20966 research outputs found
Sort by
Relationship between Neighborhood-Level Social Risk Factor Measures and Presenting Glaucoma Severity Utilizing Multilevel Modeling
No full textPURPOSE: The neighborhood and built environment social determinant of health domain has several social risk factors (SRFs) that are modifiable through policy efforts. We investigated the impact of neighborhood-level SRFs on presenting glaucoma severity at a tertiary eye care center.
DESIGN: A cross-sectional study from August 2012 to May 2022 in the University of Michigan electronic health record (EHR).
PARTICIPANTS: Patients with a diagnosis of any open-angle glaucoma with ≥1 eye care visit at the University of Michigan Kellogg Eye Center and ≥1 reliable visual field (VF).
METHODS: Participants who met inclusion criteria were identified by International Classification of Diseases ninth and tenth revision codes (365.x/H40.x). Data extracted from the EHR included patient demographics, address, presenting mean deviation (MD), and VF reliability. Addresses were mapped to SRF measures at the census tract, block group, and county levels. Multilevel linear regression models were used to estimate the fixed effects of each SRF on MD, after adjusting for patient-level demographic factors and a random effect for neighborhood. Interactions between each SRF measure with patient-level race and Medicaid status were tested for an additive effect on MD.
MAIN OUTCOME MEASURES: The main outcome measure was the effect of SRF on presenting MD.
RESULTS: In total, 4428 patients were included in the analysis who were, on average, 70.3 years old (standard deviation = 11.9), 52.6% self-identified as female, 75.8% self-identified as White race, and 8.9% had Medicaid. The median value of presenting MD was −4.94 decibels (dB) (interquartile range = −11.45 to −2.07 dB). Neighborhood differences accounted for 4.4% of the variability in presenting MD. Neighborhood-level measures, including worse area deprivation (estimate, β = −0.31 per 1-unit increase; P \u3c 0.001), increased segregation (β = −0.92 per 0.1-unit increase in Theil\u27s H index; P \u3c 0.001), and increased neighborhood Medicaid (β = −0.68; P \u3c 0.001) were associated with worse presenting MD. Significant interaction effects with race and Medicaid status were found in several neighborhood-level SRF measures.
CONCLUSIONS: Although patients\u27 neighborhood SRF measures accounted for a minority of the variability in presenting MD, most neighborhood-level SRFs are modifiable and were associated with clinically meaningful differences in presenting MD. Policies that aim to reduce neighborhood inequities by addressing allocation of resources could have lasting impacts on vision outcomes.
FINANCIAL DISCLOSURES: Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article
Evaluating antimicrobial stewardship strategies in candidemia: a novel desirability of outcome ranking (DOOR) analysis comparing blood culture versus T2Candida diagnostic approaches
No full textThe T2Candida Panel (T2 Biosystems, Lexington, MA) is a rapid diagnostic test that detects Candida from whole blood within 3-5 hours. We developed and applied a desirability of outcome ranking (DOOR) analysis to investigate if an antimicrobial stewardship program (ASP) strategy centered on T2Candida diagnosis is associated with improved outcomes compared to an ASP strategy that relies on conventional blood culture diagnosis in critically ill patients with candidemia. This is a retrospective, observational cohort of patients with candidemia identified ≤72 h of intensive care unit admission at two medical centers in Detroit, MI (one T2Candida site and one blood culture site) from 2016 to 2023. Management strategies for candidemia were compared using an original DOOR analysis with inverse probability of treatment weighting (IPTW) to account for confounding. Two hundred patients were included, 100 from each site. Baseline illness severity, race, and Candida species varied between groups; however, source control procedures, echocardiogram, and ophthalmologic exam occurred at similar frequencies. T2Candida/ASP was associated with faster median (interquartile range [IQR]) detection of candidemia (7.0 [5.0-10.75] h vs 45.5 h [34.25-68.75], P \u3c 0.001) and timelier median (IQR) initiation of directed antifungal therapy (6.0 [0-11.0] h vs 49.0 [34.0-77.0] h, P \u3c 0.001). T2Candida/ASP patients had a 58.0% probability of achieving an overall better outcome compared to those managed with blood culture/ASP (95% confidence interval: 50.4-65.2%) in IPTW-adjusted DOOR analysis. An ASP strategy incorporating T2Candida was associated with an overall better patient outcome compared to patients managed via conventional blood culture diagnosis.IMPORTANCECandida species are a significant cause of bloodstream infections in critically ill patients. Conventional diagnostic methods, such as blood cultures, have poor sensitivity and delayed results. The T2Candida Panel is a diagnostic tool that rapidly detects Candida directly from the blood in 3-5 h, enabling faster initiation of antifungal therapy. Antimicrobial stewardship programs (ASPs) optimize the management of bloodstream infections and may benefit from incorporating T2Candida to improve patient outcomes. This study examined whether an ASP intervention based on T2Candida diagnosis, compared to one relying on traditional blood culture methods, could improve outcomes in candidemia using a desirability of outcome ranking (DOOR) analysis. The DOOR method provides a comprehensive evaluation by integrating multiple outcomes into a single end point, which is ideal given the complexity of patients with candidemia. The T2Candida/ASP intervention resulted in an overall better patient outcome, considering infectious complications, treatment failure, and all-cause mortality
Editorial Commentary: Patellofemoral Stabilization for First-Time Dislocation in Skeletally Immature Patients Achieves Excellent Outcomes, Yet Indications Remain Unclear
No full textHistorically, initial management of patellofemoral instability without osteochondral fracture consists of bracing and physical therapy, but up to 50% of skeletally immature patients may develop recurrent instability. Recent studies suggest that patients with first-time dislocations may benefit from surgical stabilization. Risk stratification is essential; those with ligamentous laxity, increased patellar height, and trochlear dysplasia have greater failure rates with nonoperative management. Surgery in skeletally immature patients also entails risk. We recommend conservative management to most patients with a first-time patellar dislocation. Patients with high-risk features are counseled candidly about their elevated risk of failure potentially requiring surgery
Surface Electromyography Reveals Middle Deltoid as the Functionally Dominant Shoulder Muscle After Reverse Total Shoulder Arthroplasty
No full textBACKGROUND: Reverse total shoulder arthroplasty (RSA) increases deltoid muscle fiber recruitment and tension to compensate for deficient rotator cuff activity; however, it is unclear whether the anterior or middle deltoid becomes dominant and how the muscle activation profile changes postoperatively. Using minimally invasive electromyography, this study evaluated the activity of the deltoid and surrounding muscles during shoulder motion to assess muscle activation changes post-RSA.
METHODS: In this observational study, we assessed change in preoperative to postoperative shoulder muscle activation in 10 patients over six months. Muscle activation was measured using eight surface electrodes. Activation of the anterior, middle, and posterior deltoid, along with surrounding muscles, was recorded and quantified during shoulder abduction, flexion, and external and internal rotation. One-way analysis of variance was used to identify significant differences in activation and time or speed. The least significant difference post hoc test was used to determine specific differences in muscle activation at subsequent time points.
RESULTS: RSA shoulders at six months postoperatively showed a significant increase in activity of the middle deltoid predominantly. Middle deltoid activation increased during abduction (p\u3c 0.001), flexion (p=0.008), external (p\u3c 0.001), and internal (p\u3c 0.001) rotation.
CONCLUSIONS: Our study highlights the middle deltoid as the primary contributor to rotator cuff function in reverse shoulder arthroplasty (RSA), characterized by quantitative activation, significant involvement in all shoulder motions, and increased activation over time. These findings could inform future RSA designs to enhance deltoid wrapping, maximizing strength and efficiency
p16, COX-2, and Ki67 Protein Expression in DCIS and Risk of Ipsilateral Invasive Breast Cancer
No full textBACKGROUND: Prior research on the associations of p16, COX-2, and Ki67 immunopositivity in ductal carcinoma in situ (DCIS) tissue with the risk of subsequent ipsilateral invasive breast cancer (IBC) is limited.
METHODS: In a case-control study nested in a cohort of women diagnosed with DCIS, immunostaining for p16, COX-2, and Ki67 was performed on DCIS tissue from those who developed subsequent ipsilateral IBC (cases; n = 146) and on matched subjects who did not develop IBC (controls; n = 273). Conditional logistic regression was used to estimate ORs and 95% confidence intervals for the associations between immunopositivity for p16, COX-2, and Ki67 and the risk of subsequent ipsilateral IBC.
RESULTS: There was no association between p16, COX-2, and Ki67 immunopositivity, examined either individually or in combination, and a risk of ipsilateral IBC. Compared with all other groups, the multivariable OR (95% confidence interval) for women who were triple positive for the three markers was 1.16 (0.38-3.54).
CONCLUSIONS: p16, COX-2, and Ki67 immunopositivity was not associated with altered risk of ipsilateral IBC in women with DCIS.
IMPACT: p16, COX-2, and Ki67 may not be prognostic for ipsilateral IBC in women with DCIS
Sensory and Autonomic Fibers in Anterior Ethmoid, Posterior Nasal, Posterolateral Nasal Nerves
No full textBACKGROUND: Sensory and autonomic nerves supply the sinonasal mucosa and contribute to the pathophysiology of certain forms of chronic rhinitis, rhinosinusitis, and craniofacial pain. The compositions of these intranasal nerves have been incompletely studied. The purpose of this cadaveric study was to investigate the relative areas of sensory, parasympathetic, and sympathetic nerve fibers within different nasal nerves.
METHODS: Ten fresh cadaver heads were dissected, and anterior ethmoid (AEN), posterior nasal (PNN), and posterolateral (PLNN) sections were harvested unilaterally via endonasal and transorbital approaches. Specimens were formalin-fixed, sectioned, and stained with hematoxylin and eosin, as well as for neuropeptides (substance-P, calcitonin gene-related peptide [CGRP], neurokinins-A and B [NKA, NKB], vasointestinal peptide [VIP], neuropeptide Y [NPY]), and enzymes (choline acetyltransferase [ChAT] and tyrosine hydroxylase [TH]). Enzyme and neuropeptide nerve marker percent areas were calculated using brightfield analysis. Sensory and autonomic nerve marker percent areas were then compared within and between AENs, PNNs, and PLNNs.
RESULTS: In total, 10 PNNs and AENs and 8 PLNNs were available for analyses. Sensory, parasympathetic, and sympathetic nerve markers were identified in every PNN, PLNN, and AEN, and were mostly equivalent between nerves. Only neurokinin-A demonstrated a significantly greater percent area than other markers across different nasal nerves.
CONCLUSION: Sensory and autonomic nerve markers were present in all AENs, PNNs, and PLNNs, and were largely equivalent between nerves. NKA presented the greatest percent area consistently across each of the nerve types. Future studies should explore the relative contributions of sensory versus autonomic dysfunction in chronic rhinitis, rhinosinusitis, and craniofacial pain.
LEVEL OF EVIDENCE: Level 4
Comparative analysis of arch vessel revascularization techniques in proximal arch thoracic endovascular aortic repair
No full textOBJECTIVE: Endovascular stent grafting extending into the ascending aorta (zone 0) is increasingly used in the treatment of aortic arch disease. This study aims to evaluate the risk of stroke in patients undergoing zone 0 arch thoracic endovascular aortic repair (TEVAR) based on the technique used for head vessel revascularization.
METHODS: Patients undergoing zone 0 arch TEVAR covering all the aortic arch vessels were identified in the Vascular Quality Initiative between 2014 and 2023. Patients treated for aortic rupture or trauma were excluded. Head vessel revascularization techniques were classified into three groups: open revascularization (OR), endovascular revascularization (ER), and hybrid revascularization (HR). Multivariate logistic regression analysis was used to evaluate the association of head vessel revascularization technique with the primary outcomes of perioperative mortality and stroke.
RESULTS: A total of 409 patients underwent zone 0 arch TEVAR covering all the aortic arch vessels, of which 50% (207/409) underwent OR, 20% (80/409) underwent ER, and 30% (122/409) underwent HR of the head vessels. The in-hospital mortality and stroke rates were 9% and 12%, respectively. Survival at 30 days, 1 year, and 2 years were 88%, 79%, and 74%, respectively. Patients undergoing ER of the head vessels had significantly higher stroke compared with those undergoing OR and HR (OR 11%, ER 21%, HR 8%; P = .02). ER was associated with a two-fold higher risk of perioperative stroke compared with OR (odds ratio, 2.16; 95% confidence interval, 1.08-4.30; P = .03), whereas no difference in perioperative stroke was observed between OR and HR (P = .40). Although OR and HR of the head vessels had a significantly lower rate of perioperative stroke compared with ER in 2017-2020 (OR 10% vs ER 30% vs HR 10%, P = .02), this difference diminished over time with no significant difference observed in the most recent interval (2021-2023) studied (OR 9% vs ER 12% vs HR 8%; P = .76). Trends revealed an increase in the use of HR (from 4% in 2014 to 57% in 2023) alongside a significant decrease in ER (from 39% in 2020 to 14% in 2023).
CONCLUSIONS: Stroke remains a significant concern during zone 0 arch TEVAR. Total endovascular repair of the aortic arch is associated with a greater than two-fold higher risk of stroke compared with OR and HR of the head vessels. However, advances in ER techniques and increased use of hybrid strategies highlight an ongoing evolution toward safer and less invasive approaches resulting in a decrease in perioperative stroke rates over time
A Case of Atypical Acute Limb Ischemia and Concurrent Fournier\u27s Gangrene
No full textFournier\u27s gangrene is a severe necrotizing soft tissue infection involving the perineal, perianal, and genital areas, where early and aggressive surgical debridement is the key determinant for survival. Acute limb ischemia (ALI) occurs when vascular compromise threatens a limb, often requiring revascularization or amputation. A synergistic pathophysiological effect between Fournier\u27s gangrene and ALI can be appreciated as infection promotes microthrombi, which leads to vessel occlusion, exacerbating the soft-tissue gangrene and local ischemia. Thus, fulminant Fournier\u27s gangrene promotes a hypercoagulable state, which may result in ALI. A 63-year-old African American male with hypertension, hyperlipidemia, and a 35-pack-year smoking history presented with left lower extremity pain, scrotal swelling, and absent pedal pulses. Color Doppler showed an occlusion proximal to the left popliteal artery, and CT confirmed Fournier\u27s gangrene extending to the presacral area. The patient was taken emergently to the operating room for an attempt at reperfusion of the left lower extremity. This was unsuccessful due to the extent of vascular disease. Extensive surgical debridement of the genitals and perineum was also performed. Subsequent trips to the operating room for further debridement were required. Ultimately, a left above-knee amputation was performed. Despite source control of his infection, the patient suffered an aspiration event on hospital day seven, which led to hypercarbic respiratory failure and cardiac arrest. This resulted in a poor neurologic outcome, from which he did not recover. The patient was transitioned to comfort measures and expired on hospital day 20. The rarity of concurrent Fournier\u27s gangrene and ALI presents a unique clinical question, as one must decide which problem should be treated first on the operating table. This complex management decision requires a multidisciplinary approach accounting for the clinical severity of both disease processes
Management of non-obstructive azoospermia: advances, challenges, and expert recommendations
No full textGlobal Andrology Forum (GAF) Clinical Guidelines on the Management of Infertile Men with Varicocele
No full textPURPOSE: Varicocele is among the most common reversible causes of male infertility. Although varicocele is prevalent and there is a growing body of literature on the subject, there are still numerous debates surrounding the matter. This study presents Global Andrology Forum (GAF) clinical guidelines on the management of infertile men with varicocele.
MATERIALS AND METHODS: A team of clinicians and reproductive experts reviewed contemporary evidence on all aspects of varicocele, including systematic reviews, meta-analyses, and the results of the GAF global survey of practices. They then formulated expert statements and recommendations, subject to a modified Delphi process until a consensus was reached. The final statements and recommendations were rated using the GRADE system.
RESULTS: A total of 31 statements and recommendations on the evaluation and management of varicocele were introduced and scored by 24 experts. All experts agreed with the final statements. Varicocele is a significant contributor to male infertility. Its diagnosis is based mainly on physical examination, although imaging can be used in certain cases. Clinical varicocele associated with abnormal sperm parameters is the primary unanimous indication of varicocele repair. However, other indications can still be considered, and recommendations for a tailored approach to controversial situations have been presented. There is inadequate evidence on the use of medical therapy for varicocele.
CONCLUSIONS: These clinical guidelines on the management of infertile men with varicocele, based on the GAF surveys, systematic reviews, and meta-analyses, point out the pivotal importance of varicocele in modern Andrology. Continued research is crucial to improving diagnostic accuracy and treatment outcomes, ultimately enhancing reproductive health for men with varicocele. Therefore, the current guidelines allow clinicians to develop effective management strategies for a common issue and address practical questions where evidence is lacking