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Exploring the Obesity Paradox in All Subtypes of Intracranial Hemorrhage: A Retrospective Cohort Analysis of 13,000 Patients
No full textBackground/Objectives: Recent studies reveal an “obesity paradox”, suggesting better clinical outcomes after intracranial hemorrhage for obese patients compared to patients with a healthy BMI. While this paradox indicates improved survival rates for obese individuals in stroke cases, it is unknown whether this trend remains true across all forms of intracranial hemorrhage. Therefore, the objective of our study was to investigate the incidence, characteristics, and outcomes of hospitalized obese patients with intracranial hemorrhage. Methods: The National Inpatient Sample (NIS) database was queried for data from 2015 to 2019 to identify adult patients aged 18 years and older with a primary diagnosis of non-traumatic intracranial hemorrhage. Using International Classification of Disease 10th Edition codes, patients were stratified by BMI categories: healthy weight, overweight, class I–II obesity, and class III obesity. The cohorts were examined for demographic characteristics, comorbidities, stroke severity, inpatient complications, interventions, and clinical outcomes, including length of stay (LOS), discharge disposition, and inpatient mortality. Results: Of 41,960 intracranial hemorrhage patients identified, 13,380 (33.0%) also had an obese BMI. Class I–II obese intracranial hemorrhage patients were more likely to be of white race (OR: 1.101, 95% CI: 1.052, 1.152, p \u3c 0.001), less likely to be female (OR: 0.773, 95% CI: 0.740, 0.808, p \u3c 0.001), and more likely to have diabetes mellitus (OR: 1.545, 95% CI: 1.477, 1.616, p \u3c 0.001) and hypertension (OR: 1.828, 95% CI: 1.721, 1.943, p \u3c 0.001) in comparison to healthy-weight patients. In a matched cohort analysis adjusting for demographics and severity, intracranial hemorrhage patients with class I–II obesity had a shorter length of stay (LOS) (OR 0.402, 95% CI: 0.118, 0.705, p \u3c 0.001), reduced inpatient mortality (OR 0.847, 95% CI: 0.798, 0.898, p \u3c 0.001), and more favorable discharge disposition (OR 1.395, 95% CI: 1.321, 1.474, p \u3c 0.001) compared to their healthy-weight counterparts. Furthermore, these patients were less likely to require decompressive hemicraniectomy (OR 0.697, 95% CI: 0.593, 0.820, p \u3c 0.001). Following an analysis of individual ICH subtypes, obese subarachnoid hemorrhage (SAH) patients demonstrated reduced mortality (OR: 0.692, 95% CI: 0.577–0.831, p \u3c 0.001) and LOS (OR: 0.070, 95% CI: 0.466–0.660, p = 0.039), with no differences in discharge disposition. Similarly, intracerebral hemorrhage patients demonstrated reduced mortality (OR: 0.891, 95% CI: 0.827–0.959, p = 0.002) and LOS (OR: 0.480, 95% CI: 0.216–0.743, p \u3c 0.001). Other ICH subtypes showed improved discharge outcomes (OR: 1.504, 95% CI: 1.368–1.654, p \u3c 0.001), along with decreased mortality (OR: 0.805, 95% CI: 0.715–0.907, p \u3c 0.001) and LOS (OR: −10.313, 95% CI: −3.599 to −2.449, p \u3c 0.001). Conclusions: Intracranial hemorrhage patients with class I–II obesity exhibited more favorable clinical outcomes than those who were of a healthy weight or overweight. Despite its association with risk factors contributing to intracranial hemorrhage, class I–II obesity was associated with improved outcomes, lending support to the existence of the obesity paradox in stroke
Feasibility and Safety of Stereoelectroencephalography in Young Children
No full textPurpose: Stereoelectroencephalography (SEEG) is a diagnostic surgery that implants electrodes to identify areas of epileptic onset in patients with drug-resistant epilepsy (DRE). SEEG is effective in identifying the epileptic zone; however, placement of electrodes in very young children has been considered contraindicated due to skull thinness. The goal of this study was to evaluate if SEEG is safe and accurate in young children with thin skulls. Methods: Four children under the age of two years old with DRE underwent SEEG to locate the region of seizure onset. Presurgical planning and placement of electrodes were performed using ROSA One Brain. Preoperative electrode plans were merged with postoperative CT scans to determine accuracy. Euclidean distance between the planned and actual trajectories was calculated using a 3D coordinate system at both the entry and target points for each electrode. Results: Sixty-three electrodes were placed among four patients. Mean skull thickness at electrode entry sites was 2.34 mm. The mean difference between the planned and actual entry points was 1.12 mm, and the mean difference between the planned and actual target points was 1.73 mm. No significant correlation was observed between planned and actual target points and skull thickness (Pearson R = − 0.170). No perioperative or postoperative complications were observed. Conclusions: This study demonstrates that SEEG can be safe and accurate in children under two years of age despite thin skulls. SEEG should be considered for young children with DRE, and age and skull thickness are not definite contraindications to the surgery
Mosaic Embryos Result in Equivalent Live Birth Rates When Compared to Euploid Embryos Following Frozen Embryo Transfer
No full textStudy question
Are mosaic embryos associated with a lower live birth rate (LBR) than euploid embryos? Summary answer
In this adequately powered study, mosaic embryos had nearly identical LBR and similar miscarriage rates (MR) when compared to euploid embryos. What is known already
While prior data has suggested that mosaic embryos result in almost half the LBR and three-fold higher MR than euploid embryos, all prior data supports mosaic embryo transfers as safe with acceptable LBRs. Recent studies have suggested a revised selection criteria choosing either euploid or mosaic embryos for transfer based on embryo grade, day of freeze, low level (LL) versus high level (HL) mosaicism and segmental versus whole chromosome mosaicism. Given the lower LBR reported with mosaics, we initially offered double embryo transfer (DET). We initiated this study to assess our LBR, MR, aneuploidy and DET outcomes with mosaics. Study design, size, duration
This was a retrospective case-control cohort study. All mosaic embryos (51) that underwent frozen embryo transfer (FET) between January 2020 and June 2023 were compared to all euploid embryos (706) among all patients with tested embryos that underwent FET in the same time frame. Our Power analysis confirmed that with the 14:1 ratio of 706/51 euploid/mosaic embryos this study is sufficiently powered to exclude a \u3e 20% lower LBR following mosaic transfer. Participants/materials, setting, methods
All patients seen at our IVF center undergoing FET of mosaic or euploid embryos tested with next generation sequencing during the study period were included. Primary outcome was LBR. Further comparison included age, MR, twin rate, freeze day and grade. Embryos were further analyzed for HL versus LL mosaicism, segmental or whole chromosomal mosaicism, freeze date and grade. Statistics employed chi-squared for categorical and student t-test for continuous data with significance set at p \u3c 0.01 Main results and the role of chance
Mosaic embryos resulted in nearly identical LBR when compared to euploid embryos, 26/51(50.9%) versus 359/706(50.85%). Implantation rate was also equivalent, 29/51(54.6%) and 376/706(53.3%). Both biochemical pregnancy [mosaics, 8/45(17.8%) versus euploid 127/683(18.6)], and MR [mosaics 3/29(10.3%) versus euploids 24/373(6.4%)] were not significantly different.
Among mosaic embryos, the LBR in LL versus HL mosaics were 17/28 (60.7%) and 9/23 (39.1%), respectively. LBR following segmental only versus whole chromosomal defects were 14/27(51.9%) and 11/24(45.8%). LBR following Day 5 versus Day 6/7 freeze were 10/22(45.5%) and 16/29(55.2%) and LBR for favorably graded embryos were 19/34(55.9%) versus fair to poor graded 7/17(41.2%). None of these achieved statistical significance.
While Mosaic embryos were transferred in significantly older patients (37.6 vs 36.1 p \u3c 0.01), there was no difference in mean age associated with LBR (36.1 vs 36.3 p =.4). Additionally, there was no statistically significant difference in LBR between age groups, \u3c 35yo 143/259(55.2%), 35-37yo 96/202(47.5%), 38-40yo 96/207(46.4%) or \u3e 40yo 50/90(55.6%) among tested embryos.
DET was performed more often with mosaic 19/45 (42.2%) than euploid embryos 36/683 (5.3%) p \u3c 0.001, resulting in significantly higher twin births/LB 5/22 (23.8%) versus 6/356 (1.7%) p \u3c 0.001. All DET data sets included the 13 DETs where one euploid and one mosaic embryo were transferred. Limitations, reasons for caution
Our small mosaic numbers may have kept the higher LBR with LL, segmental and good quality mosaic embryos from achieving statistical significance, and may be too small to confirm a higher MR with mosaics.
Prospective trials are needed to confirm which euploid or mosaic embryo should be selected for transfer. Wider implications of the findings
Given the equivalent LBR, mosaic embryos should be used for transfer prior to repeating IVF retrieval for euploids.
The high rate of twin delivery following mosaic DET suggests only eSET should be utilized with any tested embryos.
Larger prospective trials are needed to further refine euploid versus mosaic embryo selection criteria
Epidemiology and Outcomes of Critical Illness and Novel Predictors of Mortality in an Ethiopian Medical Intensive Care Unit
No full textLow- and middle-income countries (LMICs) bear most of the global burden of critical illness. Managing this burden requires improved understanding of epidemiology and outcomes in LMIC intensive care units (ICUs), including LMIC-specific mortality prediction scores. This study was a retrospective observational study at Tikur Anbessa Specialized Hospital in Addis Ababa, Ethiopia, examining all consecutive medical ICU admissions from June 2014 to April 2015. The primary outcome was ICU mortality; secondary outcomes were prolonged ICU stay and prolonged mechanical ventilation. ICU mortality prediction models were created using multivariable logistic regression and compared with the Mortality Probability Model-II (MPM-II). Associations with secondary outcomes were examined with multivariable logistic regression. There were 198 admissions during the study period; mortality was 35%. Age, shock on admission, mechanical ventilation, human immunodeficiency virus, and Glasgow Coma Scale ≤8 were associated with ICU mortality. The receiver operating characteristic curve for this 5-factor model had an AUC of 0.8205 versus 0.7468 for MPM-II, favoring the simplified new model. Mechanical ventilation and lack of shock were associated with prolonged ICU stays. Mortality in an LMIC medical ICU was high. This study examines an LMIC medical ICU population, showing a simplified prediction model may predict mortality as well as complex models
The Role of Aryl Hydrocarbon Receptor Agonists in the Treatment of Vitiligo
No full textVitiligo is a chronic autoimmune disorder characterized by progressive skin depigmentation. Vitiligo significantly impacts patients’ quality of life, contributing to psychological and social burdens. Despite readily available therapeutic options, many cases remain refractory to treatment, highlighting the critical need for safer and more effective therapies. Currently, ruxolitinib is the only FDA-approved medication for vitiligo; however, it carries a black box warning for serious adverse effects, including infections, malignancy, and major cardiovascular events, limiting its use. Recent studies have identified the aryl hydrocarbon receptor (AhR) as a promising therapeutic target, suggesting that AhR agonists could address the multifaceted pathogenesis of vitiligo. Adhering to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we conducted a comprehensive search to analyze the role of AhR agonists in the treatment of vitiligo on PubMed, Cochrane, Embase, MEDLINE, and Web of Science databases on April 15, 2024. Fourteen studies met the inclusion criteria, comprising two clinical trials, two case reports, and nine basic science studies. Our search revealed that culturing AhR agonists with melanocytes upregulates melanin-synthesizing enzymes, reduces reactive oxygen species, and modulates pro-inflammatory cytokines such as IL-17A and IL-22. Tapinarof, a topical AhR agonist used commonly for the treatment of psoriasis, demonstrated clinical efficacy in repigmentation with a favorable safety profile compared to long-term steroid use. Although limited by the number of clinical studies, this review underscores the potential of using AhR agonists, such as tapinarof, as a transformative approach to vitiligo management. Future clinical trials are necessary to evaluate the safety, efficacy, and long-term outcomes of AhR agonists
The Role of IL-17 and Th17 Cells in Keloid Pathogenesis
No full textKeloids are characterized histologically by excessive fibroblast proliferation and connective tissue deposition, and clinically by scar tissue extending beyond the original site of skin injury. These scars can cause pruritus, pain, physical disfigurement, anxiety, and depression. As a result, keloid patients often have a diminished quality of life with a disproportionate burden on ethnic minorities. Despite advances in understanding keloid pathology, there is no effective Food and Drug Administration (FDA)-approved pharmacotherapy. Recent studies have highlighted the possible pathologic role of T helper (Th)17 cells and interleukin (IL)-17 in keloid formation, as well as their implication in other inflammatory disorders. This systematic review characterizes the role of Th17 cells and IL-17 in keloid pathogenesis, highlighting this pathway as a potential therapeutic target. Adhering to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we conducted a comprehensive search on PubMed, Embase, MEDLINE, and Web of Science databases on June 5, 2024. The search included terms related to Th17 cells, IL-17, and keloids. Thirteen studies met the inclusion criteria, comprising basic science and bioinformatic studies focusing on Th17 cells and IL-17. Key findings include increased Th17 cell infiltration and IL-17 expression in keloids, IL-17’s role in amplifying the inflammatory and fibrotic response via the promotion of IL-6 expression, and IL-17’s involvement in upregulating fibrotic markers via SDF-1 and HIF-1α pathways. IL-17 also activates the transforming growth factor beta (TGF-β)/Smad pathway in keloid fibroblasts. Th17 cells and IL-17 significantly contribute to the inflammatory and fibrotic processes in keloid pathogenesis. Therefore, targeting the IL-17 pathway offers a potential new therapeutic target to improve keloid patients’ outcomes. Future research could further elucidate the role of Th17 cells and IL-17 in keloid pathogenesis and assess the safety and efficacy of targeting this pathway in human studies
Impact of Right Ventricular Failure on the Outcomes of Acute Inferior Wall Myocardial Infarction
No full textAim: Right ventricular failure (RVF) complicates 30–50% of cases with inferior wall myocardial infarctions (IWMI). Large-scale studies exploring the recent trends in morbidity and mortality of IWMI with RVF in the context of improved reperfusion strategies are currently lacking. Materials & methods: The International Classification of Diseases, Tenth Revision, Clinical Modification codes were used to query the National Inpatient Sample of 2018–2019 to yield IWMI admissions and stratified based on presence of RVF. The primary outcome was in-hospital mortality. Results: Out of the 182,485 weighed hospital admissions for IWMI, 1005 patients (0.6%) also had RVF. Patients with both IWMI and RVF had significantly higher mortality than patients with IWMI and no RVF (p \u3c 0.001). Conclusion: RVF in patients with IWMI is an independent predictor of poor outcomes
InTouch Week of January 1, 2024
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