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Longitudinal Improvement in Respiratory Function Following Plasma Exchange in Patients with Severe Myasthenia Gravis
No full textBACKGROUND: There are no data on the effect size and timing of plasma exchange (PLEX) in patients with myasthenic crisis (MC).
METHODS: We retrospectively analyzed measurements of forced vital capacity (FVC) and negative inspiratory force (NIF) in the days before and after PLEX (administered every other day) in patients with MC admitted to a tertiary hospital over 4 years. For multiple measurements in one day, the average value was used. The day immediately before the first treatment with PLEX was considered baseline. Using time as a continuous or categorical variable in mixed-effects multiple linear regressions, we estimated predicted values for these tests.
RESULTS: Twenty-two patients (mean age 67.3 years, 51.9% male patients) with 27 MC episodes and 508 measurements (234 FVC and 274 NIF; from 5 days before to 20 days after PLEX) were included. Presence of antibodies was detected in 70.4%. Intubation and mechanical ventilation occurred in 36.6% of patients. The mean number of PLEX was 5.1 (range 3-11). NIF values decreased before the first PLEX but increased after by on average 1 cm H(2)O/day (95% confidence interval [CI] 0.68-1.32, p \u3c 0.001). FVC fluctuated before the first PLEX but then increased by on average 51.2 mL/day (95% CI 35.8-66.1, p \u3c 0.001). The maximum increase in NIF occurred during the day of the first PLEX (9.2 cm H(2)O, 95% CI 3.3-15.1, p = 0.002) and rather slowed after day 10. FVC increase compared to baseline became significant the second day after the first PLEX (287 mL, 95% CI 7.5-567.6, p = 0.04) and continued overall to increase (with fluctuations) up to day 17.
CONCLUSIONS: Significant increases in bedside respiratory measurements are observed as soon as the first PLEX day but with more variability on FVC than NIF, which may either reflect more FVC technique inconsistencies or more consistent effect of the treatment on NIF
A multi-institutional phase 1 clinical trial exploring upfront multimodal standard of care and combined immunotherapies for newly diagnosed glioblastoma
No full textBACKGROUND: For newly diagnosed glioblastoma (GBM), combination of surgical upfront immunotherapy with aglatimagene besadenovec (CAN-2409), followed by chemoradiation and then adjuvant nivolumab has not been tested. The aim of this study was to test the safety of this regimen and determine metrics of immune activation that may correlate with clinical outcomes.
METHODS: 41 patients with suspected newly diagnosed GBM by imaging were enrolled in this multi-institutional, open label, phase 1b clinical trial before surgical resection. Frozen section confirmation of high-grade glioma was required for administration of aglatimagene besadenovec. This was then followed with chemoradiation and adjuvant nivolumab. Tumor and blood were assayed for genetic and immune markers before and during treatment.
RESULTS: The regimen was well tolerated and generated measurable immune activation. Factors linked to survival were identified, such as baseline mutated gene pairs (e.g. MED15/ HRC), tumor immune cell composition, and changes in systemic cytokine, immune cells, and T cell diversity. The most significant serial systemic immune changes were observed in a long-term survivor subset of patients with gross total resection (GTR)/ methylated methylguanine methyltransferase (MGMT) promoter tumors. Median overall survival (mOS) in these patients was 30.6 months, while it was less for patients with unmethylated or subtotal resections.
CONCLUSIONS: These findings suggest the opportunity for patient stratification and the potential for more durable antitumor immune responses in future clinical trials of this multimodal standard of care and combined immunotherapy regimen. ClinicalTrials.gov identifier: NCT03576612
Isolated Scaphoid Dislocation Secondary to Pseudogout Arthritis: A Case Report
No full textA 69-year-old male laborer with a prolonged history of untreated gouty arthritis in the wrist with an atraumatic isolated scaphoid dislocation requiring urgent salvage procedure in the form of proximal row carpectomy. Few isolated scaphoid dislocations have been reported in the literature. They usually are a result of high-energy mechanisms. To our knowledge, no atraumatic, isolated scaphoid dislocations with underlying pseudogout have been described in the literature. This report describes one such case and brings attention to the importance of treatment of inflammatory arthropathies in the carpus due to its effect on the integrity of the carpus and the scaphoid in particular
Endonasal dome bind with incorporation of a columellar strut reduces Infratip fullness: a quantitative photographic analysis
No full textOBJECTIVE: To demonstrate the effectiveness of the dome bind suture technique with incorporation of a columellar strut in reducing infratip lobule fullness in closed rhinoplasty by use of quantitative photographic analysis.
METHODS: A retrospective review of patients who underwent rhinoplasty by two senior authors was carried out. All surgical maneuvers were documented. Photographic analysis was performed quantitatively using Rhinobase software. Results were recorded as ratio of change relative to a stable anatomic reference. This was chosen as the intercanthal distance on frontal view and lateral canthus to lateral commissure distance on lateral view.
RESULTS: Sixty-three patients were included who underwent the dome bind suture technique. On frontal view, the ratio of the infratip lobule on post-surgical images versus preintervention was 0.88, which represents a reduction of 12 % (P \u3c 0.01). This was not apparent on lateral view, with a postoperative/preoperative ratio of 1.02 (P = 0.53).
CONCLUSION: We have demonstrated that the endonasal dome bind technique with incorporation of a columellar strut is useful at reducing infratip lobule fullness on frontal view and is a valuable tool in the armamentarium of the rhinoplasty surgeon
Examining maternal and fetal outcomes across various subtypes of hypertension during pregnancy
No full textINTRODUCTION: Hypertensive disorders of pregnancy (HDP) are a leading cause of maternal morbidity and mortality worldwide. It includes chronic hypertension (CH), gestational hypertension (GH), preeclampsia (PRE), and CH with superimposed preeclampsia (SPE).We aim to assess in-hospital maternal and fetal outcomes of women in each of these groups in comparison to normotensive controls.
METHODS: Study sample included women in the National Inpatient Sample dataset from 2016 to 2020 who were categorized into the 4 groups of HDP as described above. They were compared to normotensive pregnancies for maternal and fetal outcomes using regression analysis after adjusting for age, race, C-section status, and comorbidities.
RESULTS: The study dataset from October 2015-December 2020 included 19,089,780 delivery admissions with 2,771,809 (14.5 %) of patients affected by HDP. The HDP groups were distributed as follows: GH - 38 %, PRE - 32 %, SPE - 11 %, and CH - 19 %. Women with PRE, SPE, and CH had significantly higher rates of mortality, circulatory shock, peripartum cardiomyopathy, acute kidney injury, preterm labor, stillbirth, and cerebrovascular events as compared to normotensive patients, while GH did not. Specifically, maternal mortality was highest in the SPE group (adjusted odds ratio [aOR] 3.16), followed by PRE (aOR 2.91) and CH (aOR 2.42). Additionally, all HDP groups had higher rates of small for gestational age and significant bleeding as compared to normotensive patients.
CONCLUSIONS: Pregnant patients with CH, PRE, and SPE experience higher rates of adverse maternal and fetal outcomes during their delivery admission when compared to normotensive patients. Understanding the graded risk differences across HDP subtypes may enable more tailored interventions, optimizing maternal and fetal outcomes for those at highest risk
Finishing the Job: Utilization of Amulet Device for 2 Prior Incomplete Left Atrial Appendage Occlusion
No full textDecoding High MME Opioid Usage: A Root Cause Analysis of HFJH Outlier Status Within the System
Get PDFPurpose: The purpose of this study is to define the root cause of high morphine milligram equivalents usage, defined as morphine milligram equivalents (MME) greater than 50 milligrams, within Henry Ford Jackson Hospital (HFJH) compared to other hospitals within the Henry Ford Health System. By conducting this analysis, the study aims to uncover factors contributing to the elevated opioid prescribing rates at HFJH and to explore strategies to optimize prescribing practices, thereby improving patient safety and reducing the risk of opioid misuse. Methods: The inclusion criteria for this study require participants to be 18 years or older admitted to HFJH between January 1, 2023, and January 1, 2024. They must have received at least one scheduled order of morphine or a morphine equivalent (e.g., buprenorphine, codeine, hydromorphone, fentanyl, methadone, oxycodone, or tramadol) at a dosage of 50 MME or greater during their hospital stay. Exclusion criteria include hospice patients or individuals with terminal illnesses receiving palliative care, intubated patients on fentanyl infusion, and vulnerable groups such as children, pregnant women, and incarcerated individuals. This study will use a retrospective, descriptive medication use evaluation design. Historical data from electronic medical records will be reviewed to assess opioid prescribing practices and protocols. The study will employ statistical and qualitative analyses to identify patterns and discrepancies in high MME prescribing, focusing on opioid trends, departmental variations, and adherence to naloxone protocols. A cohort of eligible patients will be compiled through data extraction, with each assigned a unique identifier. Using a random number generator, 100 patients will be randomly selected from this pool, replacing any who meet exclusion criteria. Extracted data will include patient medical record number (MRN), admitting diagnosis, opioid prescription details, naloxone orders, pain scale, authorizing prescriber, and primary service. Results: This study found internal medicine and postsurgical care to have the highest opioid prescribing rates within HFJH, leading with internal medicine. This trend is likely influenced by the substantial number of patients with substance use disorders managed within this service, contributing to the elevated average MME per day. Additionally, naloxone prescribing at HFJH remains inadequate, as 60% of patients discharged with an opioid prescription did not receive naloxone, highlighting a critical gap in harm reduction efforts. Conclusion: Several departments of HFJH exhibit patterns of high-dose opioid prescribing as well as a lack of naloxone prescribing, indicating a gap in knowledge or adherence to best practices. This highlights the need for focused education on pain management, particularly for postoperative care, to promote more appropriate prescribing and reduce reliance on high-dose opioids, improving patient safety and minimizing overdose and addiction risks.https://scholarlycommons.henryford.com/hfjhrs2025/1001/thumbnail.jp
Dysregulation of airway and systemic interferon responses promotes asthma exacerbations in urban children
No full textBACKGROUND: Determining why some upper respiratory illnesses provoke asthma exacerbations remains an unmet need. OBJECTIVE: We sought to identify transcriptome-wide gene expression changes associated with colds that progress to exacerbation. METHODS: Two hundred eight urban children (6-17 years) with exacerbation-prone asthma were prospectively monitored for up to 2 cold illnesses. Exacerbation illnesses (Ex(+)), defined as colds leading to asthma exacerbations requiring systemic corticosteroids within 10 days, were compared to colds that resolved without exacerbation (Ex(-)). Peripheral blood and nasal lavage samples were collected at baseline and during colds for RNA sequencing. Interferon gene expression was compared between Ex(+) and Ex(-) illnesses. Generalized additive modeling revealed interferon response kinetics. Multiple linear regression models compared interferon expression to clinical variables. RESULTS: One hundred six participants were evaluated during 154 colds. There was greater upregulation of differentially expressed interferon genes during Ex(+) illnesses compared to Ex(-). Ex(+) illnesses had greater average and steeper rise in interferon expression. Within 3 days of illness, interferon expression was positively associated with nasal rhinovirus quantity (nasal: adjusted R(2) = 0.48, P = .015; blood: adjusted R(2) = 0.22, P = .013), and interferon expression was negatively associated with percentage predicted forced expiratory volume in 1 second (nasal: β = -0.010, P = .048; blood: β = -0.008, P = .023). Participants with lower baseline interferon expression had shorter time to exacerbation, higher risk for exacerbation with viral illnesses, and greater increase in interferon expression during viral colds (nasal: β = -0.80, P \u3c .0001; blood: β = -0.75, P \u3c .0001). CONCLUSION: Dysregulated interferon responses are important contributors to asthma exacerbation risk in children. Low baseline interferon expression followed by greater upregulation of interferon pathways in airway and blood during respiratory illnesses increased exacerbation risk. Targeting this pathway in at-risk individuals holds promise for the personalized prevention of asthma exacerbations
Residents Vote! A Framework and Toolkit to Improve Resident Voting Rates.
No full textBackground Elections substantially impact health care, yet physicians vote less frequently compared to the general population. Engaging residents and fellows in elections, during training when professional identities are formed, may improve physician voting rates. Objective To examine the feasibility and acceptability of a centralized, institution-wide approach to improve graduate medical education (GME) trainee awareness, registration, and participation in the electoral process. Methods Our framework was implemented in academic year 2023-2024, leading up to the 2024 Michigan presidential primary election. It included: voter registration instruction during resident orientation; emails with election deadlines and nonpartisan voting information; distribution of wearable buttons displaying QR codes linking to information on voter registration, early voting, and mail-in ballots; and informational sessions with legislative experts. We created an open-access GME toolkit for other institutions. We measured trainee voting rates using a single text message question on election day. Results Of 1041 trainees, 115 (11%) attended 4 informational sessions; informal feedback was positive. One hundred twenty-three of 826 trainees (15%) responded to the text message question: 35 of 81 (43%) eligible voters reported having voted or planning to do so that day (statewide rate=23%). No additional funding was required. The institutional GME office provided support for operationalization and wearable buttons. Henry Ford Health Government Affairs supported the informational sessions (held during routine didactic time). Conclusions A series of interventions to improve GME trainees\u27 participation in elections appeared to enhance participation in a primary election with low effort and apparent acceptability. An online toolkit with reference data, tips, and tools was created to allow others to replicate this effort
Patients with PSOriasis and Suppurative Hidradenitis (PSO-SH) share genetic risk factors and are at risk of increased morbidity
No full textBACKGROUND: Select patients are diagnosed with both psoriasis (PSO) and hidradenitis suppurativa (HS), leading to a unique disease pattern. Genetic risk factors remain unidentified.
METHODS: The study harnessed an international collection of patients with PSO and HS (PSO-SH). Clinical and genetic data were collected and analyzed.
RESULTS: Eighty-seven PSO-SH patients (70% female) were identified. They had a high number of comorbidities (89%) and worse general physical health compared to PSO-only (OR: 3.09; 95% CI: 1.56-6.12) or HS-only (OR: 2.5; 95% CI: 1.23-5.00) patients. PSO-SH patients were at significantly higher risk of having Crohn\u27s disease (OR: 4.6-11.9; 95% CI). Data revealed the highest overall genetic risk score for PSO-SH patients (PSO-polygenic risk score; 108.22), followed by PSO (101.18), HS (99.84), and healthy controls (98.58). High non-human leukocyte antigen scores were associated with an increased risk for developing both PSO and HS, indicating a distinct biological profile compared to HS-only and PSO-only individuals.
LIMITATIONS: Some clinical information was collected retrospectively.
CONCLUSIONS: This study highlights a shared genetic susceptibility of HS and PSO at non-human leukocyte antigen loci. Recognizing PSO-SH patients as a distinct patient group with high morbidity and increased risk for developing Crohn\u27s disease will help to improve patient management