Category: Nevin Manimala

JAMA Netw Open. 2024 Jun 3;7(6):e2415998. doi: 10.1001/jamanetworkopen.2024.15998.

ABSTRACT

IMPORTANCE: Whether stereotactic body radiotherapy (SBRT) as a bridge to liver transplant for hepatocellular carcinoma (HCC) is effective and safe is still unknown.

OBJECTIVE: To investigate the feasibility of SBRT before deceased donor liver transplant (DDLT) for previously untreated unresectable HCC.

DESIGN, SETTING, AND PARTICIPANTS: In this phase 2 nonrandomized controlled trial conducted between June 1, 2015, and October 18, 2019, 32 eligible patients within UCSF (University of California, San Francisco) criteria underwent dual-tracer (18F-fluorodeoxyglucose and 11C-acetate [ACC]) positron emission tomography with computed tomography (PET-CT) and magnetic resonance imaging (MRI) with gadoxetate followed by SBRT of 35 to 50 Gy in 5 fractions, and the same imaging afterward while awaiting DDLT. Statistical analysis was performed on an intention-to-treat basis between October 1 and 31, 2023.

INTERVENTION: Patients received SBRT followed by DDLT when matched deceased donor grafts were available.

MAIN OUTCOMES AND MEASURES: Coprimary end points were progression-free survival (PFS) and objective response rates (ORRs) by the Response Evaluation Criteria in Solid Tumors, version 1.1 (RECIST 1.1), modified RECIST (mRECIST), and PET Response Criteria in Solid Tumors (PERCIST). Secondary end points were local control rate, overall survival (OS), and safety.

RESULTS: A total of 32 patients (median age, 59 years [IQR, 54-63 years]; 22 men [68.8%]) with 56 lesions received SBRT. After a median follow-up of 74.6 months (IQR, 40.1-102.9 months), the median PFS was 17.6 months (95% CI, 6.6-28.6 months), and the median OS was 60.5 months (95% CI, 29.7-91.2 months). The 5-year PFS was 39.9% (95% CI, 19.9%-59.9%), and the 5-year OS was 51.3% (95% CI, 31.7%-70.9%). In terms of number of patients, ORRs were 62.5% ([n = 20] 95% CI, 54.2%-68.7%) by RECIST 1.1, 71.9% ([n = 23] 95% CI, 63.7%-79.0%) by mRECIST, and 78.1% ([n = 25] 95% CI, 73.2%-86.7%) by PERCIST. In terms of number of lesions, ORRs were 75.0% ([n = 42] 95% CI, 61.6%-80.8%) by RECIST 1.1, 83.9% ([n = 47] 95% CI, 74.7%-90.6%) by mRECIST, and 87.5% ([n = 49] 95% CI, 81.3%-98.6%) by PERCIST. Twenty patients with 36 lesions received DDLT, of whom 15 patients (75.0%) with 21 lesions (58.3%) exhibited pathologic complete response. Multivariable analyses revealed that pretreatment metabolic tumor volume (MTV) based on ACC (hazard ratio [HR], 1.06 [95% CI, 1.01-1.10]; P = .01) and complete metabolic response (CMR) by PERCIST (HR, 0.31 [95% CI, 0.10-0.96]; P = .04) were associated with PFS, while pretreatment MTV based on ACC (HR, 1.07 [95% CI, 1.03-1.16]; P = .01), total lesion activity based on ACC (HR, 1.01 [95% CI, 1.00-1.02]; P = .02), and CMR by PERCIST (HR, 0.21 [95% CI, 0.07-0.73]; P = .01) were associated with OS. Toxic effects associated with SBRT were reported for 9 patients (28.1%), with 1 grade 3 event.

CONCLUSIONS AND RELEVANCE: This phase 2 nonrandomized controlled trial demonstrated promising survival and safety outcomes of SBRT before DDLT for unresectable HCC. Future randomized clinical trials are warranted.

PMID:38857045 | DOI:10.1001/jamanetworkopen.2024.15998

Am J Sports Med. 2024 Jun 10:3635465241252981. doi: 10.1177/03635465241252981. Online ahead of print.

ABSTRACT

BACKGROUND: Physical therapy is frequently utilized in the postoperative care of femoroacetabular impingement syndrome (FAIS). There has been limited research into the efficacy of a structured home exercise program (HEP) compared with formal physical therapy (FPT) in this patient population.

PURPOSE/HYPOTHESIS: The purpose was to evaluate the short-term outcomes of patients utilizing FPT versus an HEP after hip arthroscopic surgery for FAIS. It was hypothesized that both groups would show similar improvements regarding outcome scores, which would improve significantly compared with their preoperative scores.

STUDY DESIGN: Cohort study; Level of evidence, 2.

METHODS: Patients undergoing hip arthroscopic surgery for FAIS at a single center between October 2020 and October 2021 were prospectively enrolled. Patients were allowed to self-select FPT or an HEP and were administered a survey preoperatively and at 1 month, 3 months, 6 months, and 12 months postoperatively. The survey included the Single Assessment Numeric Evaluation, visual analog scale for pain, 12-item International Hip Outcome Tool, Patient-Reported Outcomes Measurement Information System Physical Function, and patient satisfaction with physical therapy and overall care. Statistical analysis was conducted between the 2 groups and within groups to compare preoperative and postoperative scores.

RESULTS: The patients’ mean age was 32.6 ± 10.4 years, with 47.2% being female and 57.4% choosing the HEP. At 12 months postoperatively, no significant differences were reported between the FPT and HEP groups regarding the Single Assessment Numeric Evaluation score (P = .795), visual analog scale for pain score (P > .05), Patient-Reported Outcomes Measurement Information System Physical Function T-score (P = .699), 12-item International Hip Outcome Tool score (P = .582), and patient satisfaction (P > .05). Outcome scores at 12 months postoperatively were significantly improved from the preoperative scores across all measures in both groups (P < .001).

CONCLUSION: There were no significant differences regarding patient outcomes between FPT and the HEP at 1-year follow-up after hip arthroscopic surgery for FAIS when patients selected their own treatment, with both groups demonstrating significant improvements in their outcome scores from their preoperative values. These findings suggest that a structured HEP may be a viable alternative to FPT after hip arthroscopic surgery in patients who prefer a self-directed rehabilitation program.

PMID:38857043 | DOI:10.1177/03635465241252981

Optom Vis Sci. 2024 May 1;101(5):252-262. doi: 10.1097/OPX.0000000000002139.

ABSTRACT

PURPOSE: We aimed to develop a paradigm that can efficiently characterize motion percepts in people with low vision and compare their responses with well-known misperceptions made by people with typical vision when targets are hard to see.

METHODS: We recruited a small cohort of individuals with reduced acuity and contrast sensitivity (n = 5) as well as a comparison cohort with typical vision (n = 5) to complete a psychophysical study. Study participants were asked to judge the motion direction of a tilted rhombus that was either high or low contrast. In a series of trials, the rhombus oscillated vertically, horizontally, or diagonally. Participants indicated the perceived motion direction using a number wheel with 12 possible directions, and statistical tests were used to examine response biases.

RESULTS: All participants with typical vision showed systematic misperceptions well predicted by a Bayesian inference model. Specifically, their perception of vertical or horizontal motion was biased toward directions orthogonal to the long axis of the rhombus. They had larger biases for hard-to-see (low contrast) stimuli. Two participants with low vision had a similar bias, but with no difference between high- and low-contrast stimuli. The other participants with low vision were unbiased in their percepts or biased in the opposite direction.

CONCLUSIONS: Our results suggest that some people with low vision may misperceive motion in a systematic way similar to people with typical vision. However, we observed large individual differences. Future work will aim to uncover reasons for such differences and identify aspects of vision that predict susceptibility.

PMID:38857038 | DOI:10.1097/OPX.0000000000002139

Am J Sports Med. 2024 Jun 10:3635465241253849. doi: 10.1177/03635465241253849. Online ahead of print.

ABSTRACT

BACKGROUND: Meniscal allograft transplantation (MAT) is a viable option for patients experiencing unicompartmental knee pain after total or subtotal meniscectomy. Nonetheless, caution is recommended when suggesting this procedure in the presence of knee osteoarthritis (OA) because of the higher risk of poor survival and outcomes.

PURPOSE/HYPOTHESIS: The purpose was to document the long-term survival of MAT performed as a salvage procedure in patients with knee OA. The hypothesis was that MAT would significantly reduce pain and increase the function of the affected joint at a long-term follow-up compared with the preoperative condition, with a low number of failures and knee replacement surgeries.

STUDY DESIGN: Case series; Level of evidence, 4.

METHODS: A total of 47 patients (37 men and 10 women) with symptomatic knee OA (Kellgren-Lawrence grades 2 or 3) treated with MAT were evaluated at baseline, 5 years, and a minimum 10-year final follow-up (11.1 ± 1 years) using the Lysholm score, the visual analog scale for pain, the Knee injury and Osteoarthritis Outcome Score subscales, and the Tegner score. A total of 44 patients had undergone previous surgeries. Patient satisfaction, revision surgeries, and failures were also recorded.

RESULTS: A statistically significant improvement was observed in all clinical scores from the baseline assessment to the final follow-up. The Lysholm score improved significantly from 46.4 ± 17.2 at the preoperative assessment to 77.7 ± 20.4 at the intermediate follow-up (P < .001), with a significant decrease at the final follow-up (71 ± 23.3; P = .018). A similar trend was reported for the visual analog scale scale for pain, Knee injury and Osteoarthritis Outcome Score, and Tegner score, with no complete recovery to the previous sports activity level. A total of 33 patients required concurrent procedures, such as anterior cruciate ligament reconstructions, osteotomies, and cartilage procedures. Five patients underwent reoperation and were considered surgical failures, while 15 patients presented a clinical condition of <65 of the Lysholm score and were considered clinical failures. Among these, 4 patients were considered both surgical and clinical failures.

CONCLUSION: MAT surgery has proven to be a valid option for improving pain and function even in OA joints (Kellgren-Lawrence grades 2 or 3), yielding satisfactory results despite a worsening clinical outcome in the long-term follow-up. Therefore, based on the data from this study, orthopaedic surgeons may consider recommending MAT as a salvage procedure even in knees affected by early to moderate OA, while advising patients that the need for combined interventions could potentially reduce graft survival.

PMID:38857030 | DOI:10.1177/03635465241253849

JAMA. 2024 Jun 10. doi: 10.1001/jama.2024.8931. Online ahead of print.

NO ABSTRACT

PMID:38857021 | DOI:10.1001/jama.2024.8931

Ann Plast Surg. 2024 Jun 1;92(6S Suppl 4):S453-S460. doi: 10.1097/SAP.0000000000003950.

ABSTRACT

BACKGROUND: Individual outcomes may not accurately reflect the quality of perioperative care. Textbook outcomes (TOs) are composite metrics that provide a comprehensive evaluation of hospital performance and surgical quality. This study aimed to investigate the prevalence and predictors of TOs in a multi-institutional cohort of patients who underwent breast reconstruction with deep inferior epigastric artery perforator flaps.

METHODS: For autologous reconstruction, a TO was previously defined as a procedure without intraoperative complications, reoperation, infection requiring intravenous antibiotics, readmission, mortality, systemic complications, operative duration ≤12 hours for bilateral and ≤10 hours for unilateral/stacked reconstruction, and length of stay (LOS) ≤5 days. We investigated associations between patient-level factors and achieving a TO using multivariable regression analysis.

RESULTS: Of 1000 patients, most (73.2%) met a TO. The most common reasons for deviation from a TO were reoperation (9.6%), prolonged operative time (9.5%), and prolonged LOS (9.2%). On univariate analysis, tobacco use, obesity, widowed/divorced marital status, and contralateral prophylactic mastectomy or bilateral reconstruction were associated with a lower likelihood of TOs (P < 0.05). After adjustment, bilateral prophylactic mastectomy (odds ratio [OR], 5.71; P = 0.029) and hormonal therapy (OR, 1.53; P = 0.050) were associated with a higher likelihood of TOs; higher body mass index (OR, 0.91; P = <0.001) was associated with a lower likelihood.

CONCLUSION: Approximately 30% of patients did not achieve a TO, and the likelihood of achieving a TO was influenced by patient and procedural factors. Future studies should investigate how this metric may be used to evaluate patient and hospital-level performance to improve the quality of care in reconstructive surgery.

PMID:38857013 | DOI:10.1097/SAP.0000000000003950

Ann Plast Surg. 2024 Jun 1;92(6S Suppl 4):S445-S452. doi: 10.1097/SAP.0000000000003985.

ABSTRACT

BACKGROUND: Management of vasospastic and vaso-occlusive disorders is a complex challenge, with current treatments showing varied success. Cannabinoids have demonstrated both vasodilatory and antifibrotic properties, which present potential mechanisms for therapeutic relief. No existing review examines these effects in peripheral circulation in relation to vasospastic and vaso-occlusive disorders. This study aims to investigate vasodilatory and antifibrotic properties of cannabinoids in peripheral vasculature for application in vasospastic and vaso-occlusive disorders affecting the hand.

METHODS: A systematic search was conducted by 2 independent reviewers across PubMed, Cochrane, Ovid MEDLINE, and CINAHL to identify studies in accordance with the determined inclusion/exclusion criteria. Information regarding study design, medication, dosage, and hemodynamic or antifibrotic effects were extracted. Descriptive statistics were used to summarize study findings as appropriate.

RESULTS: A total of 584 articles were identified, and 32 were selected for inclusion. Studies were grouped by effect type: hemodynamic (n = 17, 53%) and antifibrotic (n = 15, 47%). Vasodilatory effects including reduced perfusion pressure, increased functional capillary density, inhibition of vessel contraction, and increased blood flow were reported in 82% of studies. Antifibrotic effects including reduced dermal thickening, reduced collagen synthesis, and reduced fibroblast migration were reported in 100% of studies.

CONCLUSION: Overall, cannabinoids were found to have vasodilatory and antifibrotic effects on peripheral circulation via both endothelium-dependent and independent mechanisms. Our review suggests the applicability of cannabis-based medicines for vasospastic and vaso-occlusive disorders affecting the hand (eg, Raynaud disease, Buerger disease). Future research should aim to assess the effectiveness of cannabis-based medicines for these conditions.

PMID:38857012 | DOI:10.1097/SAP.0000000000003985

Ann Plast Surg. 2024 Jun 1;92(6S Suppl 4):S413-S418. doi: 10.1097/SAP.0000000000003977.

ABSTRACT

BACKGROUND: Hourly flap checks are the most common means of flap monitoring during the first 24 hours following autologous breast reconstruction (ABR). This practice often requires intensive care unit (ICU) admission, which is a key driver of health care costs and decreased patient satisfaction. This study addresses these issues by demonstrating decreased cost and length of admission associated with a 4-hour interval between flap checks during the first 24 hours following ABR.

METHODS: This is a retrospective review of ABR surgeries performed by multiple surgeons from 2017 to 2020. Two cohorts were identified, one that underwent flap checks every hour in the ICU (Q1 cohort) and the other that underwent flap checks every 4 hours on the hospital floor (Q4 cohort). Our primary outcome measures were length of stay (LOS), flap takebacks, flap loss, and encounter cost.

RESULTS: Rates of flap takeback and loss did not differ between cohorts (P = 0.18, P = 0.21). The Q4 cohort’s average LOS was shorter than the Q1 cohort (P = 0.002). The Q4 cohort’s average cost was also $25,554.80 less than the Q1 cohort (P < 0.001). This association persisted after controlling for LOS, operating room takeback, timing and laterality of reconstruction, and flap configuration (hazard ratio = 0.65, P = 0.0007).

CONCLUSION: This study demonstrates the benefits of lengthened flap check intervals during the first 24 hours following ABR. These intervals decrease the cost of ABR while also maintaining safety, making ABR a more accessible option for breast reconstruction patients.

PMID:38857006 | DOI:10.1097/SAP.0000000000003977

Ann Plast Surg. 2024 Jun 1;92(6S Suppl 4):S408-S412. doi: 10.1097/SAP.0000000000003954.

ABSTRACT

INTRODUCTION: The healthcare costs for treatment of community-acquired decubitus ulcers accounts for $11.6 billion in the United States annually. Patients with stage 3 and 4 decubitus ulcers are often treated inefficiently prior to reconstructive surgery while physicians attempt to optimize their condition (debridement, fecal/urinary diversion, physical therapy, nutrition, and obtaining durable medical goods). We hypothesized that hospital costs for inpatient optimization of decubitus ulcers would significantly differ from outpatient optimization costs, resulting in significant financial losses to the hospital and that transitioning optimization to an outpatient setting could reduce both total and hospital expenditures. In this study, we analyzed and compared the financial expenditures of optimizing patients with decubitus ulcers in an inpatient setting versus maximizing outpatient utilization of resources prior to reconstruction.

METHODS: Encounters of patients with stage 3 or 4 decubitus ulcers over a 5-year period were investigated. These encounters were divided into two groups: Group 1 included patients who were optimized totally inpatient prior to reconstructive surgery; group 2 included patients who were mostly optimized in an outpatient setting and this encounter was a planned admission for their reconstructive surgery. Demographics, comorbidities, paralysis status, and insurance carriers were collected for all patients. Financial charges and reimbursements were compared among the groups.

RESULTS: Forty-five encounters met criteria for inclusion. Group 1’s average hospital charges were $500,917, while group 2’s charges were $134,419. The cost of outpatient therapeutic items for patient optimization prior to wound closure was estimated to be $10,202 monthly. When including an additional debridement admission for group 2 patients (average of $108,031), the maximal charges for total care was $252,652, and hospital reimbursements were similar between group 1 and group 2 ($65,401 vs $50,860 respectively).

CONCLUSIONS: The data derived from this investigation strongly suggests that optimizing patients in an outpatient setting prior to decubitus wound closure versus managing the patients totally on an inpatient basis will significantly reduce hospital charges, and hence costs, while minimally affecting reimbursements to the hospital.

PMID:38857005 | DOI:10.1097/SAP.0000000000003954

Ann Plast Surg. 2024 Jun 1;92(6S Suppl 4):S401-S403. doi: 10.1097/SAP.0000000000003951.

ABSTRACT

OBJECTIVE: This study examines an Enhanced Recovery After Surgery (ERAS) protocol for patients with cleft palate and hypothesizes that patients who followed the protocol would have decreased hospital length of stay and decreased narcotic usage than those who did not.

DESIGN: Retrospective cohort study.

SETTING: The study takes place at a single tertiary children’s hospital.

PATIENTS: All patients who underwent cleft palate repair during a 10-year period (n = 242).

INTERVENTIONS: All patients underwent cleft palate repair with the most recent cohort following a new ERAS protocol.

MAIN OUTCOME MEASURES: Primary outcomes included hospital length of stay and narcotic usage in the first 24 hours after surgery.

RESULTS: Use of local bupivacaine during surgery was associated with decreased initial 24-hour morphine equivalent usage: 2.25 vs 3.38 mg morphine equivalent (MME) (P < 0.01), and a decreased hospital length of stay: 1.71 days vs 2.27 days (P < 0.01). The highest 24-hour morphine equivalent a patient consumed prior to the ERAS protocol implementation was 24.53 MME, compared with 6.3 MME after implementation. Utilization of the ERAS protocol was found to be associated with a decreased hospital length of stay: 1.67 vs 2.18 days (P < 0.01).

CONCLUSIONS: Use of the proposed ERAS protocol may lead to lower narcotic usage and decreased length of stay.

PMID:38857003 | DOI:10.1097/SAP.0000000000003951