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Living Donor Liver Transplantation for Alcohol-related Liver Disease: An Intention-to-treat Analysis
No full textBACKGROUND: Alcohol-associated liver disease (ALD) is the leading indication for liver transplantation (LT) in the Western world. Although 6 mo of abstinence is no longer a criterion for patients with ALD, the outcomes of living donor LT (LDLT) versus deceased donor LT (DDLT) are not well established.
METHODSS: We performed an intention-to-treat analysis to evaluate the impact of listing and pursuing primary LDLT (pLDLT) compared with primary DDLT (pDDLT). The primary endpoint was overall survival from date of listing, evaluated using Cox regression (hazard ratios).
RESULTS: Two hundred thirty-three patients with ALD were listed for LT, of which 27 (12%) were pLDLT. The overall median model for end-stage liver disease (MELD) score at listing was 20 and Na-MELD 24, a median abstinence of 4.5 mo, and 128 (55%) underwent transplantation. There was no statistically significant adjusted difference at 3-y overall survival between pLDLT versus pDDLT (adjusted hazard ratio [HR] 0.72; P = 0.550) and in the as-treated analysis (HR 1.22; P = 0.741). No patients were delisted in the pLDLT group, whereas 86 (42%) patients were delisted in the pDDLT group; primarily because of death (46 [50%]) and medical improvement (24 [28%]). Alcohol use since the time of listing was documented in 29 (13%) patients; immortal time bias adjusted analysis found no significant difference between pLDLT and pDDLT (adjusted HR 1.07; P = 0.900) and the as-treated analysis (HR 2.95; P = 0.130).
CONCLUSIONS: Patients with ALD benefit from intention pLDLT with lower rates of waitlist dropout and delisting, attributable to mortality or medical deterioration, and should be encouraged to pursue this option
Peer Support Intervention for Suicide Prevention Among High-Risk Adults in Michigan: A Randomized Clinical Trial
No full textIMPORTANCE: Innovative approaches to address interpersonal risk factors for suicide attempts and suicidal ideation may help reduce persistently elevated suicide rates in the US.
OBJECTIVE: To determine whether Peers for Valued Living (PREVAIL), a posthospital peer support intervention, reduces suicide attempts and suicidal ideation among adults psychiatrically hospitalized for suicide risk.
DESIGN, SETTING, AND PARTICIPANTS: This single-masked, randomized clinical trial recruited adult psychiatric inpatients aged 18 years or older from 3 Michigan-based facilities between June 22, 2018, and December 30, 2022. The study compared 3 months of the PREVAIL intervention plus enhanced usual care with enhanced usual care only, with 3 months of postintervention follow-up.
INTERVENTION: One-on-one support from a peer specialist initiated during hospital admission and continued 3 months after discharge.
MAIN OUTCOMES AND MEASURES: Suicide attempts were measured using the Columbia Suicide Severity Rating Scale, and suicidal ideation was measured using the Beck Scale for Suicidal Ideation at 3 and 6 months after randomization.
RESULTS: Of 5310 patients screened, 455 were randomized using a minimization algorithm. A total of 229 participants were randomized to the PREVAIL peer mentorship arm (mean [SD] age, 32.4 [14.0] years, 134 women [58.5%]), and 226 were randomized to the enhanced usual care arm (mean [SD] age, 31.6 [13.5] years; 139 women [61.5%]). In the intention-to-treat sample with nonmissing data, the percentage of participants with any suicide attempt over 6 months (including participants who only completed 3-month follow-up assessments) was 17.2% (28 of 163) for enhanced usual care and 14.9% (24 of 161 with 2 deaths by suicide) for PREVAIL. Mean (SD) suicidal ideation scores were 4.3 (95% CI, 3.2-5.3) for enhanced usual care and 4.9 (95% CI, 3.7-6.1) for PREVAIL at 6 months. There were no statistically significant effects of the intervention for either outcome in the primary analyses. In post hoc analyses, the interaction between study arm and the COVID-19 pandemic was statistically significant. The enhanced usual care arm had a mean (SD) 6-month suicidal ideation score of 3.5 (6.1) before and 6.1 (7.4) after the pandemic vs the PREVAIL arm (mean [SD] scores, 5.0 [7.7] and 4.5 [6.6], respectively). There were 2 study-related adverse events, with 1 resulting in participant withdrawal from the intervention arm.
CONCLUSIONS AND RELEVANCE: In this randomized clinical trial, the peer-delivered PREVAIL intervention up to 3 months after discharge did not significantly differ from enhanced usual care in terms of reducing subsequent suicide attempts or suicidal ideation.
TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT03373916
Propensity matched analysis of single access technique for Impella-assisted unprotected left main percutaneous coronary intervention
No full textBACKGROUND: The single access for high-risk percutaneous coronary intervention (SHiPCI) technique is an intriguing alternative to traditional dual access Impella-assisted PCI, potentially reducing access-site complications. Current data is limited to retrospective case studies.
OBJECTIVES: To analyze procedural complications and clinical outcomes of SHiPCI.
METHODS: This single-center retrospective observational study evaluated consecutively admitted patients undergoing high-risk unprotected left main PCI (UPLM-PCI) from 2018 through 2023. Patients were grouped according to index strategy of single or dual access Impella-assisted UPLM-PCI, and propensity score matching without replacement was used to match patients 1:1. The primary outcome was a composite of all-cause in-hospital mortality, major bleeding, vascular access site complications, and blood transfusion.
RESULTS: Six-hundred patients underwent UPLM-PCI during the study period, and one hundred patients were matched (50 patients per group). There were no significant differences in baseline characteristics between the two groups. Up-front balloon tamponade assistance was higher in the dual access group (14 % vs 4.0 %, p = 0.027), and rate of successful hemostasis post-closure was lower (82 % vs 100 %, p = 0.001). The primary composite outcome occurred in 7 patients (14 %) in the single access group, compared to 16 patients (32 %) in the dual access group (p = 0.033). Patients in the dual-access group had higher rates of major bleeding (17 % vs 2 %, p = 0.014).
CONCLUSIONS: SHiPCI compared to standard dual access for Impella-assisted UPLM-PCI demonstrated a lower rate lower rate of the composite outcome, driven primarily by a lower rate of major bleeding. Prospective randomized controlled trials are needed to delineate the efficacy and safety of SHiPCI
Sunscreens: Updates on Sunscreen Filters and Formulations
No full textBACKGROUND/PURPOSE: Sunscreens are a critical component of photoprotection, shielding the skin from the harmful effects of solar radiation. However, current sunscreens have limitations, including insufficient filters with long-wavelength ultraviolet A (UVA) and visible light (VL) coverage. This review briefly discusses the mechanisms of sunscreen filters, newly developed filters that improve broad-spectrum protection, and examines recent advances in sunscreen formulations that enhance efficacy.
METHODS: A targeted literature review was conducted using databases such as Pubmed to identify recent studies published on advancements in sunscreen filters.
RESULTS: Recent developments include novel filters with extended UVA and VL coverage. Additives such as antioxidants and anti-inflammatory agents are also being integrated to bolster skin protection.
CONCLUSION: Although traditional sunscreens have limitations, ongoing innovations in filter development and formulation science are progressively addressing existing gaps in photoprotection
ACR Appropriateness Criteria® Acute Spinal Trauma: 2024 Update
No full textDue to its wide spectrum of injury patterns, imaging of acute blunt spine trauma can present many challenges. CT is generally the first-line imaging modality, as it is fast, accurate, and easily accessible. Choice of appropriate imaging is important, as overuse of imaging is associated with prolonged emergency visits and unnecessary hospital admission, potentially leading to iatrogenic injuries and an increase in economic burden. In contrast, failure to identify injuries can have severe consequences. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation
Comparison of treatment-emergent resistance-associated mutations and discontinuation due to adverse events among integrase strand transfer inhibitor-based single-tablet regimens and cabotegravir + rilpivirine for the treatment of virologically suppressed people with HIV: A systematic literature review and network meta-analysis
No full textOBJECTIVE: This study evaluated rates of treatment-emergent resistance-associated mutations (TE-RAMs) and discontinuation due to adverse events (DC-AEs) across integrase strand transfer inhibitor (INSTI)-based single-tablet regimens and injectable cabotegravir + rilpivirine (CAB + RPV) in virologically suppressed people with HIV.
METHODS: A systematic literature review was conducted for phase 2-4 randomized controlled trials with ≥ 48 weeks of follow-up involving virologically suppressed people with HIV aged ≥ 12 years and published January 2003-March 2024. A random-effects network meta-analysis estimated comparative rates of TE-RAMs and DC-AEs among regimens at 48 weeks. Risk of bias and strength of evidence were assessed using Cochrane RoB and CINeMA, respectively.
RESULTS: Fourteen (7509 participants) and nine (4656 participants) studies were included in the TE-RAMs and DC-AEs analyses, respectively. No significant differences in rates of TE-RAMs were observed; risk ratios (RRs) for TE-RAMs for bictegravir/emtricitabine/tenofovir alafenamide (B/F/TAF), dolutegravir/abacavir/lamivudine (DTG/ABC/3TC) and CAB + RPV every 4 weeks (Q4W) versus CAB + RPV every 8 weeks (Q8W) were 0.22 (95% CI, 0.02-2.04), 0.22 (95% CI, 0.00-19.85) and 0.40 (95% CI, 0.14-1.09). Compared with CAB + RPV Q4W and Q8W, DC-AEs were significantly lower with B/F/TAF (RR, 0.15 [95% CI, 0.03-0.75] and RR, 0.16 [95% CI, 0.04-0.67], respectively) and DTG/ABC/3TC (RR, 0.05 [95% CI, 0.01-0.48] and RR, 0.05 [95% CI, 0.01-0.46], respectively).
CONCLUSIONS: In virologically suppressed people with HIV, switching to CAB + RPV Q8W yielded a non-significant increased risk of TE-RAMs compared with INSTI-based 2- and 3-drug regimens and CAB + RPV Q4W. Both CAB + RPV Q4W and Q8W had significantly higher risks of DC-AEs than B/F/TAF and DTG/ABC/3TC. Findings highlight the importance of considering both resistance and tolerability when switching regimens
Participant Perceptions of Using Research Mentorship to Create a Pipeline Program for Premedical Students Underrepresented in Medicine
No full textThe Medical Mentorship Program (MMP) at the University of Michigan was established to use research as a vehicle to mentor undergraduate students from backgrounds underrepresented in medicine (URiM). Eleven undergraduate students were paired with a medical student mentor and faculty principal investigator to lead a research project and participate in educational sessions. We found that 100% of undergraduates agreed that the program increased their interest in medicine. Additionally, 83.4% of medical students and 100% of faculty agreed they gained valuable mentorship experience. In conclusion, MMP provided URiM undergraduate students with valuable research, mentorship, networking, and medical exposure
Impact of antithrombotic medications on postprocedural outcomes of percutaneous endoscopic gastrostomy: a US Collaborative Network study
No full textBACKGROUND AND AIMS: Percutaneous endoscopic gastrostomy (PEG) is an essential procedure for patients who require long-term enteral nutrition but are unable to eat orally. However, it carries a risk of bleeding, particularly in patients on anticoagulation or dual antiplatelet therapy (DAPT). This study aimed to assess the bleeding risk associated with continuing anticoagulation or DAPT during PEG placement.
METHODS: Using the TriNetX US Collaborative Network Database, we analyzed four cohorts: patients on anticoagulants, patients not on anticoagulants, patients on DAPT, and patients on aspirin (ASP), focusing on gastrostomy-related bleeding within 7 and 30 days, along with secondary outcomes such as mortality and the need for blood transfusion or endoscopic reintervention.
RESULTS: Our analysis showed no statistically significant difference in the 7-day bleeding risk between the anticoagulant and no anticoagulant groups. However, a higher 30-day bleeding risk was observed in the anticoagulant group (0.9 vs. 0.4%, P = 0.007). There was no significant difference in the incidence of severe bleeding events requiring endoscopic intervention or blood transfusion. In addition, the difference in the bleeding risk between the DAPT and ASP groups was not statistically significant within 7 and 30 days.
CONCLUSION: These findings suggest that while anticoagulant use increases the risk of minor post-PEG bleeding, it does not lead to a higher incidence of severe bleeding. Additionally, the continuation of DAPT was not associated with statistically significant increase in bleeding risk. This study provides valuable insights into the management of antithrombotic therapy in patients undergoing PEG
Recommendations to overcome barriers to transplant fellowship training: A report from the American Society of Transplantation Fellows Task Force
No full textWith the expansion of solid organ transplantation activities in the United States, there is a critical need for more transplant care providers and trainees to sustain and advance the field of transplantation. However, there has been a pending shortage of trainees pursuing transplant fellowship training in the United States in recent years. To address this issue, the American Society of Transplantation (AST) organized the fellows\u27 task force, including representatives of all 4 major organs from various AST communities of practice, to understand the drivers of this pending shortage and develop strategies to increase interest in transplant specialization. The task force identified 4 areas of focus, including early and sustained exposure to transplant medicine, awareness through education, flexible fellowships and pathways to transplant, and work-life resources. Based on these focus areas, the task force developed recommendations and action items, which were compiled into a report to be implemented by individuals, institutions, communities of practice (work groups), and societies such as the AST. We hope that this report will be the first step in overcoming barriers and concerns to encourage the pursuit of specialization in transplantation in the United States
Elective fertility preservation among graduate medical trainees: a survey study of perceived barriers and the impact of employer-sponsored financial benefits
No full textPURPOSE: To assess the impact of employer-provided financial support on graduate medical trainees\u27 decision to pursue fertility preservation and to identify perceived barriers to participation in fertility preservation.
METHODS: An anonymous online survey study addressing perspectives surrounding participation in elective fertility preservation while in training was distributed in August 2024 to residents and fellows in graduate medical programs across the United States.
RESULTS: Of 306 medical trainee respondents, 202 (67.1%) had intentionally delayed childbearing due to their medical training. There were 66.4% (n = 200) who reported that their sex/gender impacted their interest in fertility preservation, including 87% (n = 172) of whom had been assigned female at birth. High costs and time constraints of training were the most commonly cited factors (63.1%) negatively impacting the decision to participate in elective fertility preservation. Employer financial support was reported by 32.9% (n = 99) as a factor that would make them more likely to pursue fertility preservation. Trainees who worked an average of 60 to \u3e 80 hours per week had the highest rate of reported intentional delay in childbearing, and the time constraints of training negatively impacted their interest in fertility preservation. Only 24% knew whether coverage for fertility services was mandated in their state, 25.2% were unfamiliar with fertility preservation, and 35.3% did not know how to access fertility services.
CONCLUSION: Medical trainees face significant financial and structural barriers to accessing fertility preservation. Widespread financial benefits and systemic changes in training programs may improve the feasibility of fertility preservation for graduate medical trainees