sectional survey collected information on patient demographics, clinical characteristics, mental health diagnoses, and depressive symptoms (assessed using the Patient Health Questionnaire-Depression screener [PHQ-9]) among recruited patients who reported a vitiligo diagnosis.
RESULTS: Of 3541 VALIANT respondents, 24.5% reported formal diagnosis of depression, and 55.0% reported moderate-to-severe symptoms of depression per the PHQ-9. Rates of formally diagnosed depression and moderate-to-severe depressive symptoms were significantly higher in younger patients, those with Fitzpatrick skin types IV-VI (i.e. darker skin), \u3e5% affected body surface area, hand or face involvement, and those receiving mental healthcare versus their counterparts (all p \u3c 0.0001). Interestingly, moderate-to-severe depressive symptoms were more common among patients with shorter disease duration (≤2 vs 3-9 and ≥ 10 years; p \u3c 0.01), but there was no correlation between diagnosed depression and disease duration.
CONCLUSIONS: These VALIANT study findings highlight that depression may be common but often undiagnosed among patients with vitiligo, reinforcing the importance of an improved and multifaceted approach to vitiligo management
Project #036: Stroke Alert to Triage, Improving Ambulatory Stroke Patient Throughput
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Project #115: Exploring Reliable Methods to Measure the Success of Quality Improvement Projects in Healthcare
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