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Thiamine Deficiency Is Common and Underrecognized in Emergency Department Oncology Patients
No full textBackground: Wernicke\u27s encephalopathy can occur in oncology patients independent of alcohol use, likely resulting from poor dietary thiamine intake. High metabolic demands, such as those in acute illnesses seen in the emergency department (ED), can exacerbate thiamine deficiency. In this study, our objective was to assess the incidence of thiamine deficiency in ED oncology patients, which could lead to Wernicke\u27s encephalopathy or other thiamine deficiency disorders if left untreated.
Methods: This was a single-center prospective cohort study. We included patients with acute illness and a history of active cancer management in the ED of a large, urban hospital. We also included age and sex-matched control patients with no history of cancer who sought ED care. We excluded patients with a history of alcohol use or parenteral thiamine administration before enrollment. We recorded whole blood thiamine levels to measure total body thiamine stores and collected data on clinical variables, thiamine treatment, and adverse events.
Results: In total, 87 oncology and 71 control patients were included in the study. The mean age was 62.1 ± 13.7 and 58.9 ± 12.6 years, respectively, and 48% of oncology vs. 55% of control participants were female. The most common cancers represented were colon (23%), lung (25%), prostate (10%), and breast (9%). Thiamine deficiency was significantly higher in ED oncology patients (25, 28.7%) compared to controls (6, 8.5%), odds ratio 4.4 (95% CI 1.7-11.4). None of the oncology patients with deficiency received thiamine treatment in the ED.
Conclusions: Our findings suggest that thiamine deficiency is prevalent in acutely ill oncology patients, yet rarely treated in the ED
Molecular Differences in Pancreatic Ductal Adenocarcinomas from Black versus White Patients
No full textPancreatic cancer is the third leading cause of cancer-related death in the US. Black or African American patients have a higher incidence of pancreatic cancer compared to other racial groups. It is unclear whether distinct molecular mechanisms are involved in the development of pancreatic cancer in different racial groups. To identify tumor molecular features that are distinctly associated with race in Black or African American and White patients with pancreatic ductal adenocarcinoma (the main subtype of pancreatic cancer), we analyzed de-identified patient records, including tumor sequencing data and expression of PD-L1, from the Tempus multimodal database. Patients with a primary diagnosis of pancreatic ductal adenocarcinoma and who received molecular testing between 2017-11 and 2023-03 were included in analyses. Among 4,249 patients analyzed in this study, 452 (10.6%) were Black or African American and 3797 (89.4%) were White. Black patients had a higher prevalence of TP53 mutations compared to White patients (p\u3c0.001). KRASG12R mutations occurred more frequently in female patients in the Black vs White group (p=0.007). Compared to White patients, Black patients had a higher tumor mutational burden (p\u3c0.001) and PD-L1 overexpression (p=0.047). In a separate analysis of recent clinical trials testing immunotherapies for pancreatic cancer, we found that Black patients and other minorities were underrepresented in most trials. These findings suggest race-associated molecular differences in tumors that may impact patient responses to immunotherapies. Our study also supports the importance of improving patient diversity in clinical trials on pancreatic cancer treatments
Associations between per- and polyfluoroalkyl substances (PFAS) and female sexual function in a preconception cohort
No full textBACKGROUND: Female sexual function is important for sexual well-being, general health, fertility, and relationship satisfaction. Distressing impairments in sexual function, clinically recognized as female sexual dysfunction (FSD), can manifest as issues with interest/desire, arousal, orgasm, and pain during vaginal penetration. Some evidence suggests that exposure to endocrine-disrupting chemicals may adversely affect female sexual function, but associations for per- and polyfluoroalkyl substances (PFAS) have not been previously evaluated.
OBJECTIVE: We investigated associations between serum PFAS concentrations and female sexual function among U.S. pregnancy planners.
METHODS: We used cross-sectional data from participants from Pregnancy Study Online (PRESTO), a prospective preconception cohort study. Participants reported sexual function and distress at baseline on two validated measures: a modified version of the Female Sexual Function Index-6 (FSFI-6) and the Female Sexual Distress Scale (FSDS). We quantified PFAS serum concentrations in samples collected in the preconception period (i.e., at baseline) using solid phase extraction-high performance liquid chromatography-isotope-dilution-mass spectrometry. Participants reported sociodemographic information on structured baseline questionnaires. We included 78 participants with complete PFAS and sexual function data and fit multivariable linear regression models to estimate mean differences in FSFI-6 scores (β) or percent differences (%) in FSDS scores per interquartile range (IQR) increase in PFAS concentrations, adjusting for age, annual household income, years of education, parity, and body mass index. We further investigated effect measure modification by parity (parous vs. nulliparous) in stratified models.
RESULTS: An IQR increase in perfluorohexanesulfonic acid was associated with a 1.0-point decrease (95% CI = -1.8, -0.1) in reported FSFI-6 scores, reflecting poorer sexual function. PFAS were consistently associated with lower FSFI-6 scores among parous participants. PFAS were also associated, though imprecisely, with greater sexual distress.
CONCLUSION: Some PFAS were associated with poorer sexual function among U.S. pregnancy planners, but future studies are needed to clarify the extent to which PFAS influences female sexual health
Longitudinal changes in the impact of socioeconomic status on graft survival in kidney transplantation
No full textBackground: It is well known that socioeconomic status affects graft survival (GS) in adult kidney transplant recipients. However, there is little data to assess the impact of socioeconomical status on long-term GS. We hypothesized that impact of socioeconomic status on GS might change depending on the period post- transplantation. We assessed longitudinal changes in impact of socioeconomic status on GS. Method: Adult kidney transplant alone performed from 2003-2013 were evaluated using the United Network for Organ Sharing database. The period of post-transplantation was divided into 3 categories; Group1: 1-year survival in all patients, Group2: 5-year survival in 1 year-survivors, Group3: 10-year survival in 5-year survivors.(Figure 1) Socioeconomic factors included patient education level and employment status at transplant. The impact of socioeconomical factors on GS in each group was evaluated by Cox proportional hazard model. Result: In total, 186,342 adult KT were performed from 2003-2013 (Group1), of which 176,656 recipients survived at 1 year (Group2) and 126,405 recipients survived at 5 years (Group3) post-transplant. (Figure 1) Multivariable Cox hazard model revealed that employment status at transplant was significantly associated with better graft survival in all groups, independent of race, age, gender, diabetes mellitus and KDPI. (Figure 2) While lower education level (high school or lower, reference; postcollege graduate degree) was not the risk factor in Group1, it increased the risk of graft failure in later periods. (HR1.09, 95%CI 1.04-1.15, p\u3c 0.01 in Group2, HR1.12, 95%CI 1.04-1.21, p\u3c 0.01 in Group3). Conclusion: In kidney transplantations, the impact of socioeconomic status on GS changed over time. Of note, the influence of the patient’s education level on GS became more significant in later periods post-transplantation, where prognostic impacts of early post-transplant complications are limited. To improve the very long-term outcomes in later periods, consideration of the patient’s education level in follow- up care might be necessary. Distensibility. PPFI (Systolic Pressure-Diastolic Pressure/Flow), is quantifies renal allograft arterial stiffness during HMP. Distensibility (Initial Resistance-Current Resistance/Initial Resistance) quantifies microvascular function, recruitment, and perfusion. We determined the association between PPFI and distensibility with 1 year graft failure and delayed graft function (DGF). Results: During the study period, 57 DDKTs met inclusion criteria, of which 12% (N=7) experienced a one-year graft failure and 51% (n=29) had DGF. As arterial stiffness is a fixed biomechanical property, PPFI is stable across time during. PPFI was two-fold higher in kidneys with graft failure in the first year compared to those with graft survival at one year (p\u3c 0.05, Figure 1). Consistent with improved microvascular recruitment and perfusion, Distensibility increased during HMP. It was significantly lower at 1 hour in kidneys with DGF (Figure 2). These findings were robust to sub-analyses of specific donor categories (Figure 2). Conclusions: Allografts with one year graft failure had high PPFI indicating that stiffer, more diseased renal vasculature negatively impacts post-transplant outcomes. Allografts with DGF had low Distensibility indicating poor microvascular recruitment and function during HMP may impact early graft function. These novel biomechanical based perfusion parameters have the potential to become powerful tools to assess renal allografts during HMP. [Formula presented] [Formula presented] DISCLOSURES: R. Oki: None. A. Nishimagi: None. I. Rocha: None. S. Al-Juburi: None. L. Rajendran: None. E. Kerby: None. D. Kim: None. L. Malinzak: None. J. Denny: None. A. Yoshida: None. M. Abouljoud: None. S. Nagai: None
Patient-reported Outcomes In Heart Failure: Insights From A Simplified Kccq In Heartmate 3 Lvad Recipients
No full textBackground: Patient-reported outcomes, such as the Kansas City Cardiomyopathy Questionnaire (KCCQ), are pivotal in assessing the impact of left ventricular assist device (LVAD) support on patients’ heart failure-related quality of life (hf-QOL) as part of hierarchical outcomes. However, translating improvements in composite KCCQ scores into a meaningful message for patients and referring providers remains challenging. In registries, incompleteness of KCCQ scores is also common after 1 year, perhaps due to questionnaire length. Purpose: This study aims to a) evaluate the utility of a simplified KCCQ score in describing the LVAD patient journey and b) to generate a patient-friendly graphic on hf-QOL trajectory for use during shared decision making encounters. Methods: Question-level KCCQ responses were analyzed in HeartMate 3 LVAD recipients from the MOMENTUM 3 studies (2,200 patients) preoperatively and at 6- 12-, and 24-months after implant. Patients had to complete one preoperative and ≥1 postoperative KCCQ assessment for inclusion. The simplified LVAD-KCCQ is as follows: 23 KCCQ questions from 5 domains were simplified into 5 questions, 1 from each domain. Response options were consolidated into severely, moderately and minimal/none from 5-7 prior options. The trajectories of within patient changes in the simplified KCCQ domains were evaluated at each time point. Results: There were sustained improvements from baseline in the summary standard and simplified KCCQ scores and within each simplified domain, beginning 6 months postoperatively (table 1, figure 1). Intra-patient improvements occurred rapidly in each domain and were sustained to two years. Of those who were severely limited in their enjoyment of life (blue) prior to LVAD (n=1133), \u3c17.8% (n=202) and \u3c8.2% (n=93) had persistently severe limitations at 6 months and 1 year, respectively. Overall, 63% of patients has no/minimal limitations at 2 years (Fig 1A, Fig 2). Similar rapid and sustained improvements were noted for response to the other simplified KCCQ domains (Fig 1B-C). Conclusion: An assessment of individual simplified KCCQ domain responses allows for a succinct assessment of the patient journey after HM3. These data may assist in improving KCCQ data compliance with registries and in conveying average changes in hf-QOL after LVAD to patients
Midline vs Peripherally Inserted Central Catheter for Outpatient Parenteral Antimicrobial Therapy
No full textIMPORTANCE: Little is known about the safety of midline catheters vs peripherally inserted central catheters (PICCs) for outpatient parenteral antimicrobial therapy (OPAT).
OBJECTIVE: To compare outcomes from midline catheters vs PICCs for OPAT.
DESIGN, SETTING, AND PARTICIPANTS: This retrospective cohort study included patients who received antimicrobial therapy through a midline catheter or PICC between January 2017 and November 2023 across 69 Michigan hospitals. Because peripherally compatible OPAT was the indication of interest, vancomycin therapy was excluded. Data were analyzed from April to June 2024.
EXPOSURES: Insertion of a midline catheter or PICC for OPAT following hospitalization.
MAIN OUTCOMES AND MEASURES: The primary outcome was major device complications (ie, catheter-related bloodstream infection or catheter-related venous thromboembolism). Secondary outcomes included minor device complications (eg, catheter dislodgement, occlusion, tip migration, infiltration, superficial thrombophlebitis, or exit site concerns) and device failure, defined as catheter removal following device complication. Cox proportional hazards regression models were fit to device type and outcomes, adjusting for patient and device confounders and device dwell.
RESULTS: Of 2824 included patients, 1487 (53.5%) were male, and the median (IQR) age was 66.8 (55.9-77.1) years. Of 2824 devices placed for OPAT, 1999 (70.8%) were midline catheters and 825 (29.2%) were PICCs. The median (IQR) dwell time was 12 (8-17) days for midline catheters and 19 (12-27) days for PICCs (P \u3c .001). A major device complication occurred in 44 patients (1.6%) overall, including 16 (0.8%) with midline catheters and 28 (3.4%) with PICCs (P \u3c .001). OPAT delivered via midline catheters was associated with a lower risk of major complications vs PICCs (adjusted hazard ratio [aHR], 0.46; 95% CI, 0.23-0.91). Risks of minor complications and device failure were similar across device types (minor complications: 206 of 1999 [10.3%] vs 114 of 825 [13.8%]; aHR, 1.07; 95% CI, 0.83-1.38; device failure: 191 of 1999 [9.6%] vs 100 of 825 [12.1%]; aHR, 1.26; 95% CI, 0.96-1.65). For device dwell of 14 or fewer days, midline catheters were associated with a lower risk of major complications (12 of 1324 [0.9%] vs 16 of 304 [5.3%]; aHR, 0.29; 95% CI, 0.12-0.68) and similar risk of failure (151 of 1324 [11.4%] vs 52 of 304 [17.1%]; aHR, 0.79; 95% CI, 0.56-1.12) vs PICCs. For dwell longer than 14 days, no significant difference in rates of major complications (4 of 675 [0.6%] vs 12 of 521 [2.3%]; aHR, 0.42; 95% CI, 0.13-1.40) or device failure (40 of 675 [5.9%] vs 48 of 521 [9.2%]; aHR, 1.02; 95% CI, 0.64-1.61) were observed.
CONCLUSIONS AND RELEVANCE: In this study, midline catheters appeared to be safe alternatives to PICCs for OPAT, particularly if infusions were planned for 14 or fewer days
Assessment and mitigation of bias in influenza and COVID-19 vaccine effectiveness analyses - IVY Network, September 1, 2022-March 30, 2023
No full textBACKGROUND: In test-negative studies of vaccine effectiveness (VE), including patients with co-circulating, vaccine-preventable, respiratory pathogens in the control group for the pathogen of interest can introduce a downward bias on VE estimates.
METHODS: A multicenter sentinel surveillance network in the US prospectively enrolled adults hospitalized with acute respiratory illness from September 1, 2022-March 31, 2023. We evaluated bias in estimates of VE against influenza-associated and COVID-19-associated hospitalization based on: inclusion vs exclusion of patients with a co-circulating virus among VE controls; observance of VE against the co-circulating virus (rather than the virus of interest), unadjusted and adjusted for vaccination against the virus of interest; and observance of influenza or COVID-19 against a sham outcome of respiratory syncytial virus (RSV).
RESULTS: Overall VE against influenza-associated hospitalizations was 6 percentage points lower when patients with COVID-19 were included in the control group, and overall VE against COVID-19-associated hospitalizations was 2 percentage points lower when patients with influenza were included in the control group. Analyses of VE against the co-circulating virus and against the sham outcome of RSV showed that downward bias was largely attributable the correlation of vaccination status across pathogens, but also potentially attributable to other sources of residual confounding in VE models.
CONCLUSION: Excluding cases of confounding respiratory pathogens from the control group in VE analysis for a pathogen of interest can reduce downward bias. This real-world analysis demonstrates that such exclusion is a helpful bias mitigation strategy, especially for measuring influenza VE, which included a high proportion of COVID-19 cases among controls
Return to play following craniotomy for non-traumatic brain lesions
No full textOBJECTIVE: Return to play (RTP) decisions after cranial surgery are important to patients. Most published data relate to RTP following sports-related brain injury. This study investigated factors that influence neurosurgical RTP decision-making following craniotomy for non-traumatic brain lesions.
METHODS: A patient scenario-based survey was distributed to U.S. and Europe-based neurosurgeons via the American Association of Neurological Surgeons/Congress of Neurological Surgeons Tumor Section and the European Association of Neuro-Oncology. From one core patient scenario, 5 further scenarios were developed involving patients of varying age, sport preference, tumor pathology, and craniotomy approach. Respondents provided RTP recommendations and factors important in forming these recommendations.
RESULTS: Forty-one responses were received; Europe (48%), U.S. (37%). The most commonly cited factors influencing RTP decision-making across scenarios were symptomatic recovery (85.4%), resolution of blood and/or air on imaging (43.4%), and patient demand (31.7%). The sports with the longest average RTP timeline were boxing (10.3 months), rugby (8.7 months), and American football (8.5 months) in the core patient scenario. Twenty-nine percent of neurosurgeons requested neuroimaging before determining RTP recommendations in this scenario, more commonly in America than Europe (46.7% and 5.0% respectively, p = .006).
CONCLUSIONS: Although limited by sample size, the data provides a foundation to support development of a systematic approach to RTP decision-making following craniotomy for brain lesions of non-traumatic etiology. Future work to develop consensus guidelines will benefit from objective data about outcomes, particularly in relation to repeat imaging prior to RTP