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Nevin Manimala Statistics

Influence of immunosuppression in patients with severe acute respiratory distress syndrome on veno-venous extracorporeal membrane oxygenation therapy

Artif Organs. 2021 Mar 16. doi: 10.1111/aor.13954. Online ahead of print.

ABSTRACT

BACKGROUND: Prognosis of patients suffering of acute respiratory distress syndrome (ARDS) is poor. This is especially true for immunosuppressed patients. If these patients should receive veno-venous extracorporeal membrane oxygenation (VV ECMO) is discussed controversial while evidence on this topic is sparse.

METHODS: We report retrospective data of a single-centre registry of patients with severe ARDS requiring ECMO support between 10/2010 and 06/2019. Patients were analysed by their status of immunosuppression. ECMO weaning success and hospital survival were analysed before and after propensity score matching (PSM). Moreover, ventilator free days (VFD) were compared.

RESULTS: A total of 288 patients were analysed (age 55years, 67%male), 88 (31%) presented with immunosuppression. Survival rates were lower in immunosuppressed patients (27%vs.53%, p<0.001 and 27%vs.48% after PSM, p=0.006). VFD (60 days) were lower for patients with immunosuppression (11.9vs.22.4, p<0.001) and immunosuppression was an independent predictor for mortality in multivariate analysis. Hospital survival was 20%, 14%, 35% and 46% for patients with oncological malignancies, solid organ transplantation, autoimmune diseases and HIV, respectively.

CONCLUSION: In this analysis immunosuppression was an independent predictor for mortality. However, there were major differences in the weaning and survival rates between the aetiologies of immunosuppression which should be considered in decision making.

PMID:33725377 | DOI:10.1111/aor.13954

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Chronic Pain in Parturients with an Accidental Dural Puncture: A Case Controlled Prospective Observational Study

Acta Anaesthesiol Scand. 2021 Mar 16. doi: 10.1111/aas.13816. Online ahead of print.

ABSTRACT

BACKGROUND: We set out to examine incidence of chronic headache and back pain in women with PDPH after accidental dural puncture during labor.

METHODS: Chronic headache, backache and disability were assessed 18-24 months postpartum. Women with PDPH treated with epidural blood patch (PDPH-EBP) were identified and matched with women who had a PDPH without epidural blood patch (PDPH-no EBP), with women with uncomplicated epidural analgesia and with women without epidural analgesia. Our primary outcome was incidence of chronic headache and backache. Secondary outcome was the effect of epidural blood patch on chronic pain development. We used Chi-square or Fisher’s exact test to calculate odds ratios.

RESULTS: There was no statistically significant difference in demographic characteristics between groups. In the no epidural group, no women reported chronic headache, 2/116 (1.7%) reported chronic backache. In the uncomplicated epidural group, no women reported chronic headache, 7/116 (6.0%) reported chronic backache. In the PDPH-no EBP group 9/56 (16.1%) women reported chronic headache, 10/56 (17.9%) reported chronic backache. In the PDPH-EBP group, 12/59 (20.3%) had chronic headache, 14/59 (23.7%) had chronic backache. No women in the no epidural or uncomplicated epidural group reported disability (chronic pain score of 3 or 4). High disability was reported by 8.9% of women in the PDPH-no EBP group and by 8.4% in the PDPH-EBP group.

CONCLUSION: Women with PDPH had a high incidence of chronic headache, back pain and disability. We did not find a statistically significant difference in chronic pain development between conservatively treated and EBP treated patients.

PMID:33725362 | DOI:10.1111/aas.13816

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Anatomic, computed tomographic, and ultrasonographic assessment of the lymph nodes in presumed healthy adult cats: The head, neck, thorax, and forelimb

J Anat. 2021 Mar 16. doi: 10.1111/joa.13429. Online ahead of print.

ABSTRACT

Assessment of the lymph nodes is key in staging cancer patients. Descriptions of normal features of the feline lymph nodes using computed tomography (CT) and ultrasound (US) are limited. A prospective anatomic and comparative imaging study was performed. The frequency of identification and the size of the lymph nodes during gross pathology from 6 feline cadavers were compared to the images of lymph nodes from 30 presumed healthy adult cats obtained by CT and US. Measurements (length, width, and height) were compared among techniques. The CT and US features of the identified lymph nodes were also recorded. The frequency of identification of the lymph centers varied among techniques and individually. The mandibular lymph nodes were identified in 100% of the cadavers and in 100% of the healthy cats using CT and US. The medial retropharyngeal lymph nodes were identified in 100% of the cats using CT and US. The deep cervical lymph nodes were not visualized in the cadavers. The cranial mediastinal and tracheobronchial lymph nodes were not visualized using US. Lymph nodes showed a higher length on CT and higher width on US. The height was the most statistically significant variable measurement among techniques. On CT, lymph nodes were most frequently isoattenuating or slightly hypoattenuating to surrounding musculature, with homogeneous contrast enhancement. On US, most lymph nodes were isoechoic or hypoechoic to surrounding fat tissue. The lymph nodes were most frequently elongated or rounded.

PMID:33725361 | DOI:10.1111/joa.13429

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Enhanced recovery after surgery (ERAS) in adolescent idiopathic scoliosis (AIS): a meta-analysis and systematic review

Spine Deform. 2021 Mar 16. doi: 10.1007/s43390-021-00310-w. Online ahead of print.

ABSTRACT

STUDY DESIGN: A systematic review reporting on the efficacy of an ERAS protocol in patients undergoing spinal fusion for AIS.

OBJECTIVE: To systematically evaluate the relevant literature pertaining to the efficacy of ERAS protocols with respect to the length of stay, complication, and readmission rates in patients undergoing posterior spinal corrective surgery for AIS. ERAS is a multidisciplinary approach aimed at improving outcomes of surgery by a specific evidence-based protocol. The rationale of this rapid recovery regimen is to maintain homeostasis so as to reduce the postoperative stress response and pain. No thorough review of available information for its use in AIS has been published.

METHODS: A systematic review of the English language literature was undertaken using search criteria (postoperative recovery AND adolescent idiopathic scoliosis) using the PRISMA guidelines (Jan 1999-May 2020). Isolated case reports and case series with < 5 patients were excluded. Length of stay (LOS), complication and readmission rates were used as outcome measures. Statistical analysis was done using the random effects model.

RESULTS: Of a total of 24 articles, 10 studies met the inclusion criteria (9 were Level III and 1 of level IV evidence) and were analyzed. Overall, 1040 patients underwent an ERAS-type protocol following posterior correction of scoliosis and were compared to 959 patients following traditional protocols. There was a significant reduction in the length of stay in patients undergoing ERAS when compared to traditional protocols (p < 0.00001). There was no significant difference in the complication (p = 0.19) or readmission rates (p = 0.30). Each protocol employed a multidisciplinary approach focusing on optimal pain management, nursing care, and physiotherapy.

CONCLUSION: This systematic review demonstrates advantages with ERAS protocols by significantly reducing the length of stay without increasing the complications or readmission rates as compared to conventional protocols. However, current literature on ERAS in AIS is restricted largely to retrospective studies with non-randomized data, and initial cohort studies lacking formal control groups.

LEVEL OF EVIDENCE: 3.

PMID:33725329 | DOI:10.1007/s43390-021-00310-w

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Prognostic value of immunohistochemical markers in canine cutaneous mast cell tumours: A systematic review and meta-analysis

Vet Comp Oncol. 2021 Mar 16. doi: 10.1111/vco.12692. Online ahead of print.

ABSTRACT

Histological grading systems remain cornerstones in the prognosis of canine cutaneous mast cell tumours (MCTs), but the distinct biological behaviour of each tumour often necessitates the use of complementary markers. Although a plethora of immunohistochemical markers have been proposed as prognostic factors, few are presently applied in routine diagnosis. This systematic review and meta-analysis was designed to establish which immunohistochemical markers have verifiable prognostic value for cutaneous MCTs in dogs. A Boolean search of five databases identified 200 articles for screening, of which 73 were selected for full-text assessment and 24 ultimately included in the systematic review. Odds Ratio (OR) was adopted as the summary measure for subsequent meta-analysis but only 15 articles, relating to the immunomarkers Ki-67 (9), KIT (5) and BAX (2), provided either a value for OR or sufficient data to calculate this statistic. Meta-analysis verified that canine cutaneous MCTs with elevated expression of Ki-67 or BAX, as well aberrant immuno-expression of KIT, showed an increased odds of death, with respective OR values of 11.2 (95% CI 6.3-20.0; P < 0.01), 9.9 (95% CI 1.3-73.6; P = 0.03) and 4.1 (95% CI 1.1-15.3; P = 0.03). Despite KIT, Ki67 and BAX arise as suitable prognostic factor for canine MCTs, this study highlighted the lack of important clinical and statistical data in many published articles, rendering it impossible to complete the meta-analysis of several potentially valuable immunohistochemical markers. This article is protected by copyright. All rights reserved.

PMID:33724647 | DOI:10.1111/vco.12692

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A comparison of faecal incontinence scoring systems

Colorectal Dis. 2021 Mar 16. doi: 10.1111/codi.15634. Online ahead of print.

ABSTRACT

AIM: Questionnaires designed to score the severity of faecal incontinence (FI) are widely used to provide an evaluation of symptoms across settings, studies and time. The Pelvic Floor Disorders Consortium have recommended the use of multiple questionnaires despite some overlap of questions. This study aimed to evaluate whether patient responses to these questionnaires are consistent.

METHOD: A retrospective analysis was undertaken of patients who attended a dedicated pelvic floor unit with FI between January 2018 and December 2019 and completed Faecal Incontinence Severity Index [FISI], Cleveland Clinic Florida Incontinence Score [CCFIS] and St Mark’s Incontinence Score [Vaizey]) simultaneously. For each questionnaire the frequency of incontinence episodes to solid stool, liquid stool and gas were divided into 5 categories to allow direct comparison. Answers were deemed equivalent if the allocated response was identical, slightly different if the response was in an adjacent category, or very different if the response differed to a greater extent.

RESULTS: There were 193 patients who simultaneously completed all three FI questionnaires. There were statistically significant differences between the responses regarding frequency of solid stool, liquid stool and gas incontinence on all three questionnaires (p<0.005). Across all domains, between 58.0%-69.9% of responses were equivalent, 14.1-34.0% of answers were slightly different and 8.0%-18.8% were very different.

CONCLUSION: Even when completed at the same time, and by the same person, similar questions are answered differently a significant proportion of the time. The utility of using multiple questionnaires simultaneously in the clinical setting to assess FI symptoms should be questioned.

PMID:33724629 | DOI:10.1111/codi.15634

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A Machine Learning Risk Score Predicts Mortality Across the Spectrum of Left Ventricular Ejection Fraction

Eur J Heart Fail. 2021 Mar 16. doi: 10.1002/ejhf.2155. Online ahead of print.

ABSTRACT

BACKGROUND: Heart failure (HF) guideline recommendations categorize patients according to left ventricular ejection (LVEF). Mortality risk, however, varies considerably within each category and the likelihood of death in an individual patient is often uncertain. Accurate assessment of mortality risk is an important component in the decision-making process for many therapies. In this report, we assess the accuracy of MARKER-HF, a recently described machine learning based risk score, in predicting mortality of patients in the three guideline defined HF categories and its ability to distinguish risk of death for patients within each category.

METHODS AND RESULTS: MARKER-HF was used to calculate mortality risk in a hospital based cohort of 4064 patients categorized into groups with reduced LVEF (HFrEF), mid-range LVEF (HFmrEF) or preserved LVEF (HFpEF). MARKER-HF was substantially more accurate than LVEF in predicting mortality and was highly accurate in all three HF categories, with c-statistics ranging between 0.83 to 0.89. Moreover, MARKER-HF accurately discriminated between patients at high, intermediate and low levels of mortality risk within each of the three categories of HF used by guidelines.

CONCLUSIONS: MARKER-HF accurately predicts mortality in patients within the three categories of HF used in guidelines for management recommendations and it discriminates between magnitude of risk of patients in each category. MARKER-HF mortality risk prediction should be helpful to providers in making recommendations regarding the advisability of therapies designed to mitigate this risk, particularly when they are costly or associated with adverse events, and for patients and their families in making future plans.

PMID:33724626 | DOI:10.1002/ejhf.2155

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Comparison of Acute and Long-term Outcomes of Evolution® and TightRail Mechanical Dilator Sheaths during Transvenous Lead Extraction

J Cardiovasc Electrophysiol. 2021 Mar 16. doi: 10.1111/jce.15006. Online ahead of print.

ABSTRACT

BACKGROUND: Powered transvenous lead extraction (TLE) tools are commonly required to remove the leads with long implant duration due to fibrotic adhesions. However, comparative data are lacking among different types of TLE tools.

AIM: To compare the efficacy and safety of two different rotational mechanical dilator sheaths in retrospectively analyzed patients who underwent TLE.

METHODS AND RESULTS: A total of 566 lead extractions from 302 patients using TightRailTM (333 lead extractions from 169 patients) and Evolution® (233 lead extractions from 133 patients) mechanical dilator sheaths were performed between July 2009 and June 2018. Acute and long term outcomes of study groups were compared. There is no statistically significant difference between Evolution® and TightRailTM groups in procedural success (93.9% vs. 94%), clinical success (99.2% vs. 98%) and major complications (3.8% vs. 1.2%), respectively (p>0.05). In multivariate regression analysis, lead dwell time, the number of extracted leads, and baseline leukocyte count was found as independent predictors of procedural success (p<0.05). During the median follow-up of 36.6 (0.2-118) months, all-cause mortality was observed in 73 patients (25.6% in the Evolution® vs. 23.1 in the TightRailTM group, p>0.05). Chronic renal disease, heart failure, and coagulopathy were shown as independent predictors of all-cause mortality in multivariate regression analysis (p<0.05).

CONCLUSIONS: TLE using TightRailTM or Evoluation® mechanical dilator sheaths was a safe and effective therapeutic option. Both mechanical dilator sheaths showed similar efficacy, safety, and all-cause mortality at acute and long-term follow-up of patients who underwent TLE. This article is protected by copyright. All rights reserved.

PMID:33724617 | DOI:10.1111/jce.15006

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Preservation of the rectum is possible in early rectal cancer with neoadjuvant radiotherapy, delay and local excision – A 12-year single centre experience of the evolution of early rectal cancer treatment

Colorectal Dis. 2021 Mar 16. doi: 10.1111/codi.15631. Online ahead of print.

ABSTRACT

AIM: Treatment of early rectal cancer (ERC) is undergoing a revolution towards rectum preservation. Adjuvant and neoadjuvant therapy alongside local excision (LE) means that organ preservation is a real possibility for most patients and a viable alternative for frailer patients. This study presents our 12-year experience as a specialist regional early rectal cancer unit, evolving towards organ preservation.

METHOD: Data was collected prospectively between 2006 – 2018 for all patients referred to the regional ERC multidisciplinary team (MDT) with suspected or confirmed ERC. Patients considered suitable for LE, or those declining radical surgery, were offered LE or neoadjuvant short course radiotherapy (SCRT), delay and LE with subsequent rescue surgery or contact brachytherapy for unfavourable histopathology.

RESULTS: 102 patients underwent LE. 10 patients were excluded (N=92). 45 patients underwent LE directly and 47 patients received SCRT and LE. After SCRT & LE, a pathological complete response was achieved in 44.7%. This approach also resulted in a lower rate of lymphovascular invasion (22.2% vs. 6.4%), fewer distant recurrences (4.4% vs 0%) and a better disease-specific mortality (11.1% vs 0%) (p<0.05). Although statistically insignificant, fewer patients required rescue surgery after SCRT(15.6% vs 4.3%).

CONCLUSION: Organ preservation with a good oncological outcome is better achieved by neoadjuvant radiotherapy, delay and LE. To achieve this, careful patient selection, thorough preoperative investigation, experienced surgical technique and a deep appreciation of tumour biology, managed via a dedicated early rectal cancer network is paramount.

PMID:33724612 | DOI:10.1111/codi.15631

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Improving the sensitivity of cluster-based statistics for functional magnetic resonance imaging data

Hum Brain Mapp. 2021 Mar 16. doi: 10.1002/hbm.25399. Online ahead of print.

ABSTRACT

Because of the high dimensionality of neuroimaging data, identifying a statistical test that is both valid and maximally sensitive is an important challenge. Here, we present a combination of two approaches for functional magnetic resonance imaging (fMRI) data analysis that together result in substantial improvements of the sensitivity of cluster-based statistics. The first approach is to create novel cluster definitions that optimize sensitivity to plausible effect patterns. The second is to adopt a new approach to combine test statistics with different sensitivity profiles, which we call the min(p) method. These innovations are made possible by using the randomization inference framework. In this article, we report on a set of simulations and analyses of real task fMRI data that demonstrate (a) that the proposed methods control the false-alarm rate, (b) that the sensitivity profiles of cluster-based test statistics vary depending on the cluster defining thresholds and cluster definitions, and (c) that the min(p) method for combining these test statistics results in a drastic increase of sensitivity (up to fivefold), compared to existing fMRI analysis methods. This increase in sensitivity is not at the expense of the spatial specificity of the inference.

PMID:33724597 | DOI:10.1002/hbm.25399