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Validation of the Graded Prognostic Assessment and Recursive Partitioning Analysis as Prognostic Tools Using a Modern Cohort of Patients with Brain Metastases
No full textBackground
Prognostic indices for patients with brain metastases (BM) are needed to individualize treatment and stratify clinical trials. Two frequently used tools to estimate survival in patients with BM are the recursive partitioning analysis (RPA) and the diagnosis-specific graded prognostic assessment (DS-GPA). Given recent advances in therapies and improved survival for patients with BM, this study aims to validate and analyze these 2 models in a modern cohort.
Methods
Patients diagnosed with BM were identified via our institution’s Tumor Board meetings. Data were retrospectively collected from the date of diagnosis with BM. The concordance of the RPA and GPA was calculated using Harrell’s C index. A Cox proportional hazards model with backwards elimination was used to generate a parsimonious model predictive of survival.
Results
Our study consisted of 206 patients diagnosed with BM between 2010 and 2019. The RPA had a prediction performance characterized by Harrell’s C index of 0.588. The DS-GPA demonstrated a Harrell’s C index of 0.630. A Cox proportional hazards model assessing the effect of age, presence of lung, or liver metastases, and Eastern Cooperative Oncology Group (ECOG) performance status score of 3/4 on survival yielded a Harrell’s C index of 0.616. Revising the analysis with an uncategorized ECOG demonstrated a C index of 0.648.
Conclusions
We found that the performance of the RPA remains unchanged from previous validation studies a decade earlier. The DS-GPA outperformed the RPA in predicting overall survival in our modern cohort. Analyzing variables shared by the RPA and DS-GPA produced a model that performed analogously to the DS-GPA
Non-Surgical Bleeding and Transurethral Resection of the Prostate (TURP) Syndrome after TURP Surgery: A Case Report and Literature Review
Get PDFPatients undergoing transurethral resection of the prostate (TURP) surgery can develop TURP syndrome and post-TURP bleeding. Post-TURP bleeding can be surgical, from arteries or venous sinuses, or non-surgical, due to coagulopathy preventing clot formation. Non-surgical post-TURP bleeding may be due to high concentrations of urokinase and tissue plasminogen activator (tPA) in the urine that cause fibrinolytic changes and increase bleeding risk. Urine urokinase and tPA may have both local and systemic fibrinolytic effects that may prevent blood clot formation locally at the site of surgery, and cause fibrinolytic changes systemically through leaking into the blood stream. Another post-TURP complication that may happen is TURP syndrome, due to absorption of hypotonic glycine fluid through the prostatic venous plexus. TURP syndrome may present with hyponatremia, bradycardia, and hypotension, which may be preceded by hypertension. In this case report, we had a patient with benign prostatic hyperplasia (BPH) who developed both TURP syndrome and non-surgical post-TURP bleeding. These complications were transient for one day after surgery. The local effect of urine urokinase and tPA explains the non-surgical bleeding after TURP by preventing clot formation and inducing bleeding. Coagulation studies showed fibrinolytic changes that may be explained by urokinase and tPA leakage into the blood stream. In conclusion, non-surgical bleeding after TURP can be explained by the presence of fibrinolytic agents in the urine, including urokinase and tPA. There is a deficiency in existing studies explaining the pathophysiology of the fibrinolytic changes and risk of bleeding after TURP. Herein, we discuss the possible pathophysiology of developing fibrinolytic changes after TURP. More research effort should be directed to explore this area to investigate the appropriate medications to treat and prevent post-TURP bleeding. We suggest monitoring patients’ coagulation profiles and electrolytes after TURP because of the risk of developing severe acute hyponatremia, TURP syndrome, fibrinolytic changes, and non-surgical bleeding. In our review of the literature, we discuss current clinical trials testing the use of an antifibrinolytic agent, Tranexamic acid, locally in the irrigation fluid or systemically to prevent post-TURP bleeding by antagonizing the fibrinolytic activity of urine urokinase and tPA
SNARE-ing the Reason for Post-Cardiac Surgery Critical Illness-Related Corticosteroid Insufficiency
Get PDFCritical illness-related corticosteroid insufficiency (CIRCI) can cause hemodynamic instability in neonates after congenital heart surgery with manifestations that increase morbidity and potential mortality. We retrospectively reviewed neonates who underwent cardiac surgery between August 2018 and July 2020 at a freestanding children\u27s hospital, had next-generation sequencing performed, and had their cortisol levels drawn as standard clinical care after cardiac surgery. The groups were defined as CIRCI (with a cortisol level ≤ 4.5 mcg/dL) and non-CIRCI (level \u3e 4.5 mcg/dL). The CIRCI group (n = 8) had a 100% incidence of heterozygous gene mutation on STX1A with splicing or loss of function, and this mutation was not found in the non-CIRCI group (n = 8). Additional gene mutations were found in the CIRCI group on RAB6A, ABCA3, SIDT2, and LILRB3, with no incidence in the non-CIRCI group. Three additional mutations were found across the CIRCI group in INPPL1 and FAM189A2 (both splicing and missense), with 12-25% of patients in the non-CIRCI group also displaying these mutations. Novel genetic abnormalities were seen in neonates with symptoms of CIRCI with potential cardiac implications from a gene mutation for STX1A. Compounding effects of additional gene mutations need to be confirmed and explored for potential predisposition to hemodynamic instability during times of stress
Oysters, Limpets, and Elephants: A Literature Review of the Hyperkeratotic Psoriasis Variants
No full textDiffering Effects of Alcohol Use on Epigenetic and Brain Age in Adult Children of Parents with Alcohol Use Disorder
Get PDFBackground: It is known that being the adult child of a parent with an alcohol use disorder (ACoA) can confer a wide variety of increased health and psychological risks, including higher rates of anxiety, depression, and post-traumatic stress disorder symptoms. Additionally, ACoAs are at greater risk of developing alcohol/substance use disorders (AUDs/SUDs) than individuals from families without a history of AUDs.
Methods: ACoA individuals with risky hazardous alcohol use (n = 14) and those not engaged in hazardous use (n = 14) were compared to a group of healthy controls. We examined structural brain differences and applied machine learning algorithms to predict biological brain and DNA methylation ages to investigate differences and determine any accelerated aging between these groups.
Results: Hazardous and non-hazardous ACoA groups had lower predicted brain ages than the healthy control group (n = 100), which may result from neuro-developmental differences between ACoA groups and controls. Within specific brain regions, we observed decreased cortical volume within bilateral pars orbitalis and frontal poles, and the left middle temporal gyrus and entorhinal cortex within the hazardous alcohol ACoA group. When looking at the epigenetic aging data, the hazardous ACoA participants had increased predicted epigenetic age difference scores compared to the control group (n = 34) and the non-hazardous ACoA participant groups.
Conclusions: The results demonstrate a decreased brain age in the ACoAs compared to control, concurrent with increased epigenetic age specifically in the hazardous ACoA group, laying the foundation for future research to identify individuals with an increased susceptibility to developing hazardous alcohol use. Together, these results provide a better understanding of the associations between epigenetic factors, brain structure, and alcohol use disorders
Post-Operative Complications of Cholecystectomy: What the Radiologist Needs to Know
Get PDFCholecystectomy is one of the most performed surgical procedures. The safety of this surgery notwithstanding, the sheer volume of operations results in a notable incidence of post-cholecystectomy complications. Early and accurate diagnosis of such complications is essential for timely and effective management. Imaging techniques are critical for this purpose, aiding in distinguishing between expected postsurgical changes and true complications. This review highlights current knowledge on the indications for cholecystectomy, pertinent surgical anatomy and surgical technique, and the recognition of anatomical variants that may complicate surgery. The article also outlines the roles of various imaging modalities in identifying complications, the spectrum of possible postsurgical anatomical changes, and the implications of such findings. Furthermore, we explore the array of complications that can arise post-cholecystectomy, such as biliary system injuries, gallstone-related issues, vascular complications, and the formation of postsurgical collections. Radiologists should be adept at identifying normal and abnormal postoperative findings to guide patient management effectively
Veterinary Students\u27 Perceptions Toward Incorporating and Expanding Telehealth Service Delivery Knowledge in Curricula and Future Practice: A Cross-Sectional Study
Get PDFObjective: Telehealth is the use of technology to deliver medical services. Potential uses among veterinarians include consulting with specialists about complicated cases, sending in electronic prescriptions, or meeting with clients to discuss patient health. Although the coronavirus disease 2019 pandemic posed many challenges to the veterinary profession, it accelerated the adoption of telehealth among veterinarians. As many of these changes took place quickly in response to the pandemic, many of those in practice did not receive much training or guidance; therefore, this study explores veterinary students\u27 perceptions regarding incorporating telehealth into the veterinary curriculum and the utilization of telehealth in the future.
Methods: An email survey was sent to students at a veterinary school.
Results: 80 students provided answers to the 11-question survey. Nearly 80% reported that it is either important or very important to incorporate telehealth training into the veterinarian curriculum, whereas almost 90% indicated that they would benefit from more telemedicine training prior to graduation. Almost 75% of participants had legal and malpractice concerns, which may present a barrier to using the technology upon graduation.
Conclusions: This study suggests that veterinary schools should explore how to incorporate telehealth training into their curriculum, especially in regard to navigating the potential pitfalls that may be encountered when employing telehealth within the context of a veterinarian-client-patient relationship.
Clinical relevance: Telehealth is a valuable tool, and its use has become commonplace. Educational programs that emphasize telehealth will better equip future clinicians to manage the nuances of this modality in practice
Risk Factors for Oral Infection and Dry Socket Post-Tooth Extraction in Medically Complex Patients in the Absence of Antibiotic Prophlaxis: A Case-Control Study
No full textIntroduction: Dry socket and infection are complications of tooth extractions. The objective was to determine risk factors for post-extraction complications in patients without antibiotic prophylaxis stratified by early- and late-complications and complication type (oral infection and dry socket).
Methods: Retrospective, case (with complications)-control (without complications) study of patients (n = 708) who had ≥1 extraction performed at any Veterans Health Administration facility between 2015-2019 and were not prescribed an antibiotic 30 days pre-extraction.
Results: Early complication cases (n = 109) were more likely to be female [odds ratio (OR) = 2.06; 95% confidence interval (CI):1.05-4.01], younger (OR = 0.29; 95% CI:0.09-0.94 patients ≥ 80 years old, reference:18-44 years), Native American/Alaska Native (OR = 21.11; 95% CI:2.33-191.41) and have fewer teeth extracted (OR = 0.53 3+ teeth extracted; 95% CI:0.31-0.88, reference:1 tooth extracted). Late complication cases (n = 67) were more likely to have a bipolar diagnosis (OR = 2.98; 95% CI:1.04-8.57), history of implant placement (OR = 8.27; 95% CI:1.63-41.82), and history of past smoking (OR = 2.23; 95% CI:1.28-3.88).
Conclusion: Predictors for post-extraction complications among patients who did not receive antibiotic prophylaxis were similar to prior work in cohorts who received prophylaxis. Unique factors identified in a medically complex population included being younger, Native American/Alaska Native, having mental health conditions, history of a dental implant, and fewer teeth extracted
Stone Heart Syndrome: A Curious Case of Digoxin Toxicity and Calcium Infusion
Get PDFStone heart syndrome has a complex interaction with digoxin toxicity, where, theoretically, the administration of intravenous calcium can worsen a patient\u27s condition. Research on this subject is conflicting, so it is imperative to approach it cautiously