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Endoscopic Ultrasound-Guided Drainage of Intra-Abdominal Abscess Using 15-mm vs. 10-mm Lumen-Apposing Metal Stents: An International Case-Matched Study
No full textBACKGROUND AND AIMS: Efficacy and safety of EUS-guided placement of lumen-apposing metal stents (LAMS) has been reported yet advantage of using 15-mm LAMS over 10-mm LAMS yet to be explored.
METHODS: International, retrospective, case-matched study of patients with intra-abdominal abscess who underwent EUS-guided drainage with 15-mm (case) and 10-mm (control) LAMS between 03/2019 and 09/2022.
RESULTS: 51 patients underwent EUS-guided drainage using LAMS [15-mm 29 (57%), 10-mm 22 (43%)]. The most common location of the abscess was peri-pancreatic 43%. Technical success rate was achieved in 97% of cases and 100 % of controls (p=0.412), while clinical success was achieved in 98% and 96%, respectively, (OR 1.3; p=0.089). AE occurred in 7.8% of the cases. Patients with 15-mm LAMS underwent fewer total endoscopic procedures (mean 2.5 vs.3.6; P \u3c 0.023).
CONCLUSION: Both sizes showed comparable clinical success and safety profiles, with a significant trend of the need for fewer endoscopic procedures with the 15-mm LAMS
Disparities in 180-day infection rates following coronary artery bypass grafting and aortic valve replacement
No full textOBJECTIVE: The study objective was to compare sex and racial differences in 180-day infection rates after coronary artery bypass grafting and aortic valve replacement.
METHODS: A statewide Society of Thoracic Surgeons Adult Cardiac Surgery Database was linked to Medicare claims data to identify 8887 beneficiaries undergoing coronary artery bypass grafting and aortic valve replacement (surgical or transcatheter) between 2017 and 2021. The primary outcome was the incidence of 180-day infection. Secondary outcomes included 10 infection subtypes. Multivariable logistic regression was used to evaluate the relationship between sex and race (Black vs non-Black) and infections. Two secondary analyses were conducted: (1) robustness of the primary analysis after excluding urinary tract infections given established sex-related differences and (2) testing a sex∗race interaction.
RESULTS: The mean (SD) age of the cohort was 74.5 (8.9) years, with 36.9% female and 4.2% Black. The infection rate was 19.6%, although this varied by patient sex (female vs male: 23.7% vs 17.1%) and race (Black vs non-Black: 28.0% vs 19.2%), both P less than .0001. Differences in infection rates for female patients were driven by urinary tract infections and pneumonia for Black patients. Risk-adjusted odds of infection were 1.6-fold significantly higher among female patients but nonsignificant for Black patients. A sex∗race interaction was present, with non-Black female patients versus non-Black male patients having a 1.63 higher odds of infection.
CONCLUSIONS: This multicenter study identified a 1.6-fold higher odds of infection among female patients. Non-Black female versus male patients had a 63% higher odds of infection. Transdisciplinary collaborative learning interventions should be considered to address these known disparities in infection rates
Comparing PSA Screening Patterns and Their Role as Predictor of Prostate Cancer Diagnosis: Analysis of a Contemporary North American Cohort
No full textINTRODUCTION: PSA screening remains a pivotal tool for early prostate cancer (PCa) detection. International guidelines rely on evidence from three major randomized clinical trials: ERSPC, PLCO, and CAP. We aim to examine the percentage of patients in real-world practice who get PSA screening as defined by each of the aforementioned trials. Moreover, we seek to evaluate if the different PSA screening patterns have a different impact on PCa incidence and its features at diagnosis.
MATERIALS AND METHODS: Our institutional database was queried to identify men aged 55-69 who received at least one PSA test, did not develop PCa or die within 6 years of the initial test, had follow-up within our system at least 6 years after the initial test, and did not have a previous PCa diagnosis. A total of 28,612 patients met our selection criteria. We categorized patients into three distinct PSA screening patterns based on testing frequency (PLCO: 1 PSA test per year for 6 years; ERSPC: 2 or 3 PSA tests over 6 years; CAP: 1 PSA test over 6 years). Our primary outcomes were any PCa incidence and clinically significant PCa (csPCa, defined as ISUP ≥ 3) incidence. Secondary outcome was the rate of cM1 disease. Competing risks cumulative incidence curves were used to depict any PCa and csPCa diagnosis with death before a diagnosis considered a competing risk. Multivariable competing risks regression (CRR) was used to assess the impact of the different screening patterns on any PCa and csPCa incidence, after adjusting for confounding factors.
RESULTS: The most prevalent PSA screening pattern was ERSPC, including 15,530 patients (54.3%), followed by the CAP with 9003 patients (31.5%), and the PLCO with only 4079 patients (14.2%). The median (IQR) follow-up time was 4.8 (1.7-10.8) years. At 10 years, any PCa incidence was 7.4% versus 5.6% versus 2.5% for PLCO versus ERSPC versus CAP, respectively, while for csPCa, the rates were 2.5% versus 2.5% versus 1.2% (both p \u3c 0.001). On multivariable analyses, PLCO and ERSPC patterns were associated with 2.92-fold and 2.31-fold higher risks from 1 year to the next of any PCa diagnosis, respectively, compared to CAP pattern (both p \u3c 0.001). Similarly, patients with PLCO and ERSPC patterns had 2.07-fold and 2.31-fold higher risks, respectively, of csPCa diagnosis compared to CAP pattern (both p \u3c 0.001). In men with PCa diagnosis, the rates of cM1 disease were respectively 1.7% vs 5.6% vs 10.8% for PLCO versus ERSPC versus CAP, respectively (p = 0.0009).
CONCLUSION: We observed that the most common screening pattern in real-world clinical practice is close to what ERSPC recommend, and this pattern seems to achieve a reasonable reduction in the risk of advanced PCa, while limiting overdiagnosis
Characteristics and Outcomes of Kidneys Accepted versus Turned Down by Regional Centers
No full textBackground: The number of kidney transplants performed in the US remains insufficient for the number of patients awaiting one. To meet these demands, it is important to review kidney utilization patterns, particularly for transplanted kidneys turned down by other centers. We performed an analysis of accepted versus turned down kidneys by transplant hospitals in Region 10 to examine kidney acceptance practices and recipient outcomes across the region. Methods: Retrospective analysis of OPTN data for deceased donor kidneys offered by Gift of Life Michigan to Region 10 adult kidney transplant centers between 8/2/22 and 7/19/24. Only kidneys that were ultimately transplanted were included. Offers received by each center were classified as “kidney transplanted by center (KTC)” for those accepted and transplanted by that center and “kidney transplanted elsewhere (KTE)” for those turned down by that center and transplanted elsewhere. Only kidneys turned down for donor variables or organ quality were included in the analysis. Donor characteristics and recipient outcomes were compared between the groups for each center. Outcomes of interest were occurrence of delayed graft function (DGF), recipient 6-month and 1-year serum creatinine (Se Cr), and 6-month and 1-year graft survival (GS). Results: 1046 kidneys, offered to 12 regional centers, were included. One regional center was excluded from the analysis due to lack of recipient 1-year Se Cr data. Center-specific acceptance and turndown rates varied widely and are shown in Figure 1. Selected analysis results are shown in Figure 2. Across multiple centers, KTE kidneys differed significantly in terms of KDPI, donor age, terminal creatinine, biopsy rate, and cold ischemia time. For most centers, recipient outcomes did not differ significantly in terms of DGF, 6-month or 1-year creatinine or GS. Conclusions: Despite differences in organ characteristics, renal outcomes did not differ significantly between KTC and KTE kidneys across the region. While further analysis is needed to elucidate the differences between centers, findings of comparable outcomes with KTE kidneys can help reframe a center’s understanding of acceptable organ quality metrics and motivate centers to rethink and expand their acceptance criteria. DISCLOSURES: Z.Y. Lu: None. A. Yoshida: None. A. Patel: None
The Difference in the Impact of Race on Long-Term Graft Survival Between Liver and Kidney Transplantation
No full textBackground: The issue of racial and ethnic disparities in outcomes of liver transplantation (LT) or kidney transplantation (KT) is critical, particularly with increasing diversity. It has been reported that Black has lower graft function than White in both LT and KT. However, the impact of race on long-term outcomes remains unclear. We evaluated and compared the racial influence on very long- term graft survival (GS) in LT and KT. Method: Adult LT or KT alone performed from 2003-2013 were evaluated, using the United Network for Organ Sharing database. To mitigate the prognostic effects of early to mid-term post-transplant complications, we assessed conditional 10-year GS in 5-year survivors post- transplant, which was defined as the probability of GS after 5 years in those who survived for the first 5 years. Race was classified into five categories; White, Black, Hispanic, Asian and Others. The impact of race on GS in each type of transplant was evaluated by Cox proportional hazard model. Result: 71,679 adult LT and 186,342 adult KT were performed from 2003-2013, of which 46,659LT/176,656KT recipients survived at 5 years post-transplantation. Black, white, Hispanic, Asian, and Others LT/KT recipients revealed 10-year conditional GS rates of 80.8%, 81.2%, 84.7%, 88.8%, and 82.2% in LT (p\u3c 0.01, Figure 1), and 73.5%, 67.5%, 76.8%, 78.8% and 68.6% in KT, respectively (p\u3c 0.01, Figure 2). Black showed significantly lower 10-year conditional GS in KT, compared to White, even after adjusted with age, gender, diabetes mellitus, employment status, educational level and KDPI. (HR1.07, 95%CI 1.03-1.11, p\u3c 0.01) In contrast, in LT, Black demonstrated comparable 10-year conditional GS to White after adjusting with age, gender, diabetes mellitus, employment status, educational level and MELD. (HR1.04, 95%CI 0.94-1.15, p=0.45). Conclusion: Black was associated with lower 10-year conditional GS in KT, whereas in LT, 10-year conditional GS between Black and White was comparable when the adverse impact of early to mid-term post-transplant complications was minimized. Further assessment of factors that may drive disparities, such as comorbidities and access to follow-up, is needed to address racial disparities in long-term post-transplant outcomes. [Formula presented] [Formula presented] DISCLOSURES: R. Oki: None. A. Nishimagi: None. I. Rocha: None. S. Al- Juburi: None. L. Rajendran: None. E. Kerby: None. A. Mohamed: None. A. Nassar: None. A. Al-Kurd: None. L. Malinzak: None. J. Denny: None. D. Kim: None. A. Yoshida: None. M. Abouljoud: None. S. Nagai: None
Clinicopathologic characteristics of ductal carcinoma in situ and risk of subsequent invasive breast cancer: a multicenter, population-based cohort study
No full textPURPOSE: To study the association between clinicopathologic characteristics of ductal carcinoma in situ (DCIS) and risk of subsequent invasive breast cancer (IBC).
METHODS: We conducted a case-control study nested in a multicenter, population-based cohort of 8175 women aged ≥ 18 years with DCIS diagnosed between 1987 and 2016 and followed for a median duration of 83 months. Cases (n = 497) were women with a first diagnosis of DCIS who developed a subsequent IBC ≥ 6 months later; controls (2/case; n = 959) were matched to cases on age at and calendar year of DCIS diagnosis. Univariable and multivariable conditional logistic regression models were used to examine the associations between the DCIS characteristics of interest (non-screen detection of DCIS, tumor size, positive margins, grade of DCIS, necrosis, architectural pattern, microcalcification, and estrogen receptor (ER), progesterone receptor (PR), and human epidermal growth factor receptor 2 (HER2) status) and risk of IBC.
RESULTS: In the total study population, the associations were largely null. In subgroup analyses, there were strong position associations with punctate necrosis (pre/perimenopausal women), detection by physical exam (postmenopausal women), architectural patterns other than the main types (breast-conserving surgery [BCS]), and DCIS margins (ipsilateral cases), and inverse associations with HER2 positivity (BCS) and microcalcification (mastectomy); however, the associated confidence intervals were mostly very wide.
CONCLUSION: The results of this study provide limited support for associations of the DCIS clinicopathologic characteristics studied here and risk of IBC
No Need to Restrain, Grab a Mitt and Refrain!!
Get PDFBackground: Restraint use is closely monitored through National Database of Nursing Quality Indicators (NDNQI) metrics, system, and hospital-based committees. Currently, the acuity-adaptable intensive care units (ICU) at Henry Ford Jackson Hospital (HFJH) underperform the NDNQI mean use of restraints compared to similar units. At HFJH, the most ordered restraint is a non-violent, soft, bilateral wrist restraint on intensive care units for mechanically ventilated patients. Physical restraints in the ICU are ultimately used to minimize potentially harmful consequences of patients interfering with medical therapies. The ICU Liberation initiative, created by the Society of Critical Care Medicine, is shown to decrease restraint use and improve patient outcomes in the ICU. Despite the adherence to the ICU Liberation bundle, restraint use remains prevalent within the ICUs at HFJH. A restraint alternative, a mitt, does not restrict a patient’s ability to move his or her arms but does provide a barrier to grabbing medical equipment. By revising policy and updating the standard of care for ICU patients, one hospital was able to decrease restraint use and have zero non-violent restraints for over one year through mitts. Aims: This quality improvement project aims to decrease restraint use in the ICUs by implementing mitts as a restraint alternative. Methods: Led by a clinical nurse specialist (CNS), key stakeholder buy-in was essential. In collaboration with the nursing director, the restraint policy was critiqued and compared to the restraint definitions from The Joint Commission and Center for Medicare and Medicaid Services (CMS). A proposal was pitched to change the policy to mirror evidence-based practice and current definitions from accrediting bodies. After gaining support from the key stakeholders, the policy was amended to remove mitts under the restraint definition, and education was created and distributed to the bedside staff members. The CNS also coordinated with the representative for mitt products and initiated a trial for a new mitt product. Once education was completed, the CNSs, managers, and director of the intensive care units promoted a culture change to limit restraint use in the critically ill patient population and promote restraint alternatives. Results: The project was successfully implemented in June of 2024. After one month of implementation, hospital-wide restraint use decreased by 110 orders from a total 269 restraint orders in June, compared to 379 restraint orders in May. In the medical ICU, restraint orders decreased from 122 to 49 orders, a 40.2% reduction in restraint use. Conclusion: To date, there have been no adverse outcomes from promoting the restraint alternative, mitts, in the ICU. At the bedside, patients have demonstrated the ability to complete full range of motion while utilizing mitts. The mitts provide a barrier to the patient grabbing medical equipment without restricting movement of the fingers, hands, or arms. In addition, the mitts alternative offers a cost-savings by following manufacturer guidelines and having them laundered at the facility. Ongoing surveillance and monitoring will be continued to evaluate the success of the implementation.https://scholarlycommons.henryford.com/hfjhrs2025/1000/thumbnail.jp
Reconstruction for Occlusive Lesions of Aortic Arch Branches
No full textSymptomatic arterial occlusive disease of the supra-aortic trunk vessels, namely, the brachiocephalic artery (BCA), proximal left common carotid artery (LCCA), and proximal left subclavian artery (LSCA), may manifest as neurologic events such as stroke, transient ischemic attack, or vertebrobasilar insufficiency when the cerebral hemispheres are involved or tissue loss or effort fatigue when affecting the upper extremities. While infrequently encountered in the routine practice of most vascular surgeons, a knowledge of the treatment options available including both extra- and transthoracic open arterial reconstructions and endoluminal arterial reconstructions is necessary in order to provide the optimal care for patients presenting with this disease process. The location and extent of the disease as well as patient’s overall physical condition are factors in the choice of repair
History of Carotid Artery and Vertebral Artery Surgery
No full textOver the last century, advances in vascular surgery and surgical technology have changed both our understanding and treatment of cerebrovascular disease. The diagnosis and management of extracranial carotid artery disease have undergone a tremendous evolution of thought and technique. From the days of frequently lethal attempts at carotid artery ligation to current precise surgical techniques, this chapter describes the most significant events and landmark discoveries that have led to the current standards of care in carotid artery surgery. This chapter starts by describing how the association between carotid artery disease and neurological injury was discovered. The progression of carotid surgery from early ligations for bleeding and aneurysms to carotid endarterectomy is detailed along with the evolution of modern techniques of endarterectomy. The subsequent development of endoluminal techniques for treating carotid disease and enhancements such as cerebral protection devices and transcervical access are also outlined. And finally, the most important clinical trials that have shaped today’s practice of carotid surgery are described. Vertebral artery (VA) surgery is uncommon as compared to operations on extracranial common carotid artery (CCA) and internal carotid artery (ICA). The symptoms of hindbrain ischemia secondary to vertebrobasilar artery insufficiency are difficult to diagnose. The best surgical option for the management of vertebral artery stenosis in its first portion (V1) is reimplantation of the VA into the CCA. For lesions of V2 and V3 segments, a bypass from the CCA, occipital artery, or external carotid artery to vertebral artery in its third segment (V3) is the most commonly performed procedure