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Diagnostic Yield of CSF Testing in Infants for Disorders of Biogenic Amine Neurotransmitter Metabolism
No full textBackground and ObjectivesBiochemical testing of CSF for neurotransmitter metabolites and their cofactors is often used in the diagnostic evaluation of infants with neurologic disorders but requires an invasive, labor-intensive procedure with many potential sources of error. Our aim was to determine the diagnostic yield of CSF testing for biogenic amines (serotonin, norepinephrine, epinephrine, and dopamine) and their cofactors in identifying inborn errors of neurotransmitter metabolism among infants.MethodsWe evaluated all infants aged 1 year or younger who underwent CSF biogenic amine neurotransmitter (CSFNT) testing at Children\u27s Hospital of Philadelphia (CHOP) and Boston Children\u27s Hospital (BCH) between 2008 and 2017 in this cross-sectional study. The primary outcome was the proportion of individuals who received a diagnostic result from CSFNT testing. Secondary assessments included the proportion of infants who obtained a diagnostic result from other types of diagnostic testing.ResultsThe cohort included 323 individuals (191 from CHOP and 232 from BCH). The median age at presentation was 110 days (range 36-193). The most common presenting features were seizures (71%), hypotonia (47%), and developmental delay (43%). The diagnostic yield of CSFNT testing was zero. When CSF pyridoxal-5-phosphate level was assayed with CSFNT testing, 1 patient had a diagnostic result. An etiologic diagnosis was identified in 163 patients (50%) of the cohort, with genetic testing having the highest yield (120 individuals, 37%).DiscussionOur findings support the case for deimplementation of CSFNT testing as a standard diagnostic test of etiology in infants aged 1 year or younger presenting with neurologic disorders
The Burden of Cardiovascular Diseases in Jordan: A Longitudinal Analysis From the Global Burden of Disease Study, 1990–2019
No full textBackground: Cardiovascular Disease (CVD) is the leading cause of mortality worldwide. While countries in the Arab world continue to lack public health data and be severely understudied in health research, previous research has shown that compared to 1990, CVDs had a higher burden of disease in the Arab World in 2010. Jordan, a middle-income Arab country, is profiled with unique attributes such as a dual-sector healthcare system, political stability, and its role as a haven for refugees and migrants. These distinctive factors emphasize Jordan’s suitability as a case study. This investigation aims to quantify CVD burden in Jordan and identify risk factors, contributing to a broader understanding of health challenges in the Arab region and beyond. Methods: The Global Burden of Disease (GBD) dataset was used to estimate prevalence, death, and disability-adjusted life-years (DALYs) as age-standardized rates from 1990 to 2019. We calculated percentage change for nine specific CVDs and reported trends by gender and age groups. Additionally, data on twelve a priori selected behavioral, clinical, and environmental risk factors attributing to overall age-standardized CVDs DALY were reported per 100,00 population. Results: In 2019, the age-standardized CVD prevalence, death, and DALYs rates in Jordan were 7980 (95% uncertainty interval [UI] 7629, 8360), 248 (95% UI 211, 288), and 4647 (95% UI 4028, 5388), respectively. Despite an increase in the absolute number of mortality and prevalence, between 1990 and 2019, the age-standardized prevalence, death, and DALYs rates all decreased by 5.5%, 45.1%, and 46.7%, respectively. In 2019, the leading risk factors contributing to overall age-standardized CVDs DALY per 100,000 population were high systolic blood pressure, high BMI, dietary risks, and high LDL cholesterol. Conclusion: Despite decreasing burden rate of CVDs in Jordan between 1990 and 2019, CVDs remain the leading cause of mortality in Jordan, with an increase in the total number of prevalence and mortality. Overall, this contributes to increased healthcare costs. Further research is required to quantify the burden of CVDs and understand it better. Intervention measures and policies tailored to specific CVDs should be designed to reduce the burden of CVDs in Jordan
The Weight of Frailty in Neurosurgery Patients: Analyzing the Combined Effect of Frailty and Body Mass Index on 30-Day Postoperative Mortality
No full textObjective: There is a rising prevalence of overweight and obese persons in the US, and there is a paucity of information about the relationship between frailty and body mass index. Therefore, we examined discrimination thresholds and independent relationships of the risk analysis index (RAI), modified frailty index-5 (mFI-5), and increasing patient age in predicting 30-day postoperative mortality. Methods: This retrospective American College of Surgeons National Surgical Quality Improvement Program analysis compared all overweight or obese adult patients who underwent neurosurgery procedures between 2012 and 2020. We compared discrimination using receiver operating characteristic curve analysis for RAI, mFI-5, and increasing patient age. Furthermore, multivariable analyses, as well as subgroup analyses by procedure type i.e., spine, skull base, and other (vascular and functional) were performed, and reported as odds ratios (ORs) and 95% confidence intervals (CIs). Results: We included 315,725/412,909 (76.5%) neurosurgery patients, with a median age of 59 years (interquartile range: 48–68), predominately White 76.7% and male 54.3%. Receiver operating characteristic analysis for 30-day postoperative mortality demonstrated a higher discriminatory threshold for RAI (C-statistic: 0.790, 95%CI: 0.782–0.800) compared to mFI-5 (C-statistic: 0.692, 95%CI: 0.620–0.638) and increasing patient age (C-statistic: 0.659, 95%CI: 0.650–0.668). Multivariable analyses showed a dose-dependent association and a larger magnitude of effect by RAI: frail patients OR: 11.82 (95%CI: 10.57–13.24), and very frail patients OR: 31.19 (95%CI: 24.87–39.12). A similar trend was observed in all subgroup analyses i.e., spine, skull base, and other (vascular and functional) procedures (P ≤ 0.001). Conclusions: Increasing frailty was associated with a higher rate of 30-day postoperative mortality, with a dose-dependent effect. Furthermore, the RAI had a higher threshold for discrimination and larger effect sizes than mFI-5 and increasing patient age. These findings support RAI\u27s use in preoperative assessments, as it has the potential to improve postoperative outcomes through targeted interventions
Population Pharmacokinetics of Single Bolus Dose Fentanyl in Obese Children
No full textBACKGROUND: Childhood obesity is a significant problem. Obesity may alter the pharmacokinetics (PKs) of medications. Fentanyl is commonly used for procedural sedation, but there is a paucity of bolus dose fentanyl PK data in obese children. Better understanding of fentanyl PK in obese children would facilitate dosing recommendations. We conducted a study involving children with and without obesity to assess the potential differences in bolus dose fentanyl PK between the 2 groups. METHODS: We enrolled children 2 to 12 years of age with and without obesity, defined as \u3e95th percentile body mass index (BMI) for age and sex, undergoing elective tonsillectomy ± adenoidectomy. After induction, subjects had 2 intravenous (IV) lines placed in 2 different extremities: 1 for medications and IV fluids and 1 for obtaining blood aliquots for fentanyl concentration analysis. After administration of 1 mcg/kg of fentanyl based on total body weight (TBW), blood sample collections for fentanyl concentration analysis were attempted at 5, 15, 30, 60, 90, and 120 minutes. Five-minute fentanyl concentrations were compared between obese and nonobese cohorts. Population PK analysis to examine the differences between obese and nonobese children was performed and included various body size descriptors, such as TBW, BMI, and fat-free mass (FFM), to examine their influence on model parameters. RESULTS: Half of the 30 subjects were obese. Mean fentanyl concentrations at 5 minutes were 0.53 ng/mL for the nonobese group and 0.88 ng/mL for the obese group, difference 0.35 ng/mL (95% CI, 0.08-0.61 ng/mL; P =.01). Population PK analysis showed that FFM was a significant covariate for the central volume of distribution. The potential clinical effect of an IV bolus dose of fentanyl based on TBW versus FFM in an obese child was assessed in a simulation using our model. 1 mcg/kg fentanyl dose based on TBW resulted in an approximately 60% higher peak fentanyl effect site concentration than dosing based on FFM. CONCLUSIONS: Our data demonstrated higher peak plasma fentanyl concentrations in obese compared to nonobese subjects. Population PK analysis found that FFM was a significant covariate for the central volume of distribution. Model simulation showed dosing of fentanyl in obese children based on TBW resulted in significantly higher peak concentrations than dosing based on FFM. Based on this modeling and the known concentration-effect relationship between fentanyl and adverse effects, our results suggest that bolus dosing of fentanyl in obese children should be based on FFM rather than TBW, particularly for procedures of short duration
Association of Baseline Frailty and Age With Postoperative Outcomes in Metastatic Brain Tumor Patients
No full textBACKGROUND: The impact of baseline frailty status versus that of chronological age on surgical outcomes of metastatic brain tumor patients remains largely unknown. The present study aimed to evaluate this relationship for preoperative risk stratification using a large national database. METHODS: The National Surgical Quality Improvement Program database was queried to extract data of metastatic brain tumor patients who underwent surgery between 2015 and 2019 (N.=5943). Univariate and multivariate analyses were performed to assess the effect of age and modified Frailty Index-5 on mortality, major complications, unplanned readmission and reoperation, extended length of stay (eLOS), and non-home discharge. RESULTS: Both univariate and multivariate analyses demonstrated that frailty status was significantly predictive of 30-day mortality, major complications, eLOS, and non-home discharge. Although increasing age was also a significant predictor of eLOS and discharge to non-home destination, effect sizes were smaller compared with frailty. CONCLUSIONS: The present study, based on analysis of data from a large national registry, shows that frailty, when compared with age, is a superior predictor of postoperative outcomes in metastatic brain tumor patients. Afuture prospective study, namely a randomized controlled trial, would be beneficial in helping to corroborate the findings of this retrospective study
The Prevalence and Risk Factors of Metabolic Syndrome in Patients With Hemodialysis
No full textIntroduction: Metabolic syndrome is a common disorder that puts patients at high risk for cardiovascular disease (CVD) and mortality. To our knowledge, there is no published study in Pub Med which evaluated both lifestyle and metabolic syndrome in hemodialysis patients. This study aimed to estimate the prevalence of metabolic syndrome and investigate the potential risk factors in hemodialysis patients. Methods : This was a cross-sectional study conducted on 204 patients enrolled conveniently. National Cholesterol Education Program Adult Treatment Panel III criteria considered for Metabolic Syndrome. Demographics, lifestyle, and disease characteristics were gathered. The relationship between metabolic syndrome and its severity with independent variables was investigated through multivariable multivariate logistic and linear regressions. Results : The mean (SD) age was 55 (14) years and 42% were women. 42.6% had metabolic syndrome. Low high-density lipoprotein (HDL), high fasting blood sugar, high blood pressure (BP), increased waist circumference (WC), and high triglyceride were observed in decreasing order of frequency in 54.4%, 44.1%, 38.7%, 33.3% 28.9% of patients, respectively. The logistic regression model revealed significant associations between metabolic syndrome and physical activity (OR=0.85, 95% CI: 0.74-0.97), mood (OR=1.04, 95% CI: 1.002-1.078), age (OR=1.023, 95% CI: 1.001-1.046), and missed work (OR=0.86, 95% CI: 0.76-0.97). The linear regression model revealed significant associations between metabolic syndrome severity score and physical activity (B=-0.12, 95% CI: -0.21-0.02) and sleep quality (B=0.017, 95% CI: 0.001-0.033). Conclusion: Poorer sleep quality, lower physical activity, lower mood status, and older age were associated with higher odds of metabolic syndrome/metabolic syndrome severity score in hemodialysis patients
Medicare Reimbursement for Interventional Pain Procedures: 2000 to 2023
No full textBackground: An analysis of the financial trends of Interventional Pain (IP) procedures in the United States is lacking. Understanding these relations is necessary to help optimize future IP care delivery and costs. Objective: To examine Medicare reimbursement trends for IP procedures in both facility and non-facility settings. Methods: Utilizing the Physician Fee Schedule Look-Up Tool from the Centers for Medicare and Medicaid, reimbursement data for 32 of the most performed IP procedures was collected between 2000 and 2023 for both facility and non-facility clinical sites. After adjusting for inflation, annual change, total percent change, and compound annual growth rate (CAGR) were calculated for each procedure. Results: Following inflation adjustments, the average reimbursement rate decreased by an average of 61.31 % for facility procedures over the study period and by 60.40 % for non-facility procedures. The average adjusted reimbursement rate for facility procedures decreased by 18.66 per year with an average CAGR of −4.48 %. A two-tailed t-test was performed between facility and non-facility groups for total percent change (P = 0.803), annual change (P \u3c 0.001), and CAGR (P = 0.746). Conclusion: Medicare reimbursement rates in both facility and non-facility settings have decreased from 2000 to 2023, with non-facility procedures experiencing a significantly larger decrease
