AIM: To further define variables associated with increased incidences of severe toxicities following administration of yttrium-90(90Y) microspheres. METHODS: Fifty-eight patients undergoing 79 ...treatments were retrospectively assessed for development of clinical and laboratory toxicity incidence following 90Y administration. Severe toxicity events were defined using Common Terminology Criteria for Adverse Events version 4.03 and defined as grade ≥ 3. Univariate logistic regression analyses were used to evaluate the effect of different factors on the incidence of severe toxicity events. Multicollinearity was assessed for all factors with P < 0.1 using Pearson correlation matrices. All factors not excluded due to multicollinearity were included in a multivariate logistic regression model for each measurement of severe toxicity.RESULTS: Severe（grade ≥ 3） toxicities occurred following 21.5% of the 79 treatments included in our analysis. The most common severe laboratory toxicities were severe alkaline phosphatase（17.7%）, albumin（12.7%）, and total bilirubin（10.1%） toxicities. Decreased pre-treatment albumin（OR = 26.2, P = 0.010） and increased pre-treatment international normalized ratio（INR）（OR = 17.7, P = 0.048） were associated with development of severe hepatic toxicity. Increased pre-treatment aspartate aminotransferase（AST; OR = 7.4, P = 0.025） and decreased pre-treatment hemoglobin（OR = 12.5, P = 0.025） were associated with severe albumin toxicity. Increasing pre-treatment model for end-stage liver disease（MELD） score（OR = 1.8, P = 0.033） was associated with severe total bilirubin toxicity. Colorectal adenocarcinoma histology was associated with severe alkaline phosphatase toxicity（OR = 5.4, P = 0.043）.CONCLUSION: Clinicians should carefully consider pre-treatment albumin, INR, AST, hemoglobin, MELD, and colorectal histology when choosing appropriate candidates for 90 Y microsphere therapy.
Background
In patients undergoing pancreatic resection (PR), identification of subgroups at increased risk for postoperative complications can allow focused interventions that may improve outcomes.
...Study Design
Patients undergoing PR from 2005–2010 were selected from the American College of Surgeons National Surgical Quality Improvement Program database and categorized as having any history of cardiac disease (angina, congestive heart failure (CHF), myocardial infarction (MI), cardiac stent, or bypass) or as having acute cardiac disease (symptoms of CHF or angina within 30 days or MI within 6 months). These variables were utilized to examine the relationship between cardiac disease and outcomes after PR.
Results
The rate of serious complications and perioperative mortality in patients with any history of cardiac disease vs. those without was 34 vs. 24 % (
p
< 0.001) and 4.5 vs. 2.0 % (
p
< 0.001), respectively, and in patients with acute cardiac disease compared to patients without was 37 vs. 25 % (
p
< 0.001) and 8.6 vs. 2.2 % (
p
< 0.001), respectively. In multivariate analysis, the two cardiac disease variables remained associated with mortality.
Conclusions
In patients undergoing PR, cardiac disease is a significant risk factor for adverse outcomes. These observations are critical for meaningful informed consent in patients considering pancreatectomy.
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EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NUK, OBVAL, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
Summary
Objective
Examine the association of duration of therapeutic coma (TC) with seizure recurrence, morbidity, and mortality in refractory status epilepticus (RSE). Define an optimal window for ...TC that provides sustained seizure control and minimizes complications.
Methods
Retrospective, observational cohort study involving patients who presented with RSE to the University of Alabama at Birmingham or the University of California at San Francisco from 2010 to 2016. Relationship of duration of TC with primary and secondary outcomes was evaluated using two‐sample t tests, simple linear regression, and chi‐square tests. Multivariable linear and logistic regression models were used to identify independent predictors. Predictive ability of TC for seizure recurrence was quantified using a receiver‐operating characteristic curve. Youden index was used to determine an optimal cutoff value.
Results
Multivariable analysis of clinical and treatment characteristics of 182 patients who were treated predominantly with propofol as anesthetic agent showed that longer duration of the first trial of TC (27.2 vs 15.6 hours) was independently associated with a higher chance of seizure recurrence following the first weaning attempt (P = 0.038) but not with poor functional neurologic outcome upon discharge, in‐hospital complications, or mortality. Furthermore, higher doses of anesthetic utilized during the first trial of TC were independently associated with fewer in‐hospital complications (P = 0.003) and associated with a shorter duration of mechanical ventilation and total length of stay. Duration of TC was identified as an independent predictor of seizure recurrence with an optimal cutoff point at 35 hours.
Significance
This study suggests that a shorter duration yet deeper TC as treatment for RSE may be more effective and safer than the currently recommended TC duration of 24‐48 hours. Prospective and randomized trials should be conducted to validate these assertions.
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BFBNIB, FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SAZU, SBCE, SBMB, UL, UM, UPUK
Screw-retained zirconia implant crowns with an internal titanium base have favorable mechanical properties compared with single-piece zirconia implant crowns; however, the screw-retained implant ...crowns require adequate bonding between the zirconia crown and the titanium base. This study measured the retention between a titanium base and a full-contour zirconia implant crown following different surface treatments of their bonded surfaces.
Full-contour screw-retained zirconia implant crowns were fabricated to fit a titanium base. The crowns were bonded to the titanium bases following one of four treatment protocols (n = 15 per protocol group): no surface treatment (Control), 10-methacryloyloxydecyl dihydrogen phosphate (MDP) primer on the intaglio of crown and exterior of base (MDP), alumina airborne-particle abrasion of the intaglio of crown and exterior of base (Alu), and alumina airborne-particle abrasion and an MDP primer on the intaglio of crown and exterior of base (Alu+MDP). All crowns were bonded to the base with resin cement. Specimens were stored in water for 24 hours at 37°C and then thermocycled in water, with a temperature range of 5°C to 55°C, for 15,000 cycles with a 15-second dwell time. Crowns were separated from the titanium bases using a universal testing machine. The four treatment protocols were compared using one-way analysis of variance (ANOVA), followed by Tukey post hoc tests (P < .05). Sectioned specimens were examined with scanning electron microscopy (SEM).
Retention forces for Control (737.8 ± 148.9 N) and MDP (804.1 ± 114.5 N) were significantly greater than Alu+MDP (595.5 ± 122.2 N), which was significantly greater than Alu (428.2 ± 93.8 N). Visual inspection of the debonded specimens showed that the majority of the cement remnants were seen on the external surface of the titanium bases. Microscopic examination of the interface between the crown and the unaltered base shows that the cement gap is approximately 13 μm at the crest of the microgrooves and 50 μm within the channel of the microgrooves. After airborne-particle abrasion, the microgrooves became significantly dulled, and the cement gap increased to 27 to 40 μm at the crest and 55 to 58 μm in the channels.
Airborne-particle abrasion of titanium bases that contain retentive microgrooves prior to bonding is contraindicated. Application of an MDP primer demonstrated limited improvement in the retention of the zirconia implant crowns.
A previous report indicated that secondary rhinoplasty patients with normal preoperative noses displayed significantly higher prevalences of depression, demanding behavior, previous aesthetic ...operations, and confirmed trauma (abuse/neglect) histories than patients who originally had dorsal deformities or straight noses with functional symptoms. The authors hypothesized that abuse or neglect might also influence patient satisfaction and suggest screening criteria.
One hundred secondary rhinoplasty patients stratified by their original nasal shapes were examined by bivariate analysis to determine the characteristics associated with surgical satisfaction. Mediation analysis established intervening factors between total surgery number and patients' perceived success. Random forests identified important patient attributes that predicted surgical success; logistic regression confirmed these effects.
Satisfied patients originally had dorsal humps, three or fewer previous operations, were not demanding or depressed, were not looking for perfect noses, and had no trauma histories. Dissatisfied patients originally had subjectively normal noses, more than three operations, were depressed, had demanding personalities, and had trauma histories. Patients who had undergone the most operations were most likely to request more surgery and least likely to be satisfied. A trauma (abuse/neglect) history was the most significant mediator between patient satisfaction and number of operations and the most prominent factor driving surgery in patients with milder deformities.
Potentially causative links exist between trauma (abuse/neglect), body image disorders, and obsessive plastic surgery. Body dysmorphic disorder may be a model of the disordered adaptation to abuse or neglect, a variant of posttraumatic stress disorder. Our satisfied and dissatisfied patients shared common characteristics and therefore may be identifiable preoperatively.
Trauma (neglect or abuse) can create body shame (different from body dissatisfaction), driving some patients to seek aesthetic surgery. We hypothesized that a trauma history would be related to the ...severity of the original deformity and the drive to undergo repeated operations.
Descriptive statistics were computed for 100 secondary rhinoplasty patients, 50 of whom originally had dorsal humps, 21 of whom had straight, functional noses, and 29 of whom had subjectively normal noses but underwent multiple rhinoplasties. This latter group fulfills criteria for body dysmorphic disorder.
Compared with patients with hump noses, patients with normal primary noses were 2.9 times more likely to be demanding 2.5 times more likely to be depressed, had undergone 3.0 times more rhinoplasties and other aesthetic operations, and were 3.8 times more likely to have confirmed trauma histories. Patients who had undergone more than three operations were 92.7 percent women; 85 percent originally had straight noses and had undergone an average of 7.56 rhinoplasties and 5.78 aesthetic operations; 85.4 percent had histories of abuse or neglect.
Secondary rhinoplasty patients with normal preoperative noses, who fulfill the criteria for body dysmorphic disorder, had significantly higher prevalences of depression, demanding conduct, previous rhinoplasties and other aesthetic operations, and confirmed trauma histories than patients who originally had dorsal deformities or straight noses with functional symptoms. To the authors' knowledge, this is the first report of such associations. A history of childhood trauma may impact adult patient behavior and therefore the surgical experience.
Resistant hypertension, defined as blood pressure >140/90 mm Hg despite using ≥3 antihypertensive medications, is a well-recognized clinical entity. Patients with resistant hypertension are at an ...increased risk of cardiovascular disease compared with those with more easily controlled hypertension. Coronary heart disease mortality rates of younger adults are stagnating or on the rise. The purpose of our study was to characterize the phenotype and risk factors of younger patients with resistant hypertension, given the dearth of data on cardiovascular risk profile in this cohort. We conducted a cross-sectional analysis with predefined age groups of a large, ethnically diverse cohort of 2170 patients referred to the Hypertension Clinic at the University of Alabama at Birmingham. Patients (n=2068) met the inclusion criteria and were classified by age groups, that is, ≤40 years (12.7% of total cohort), 41 to 55 years (32.1%), 56 to 70 years (36.1%), and ≥71 years (19.1%). Patients aged ≤40 years compared with those aged ≥71 years had significantly earlier onset of hypertension (24.7±7.4 versus 55.0±14.1 years; P<0.0001), higher rates of obesity (53.4% versus 26.9%; P<0.0001), and significantly higher levels of plasma aldosterone (11.3±9.8 versus 8.9±7.4 ng/dL; P=0.005), plasma renin activity (4.9±10.2 versus 2.5±5.0 ng/mL per hour; P=0.001), 24-hour urinary aldosterone (13.4±10.0 versus 8.2±6.2 µg/24 h; P<0.0001), and sodium excretion (195.9±92.0 versus 146.8±67.1 mEq/24 h; P<0.0001). Among patients with resistant hypertension, younger individuals have a distinct phenotype characterized by overlapping risk factors and comorbidities, including obesity, high aldosterone, and high dietary sodium intake compared with elderly.
Background
Adverse childhood experiences (ACEs) are linked to poor health outcomes; however, the relationship between ACEs and health outcomes among children and adolescents with sickle cell disease ...(SCD) has limited documentation in the published literature.
Procedure
This retrospective cohort study involved 45 children and 30 adolescents. Participants were screened using the Center for Youth Wellness ACE Questionnaire. Parents completed the questionnaire for children. Adolescents provided self‐report. ACEs were treated as continuous and categorical scales: 0–1 verus ≥2 original ACEs (individual and/or familial level); 0–1 versus ≥2 additional ACEs (community level); and 0–3 versus ≥4 expanded ACEs (original + additional). Pain and acute chest syndrome events were compared using Wilcoxon rank‐sum tests, and correlated with cumulative ACE scores using Spearman's correlation. Multivariable models were fitted to examine the association between ACEs and pain/acute chest syndrome.
Results
The cumulative number of original ACEs positively correlated with acute chest syndrome events (rho = .53, p = .003) and pain (rho = .40, p = .028) among adolescents. Adolescents with ≥2 versus 0–1 original ACEs had a higher number of acute chest syndrome events (4.9 ± 2.6 vs. 1.6 ± 2.2, p = .002); however, this association was confounded by asthma. Acute chest syndrome events and hospitalizations for pain did not differ among child ACE groups. Emergency department (ED) pain visits were higher among children with ≥4 versus 0–3 expanded ACEs (1.6 ± 2.8 vs. 3.3 ± 3.2, p = .042), even after controlling for SCD genotype, asthma, disease‐modifying treatment, and follow‐up years (p = .027).
Conclusion
ACEs are linked to increased morbidity among children and adolescents with SCD. Prospective studies are needed to further understand this relationship and test ACE‐protective remedies.
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BFBNIB, FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SAZU, SBCE, SBMB, UL, UM, UPUK
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