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A pretreatment nomogram to predict muscle-invasiveness in high-risk upper tract urothelial carcinoma (ROBUUST 2.0 collaborative group)
No full textBACKGROUND: The ability to predict muscle invasion in the final pathology of upper tract urothelial carcinoma (UTUC) patients after radical nephroureterectomy (RNU) potentially influences the selection of the most appropriate treatment modality. The present study aims to develop a model predicting muscle-invasive status in high-risk UTUC.
METHODS: The ROBUUST (RObotic surgery for Upper tract Urothelial cancer - UTUC - STudy) 2.0 dataset is an international, multicenter registry of patients undergoing curative surgery for UTUC between 2015 and 2022. Data about high-risk patients, classified according to EAU and NCCN prognostic stratification criteria, who underwent RNU were retrieved. The primary outcome was the identification of muscle-invasiveness. Two multivariable models, differing in the inclusion of biopsy-related data, were fitted with pT stage results at final pathology. Their predictive ability was calculated using the area under the receiver operating characteristic curve and decision curve analysis (DCA). A nomogram was developed using the model demonstrating the highest area under the curve (AUC) and clinical net benefit.
RESULTS: In the overall cohort, 1558 patients met the inclusion criteria, with 934 patients having ≥ pT2 disease. Patients in the ≥ pT2 cohort had significantly worse oncological outcomes in terms of metastases, all-cause, and cancer-specific deaths (all P\u3c 0.001). The biopsy-related model had the highest AUC (74%) and the highest net benefit in DCA. The DCA showed an improvement in the clinical risk prediction of muscle-invasiveness, and a reduction in the number of upfront or unnecessary RNU, at every ≥ pT2 probability threshold.
CONCLUSIONS: The proposed prognostic model is a valuable tool for estimating the risk of muscle-invasiveness in high-risk UTUC patients, owing to its optimal predictive ability and user-friendly design
Successful Leadless Pacemaker Implantation Despite SVC Obstruction
No full textBACKGROUND: A 69-year-old male underwent implantation of a leadless pacemaker after a failed attempt to upgrade his single lead ICD in the setting of SVC obstruction.
CASE SUMMARY: A 69-year-old male with ischemic cardiomyopathy status post single chamber ICD presented with fatigue. Device interrogation revealed increased RV pacing. Device upgrade was attempted; however, he was found to have a SVC obstruction. A leadless pacemaker was subsequently placed in the right atrium via femoral approach.
DISCUSSION: Permanent leadless pacemakers provide a safe, less invasive alternative for patients with conditions that would have previously required complex interventions. Our case demonstrates the use of a leadless pacemaker in a patient with SVC obstruction and ESRD, offering lower infection risk and benefit of retrievability
Do Not BASILICA the New Valve
No full textOBJECT: Bioprosthetic or native Aortic Scallop Intentional Laceration to prevent Iatrogenic Coronary Artery obstruction (BASILICA) is currently the standard technique for leaflet modification in transcatheter aortic valve replacement to overcome coronary obstruction. The technique involves traversal of the coronary cusp with a 0.014-inch coronary wire, snaring the wire, and then lacerating the leaflet with a denuded portion of the wire known as the flying V. The procedure requires careful planning and technical expertise. We report a new complication of BASILICA where prepositioning of a transcatheter heart valve (THV) before laceration accidentally damaged the THV.
KEY STEPS: This complication originates from the inadvertent crossing of the straight-tip wire between the flying V and the aortic cusp when the flying V was not well apposed to the cusp. Prepositioning of the THV has become a variation of the procedure for patients with a high perceived risk of hemodynamic instability after BASILICA. This backfired, resulting in a complicated procedure.
POTENTIAL PITFALLS: The exact position of the 0.014-inch wire and flying V might be difficult to visualize in patients with a large body habitus. Operators should check that the flying V is at the cusp level before crossing the aortic valve with a wire. During the initial delivery of the flying V to the cusp, care should be taken to avoid losing the wire in the guide. Multicenter data of BASILICA show that hemodynamic instability is uncommon in single-leaflet lacerations. Therefore, prepositioning of a THV before leaflet laceration is usually unnecessary and requires strong clinical justification if pursued.
TAKE-HOME MESSAGES: BASILICA is a complex procedure. Operator familiarity with potential pitfalls and appropriate bailout methods are necessary. Operators should ensure that the flying V is well apposed to the leaflet before crossing into the left ventricle with a wire to prepare for valve deployment
Socioeconomic Disparities in the Care of for High-Risk Pulmonary Embolism in the United States, 2016 to 2020
No full textThere are limited data on the impact of socioeconomic factors on the management and outcomes of high-risk acute pulmonary embolism (PE). Using the National Inpatient Sample (NIS) from 2016 to 2020, we identified adult (≥18 years) admissions with high-risk PE (defined as PE with one of: cardiogenic shock, vasopressor use, or cardiac arrest). Socioeconomic determinants included sex, race, insurance payer, and economic status. Outcomes of interest included in-hospital mortality, rates of mechanical circulatory support (MCS) and definitive PE interventions, hospitalization duration, and hospitalization costs. Among 21,521 high-risk PE hospitalizations (median age 65 years, 53% male, 64% white race), the socioeconomic variables remained stable during the 5-year period. MCS utilization was 4%, with lower rates of utilization in Medicare and Medicaid beneficiaries, uninsured admissions, and those from the lowest income quartile (all p \u3c 0.05). Racial minorities, those from lower economic status, and uninsured admissions received advanced PE interventions less frequently. There did not appear to be notable sex disparities in use of advanced PE therapies. Overall, in-hospital mortality was 50%, with higher adjusted in-hospital mortality in female, African American, Hispanic, uninsured, and economically disadvantaged individuals. In conclusion, significant inequities in in-hospital mortality, mechanical circulatory support, and definitive pulmonary embolism therapy utilization persist among high-risk PE hospitalizations in the United States based on sex, race, income, and insurance status
Oral Peptide Therapeutics as an Emerging Treatment Modality in Immune-Mediated Inflammatory Diseases: A Narrative Review
No full textImmune-mediated inflammatory diseases (IMIDs), such as psoriasis, psoriatic arthritis, and inflammatory bowel disease, encompass a heterogenous group of conditions associated with chronic inflammation. Systemic treatments for patients with IMIDs include parenterally delivered monoclonal antibodies (mAbs) that disrupt specific cytokine and cytokine receptor binding interactions, and orally delivered small molecules that inhibit certain enzymes involved in the regulation of inflammatory signaling. Many patients prefer oral alternatives to injectables, but currently available oral advanced therapies are less effective than mAbs and/or have tolerability concerns. Thus, an unmet need exists for additional oral treatment options for patients with IMIDs. Therapeutic peptides can be designed to possess characteristics that provide both the target selectivity typically associated with parenterally delivered mAbs and an oral route of administration. Oral peptide therapeutics are an area of intense research in several therapeutic areas, and, although some oral peptides are available for certain indications, such as diabetes, there are currently no targeted oral peptides available for the treatment of patients with IMIDs. Icotrokinra (JNJ-77242113), which is currently in development to treat patients with various IMIDs, is the first targeted oral peptide designed to selectively inhibit interleukin (IL)-23 signaling by blocking the IL-23 receptor on human immune cells. In a phase 2b study in adults with moderate-to-severe psoriasis, icotrokinra showed a significant dose-response effect versus placebo, and a tolerable safety profile at Week 16. Sustained skin clearance and no safety signals were observed through Week 52 in the extension study to the phase 2b study. Ongoing phase 2 and phase 3 clinical studies in patients with psoriasis, psoriatic arthritis, and ulcerative colitis will provide data to inform the therapeutic potential of icotrokinra to address the unmet need in these diseases
Mental Health and Psychosocial Burden Among Patients with Skin of Color Living with Vitiligo: Findings from the Global VALIANT Study
No full textINTRODUCTION: Factors associated with vitiligo burden in patients with darker skin (Fitzpatrick skin types IV-VI) are not fully understood. This analysis of patients in the global VALIANT study examined the quality of life (QoL) and psychosocial health among patients with vitiligo by skin type.
METHODS: Participants from 17 countries were surveyed regarding their clinical characteristics, everyday experiences with vitiligo, impact of vitiligo on daily activities, emotional well-being, and mental health.
RESULTS: Of 3541 surveyed patients, 40.8% (n = 1445) had darker skin versus 59.2% (n = 2096) with fairer skin (types I-III). Patients with darker skin had greater median disease extent than those with fairer skin (6.6% vs 2.5%; P \u3c 0.0001). Mean Vitiligo Impact Patient scale scores were higher among patients with darker skin (31.2 vs 24.5; P \u3c 0.0001); daily activities and emotional well-being were significantly more impacted among patients with darker skin. Among individual skin types, patients with types V and VI expressed considerably higher rates of burden versus all other skin types in all assessments. Interestingly, among patients with fairer skin, those with skin type I reported higher rates of burden than those with skin types II and III.
CONCLUSION: Patients with darker skin, particularly skin types V and VI, were more impacted in their daily lives, emotional well-being, and mental health than those with fairer skin, suggesting that a disproportionate need for strategies to improve QoL and mental health burden exists among patients with vitiligo who have skin of color
Role of Endoscopy in Inflammatory Bowel Disease: What Every Gastroenterologist Should Know
No full textEndoscopy plays a pivotal role in managing inflammatory bowel disease (IBD). The role of endoscopy has evolved over the years, from diagnostic to surveillance to now doing therapeutic procedures to manage patients with IBD. From the initial diagnostic endoscopy, describing the extent and severity of the disease is an essential step in differentiating between Crohn\u27s disease and ulcerative colitis. Patients with IBD frequently undergo surgeries, and understanding various postoperative configurations and performing endoscopy in postoperative patients can pose a challenge. A thorough understanding of the same can help us to assess disease activity and manage our patients. The purpose of this review was to provide an overview of the role of endoscopy in the management of IBD and to examine various anatomical variations in patients postoperatively
Things I wish I knew when implementing an ambulatory antimicrobial stewardship program at an urban health system: lessons learned and future directions
No full textLetter to the editor: Intracoronary adenosine compared with adrenaline and verapamil in the treatment of no-reflow phenomenon following primary PCI in STEMI patients
No full textGlucagon-Like Peptide-1 Receptor Agonists Use Does Not Increase the Risk for Acute Pancreatitis and Is Associated With Lower Complications in Patients With Type 2 Diabetes Who Develop Acute Pancreatitis: A Multicenter Analysis
No full textINTRODUCTION: Type 2 diabetes mellitus (T2DM) can lead to structural pancreatic changes potentially predisposing to acute pancreatitis (AP), increasing morbidity and mortality. Scarce data exist on the outcomes of AP in patients with T2DM who are taking glucagon-like peptide-1 receptor agonists (GLP-1 RAs). The study aim was to evaluate AP outcome and all-cause mortality in patients with T2DM using GLP-1 RAs.
METHODS: A retrospective cohort study was performed using population-based data from the TriNetX platform. Patients with T2DM receiving GLP-1 RAs drugs (semaglutide, liraglutide, dulaglutide, and tirzepatide) between January 1, 2015, and October 31, 2023, were included. This patient cohort was matched with patients with T2DM who did not receive GLP-1 RAs according to age, demographics, comorbidities, and medication by using 1:1 propensity matching. To avoid confounding, etiologies of AP including alcohol-induced, trauma, biliary, class Ia drug-induced, hypertriglyceridemia, and postendoscopic retrograde cholangiopancreatography were excluded from both cohorts. Primary outcomes were risk of developing AP, need for parenteral nutrition, systemic complications (sepsis, systemic inflammatory response syndrome, shock, mechanical ventilation, acute kidney injury), and local pancreatic complications. The secondary outcome was all-cause mortality. Cox proportional hazards models were used to estimate hazard ratios (HRs).
RESULTS: A total of 740,370 patients with T2DM were identified with 29,423 on GLP-1 RAs; 20,459 of those 29,423 (mean [SD] age, 58.1 [11.9] years; 10,190 [49.85%] female) were matched with 20,459 individuals (mean [SD] age, 57.5 [13.9] years; 10,301 [50.35%] female) who did not take GLP-1 RAs. The GLP-1 RAs group had lower risk of complicated pancreatitis (HR 0.32; 95% confidence interval [CI] 0.14-0.74), parenteral nutrition needs (HR 0.28; 95% CI 0.09-0.83), sepsis (HR 0.71; 95% CI 0.59-0.84), acute kidney injury (HR 0.54; 95% CI 0.49-0.60), shock (HR 0.52; 95% CI 0.36-0.75), and mechanical ventilation support during admission (HR 0.23; 95% CI 0.16-0.33) compared with the non-GLP-1 RAs group. In addition, all-cause mortality was decreased in the GLP-1 agonist group compared with the non-GLP-1 agonist group (HR 0.45; 95% CI 0.41-0.49). Important to note that the GLP-1 RAs group had a tendency of lower risk of uncomplicated pancreatitis (HR 0.71; 95% CI 0.49-1.01) but without statistically significant result. No difference was found between the groups in risk of developing systemic inflammatory response syndrome if it occurs.
DISCUSSION: GLP-1 RAs use does not increase AP risk is associated with lower complications in those who developed AP and linked with lower all-cause mortality in patients with T2DM. Prospective studies are needed to determine the mechanisms behind these findings