A risk score system for stratifying the risk of relapse in B cell acute lymphocytic leukemia patients after allogenic stem cell transplantation

BACKGROUND

For patients with B cell acute lymphocytic leukemia (B-ALL) who underwent allogeneic stem cell transplantation (allo-SCT), many variables have been demonstrated to be associated with leukemia relapse. In this study, we attempted to establish a risk score system to predict transplant outcomes more precisely in patients with B-ALL after allo-SCT.

METHODS

A total of 477 patients with B-ALL who underwent allo-SCT at Peking University People's Hospital from December 2010 to December 2015 were enrolled in this retrospective study. We aimed to evaluate the factors associated with transplant outcomes after allo-SCT, and establish a risk score to identify patients with different probabilities of relapse. The univariate and multivariate analyses were performed with the Cox proportional hazards model with time-dependent variables.

RESULTS

All patients achieved neutrophil engraftment, and 95.4% of patients achieved platelet engraftment. The 5-year cumulative incidence of relapse (CIR), overall survival (OS), leukemia-free survival (LFS), and non-relapse mortality were 20.7%, 70.4%, 65.6%, and 13.9%, respectively. Multivariate analysis showed that patients with positive post-transplantation minimal residual disease (MRD), transplanted beyond the first complete remission (≥CR2), and without chronic graft-versus-host disease (cGVHD) had higher CIR (P  < 0.001, P = 0.004, and P  < 0.001, respectively) and worse LFS (P  < 0.001, P = 0.017, and P  < 0.001, respectively), and OS (P  < 0.001, P = 0.009, and P  < 0.001, respectively) than patients without MRD after transplantation, transplanted in CR1, and with cGVHD. A risk score for predicting relapse was formulated with the three above variables. The 5-year relapse rates were 6.3%, 16.6%, 55.9%, and 81.8% for patients with scores of 0, 1, 2, and 3 (P  < 0.001), respectively, while the 5-year LFS and OS values decreased with increasing risk score.

CONCLUSION

This new risk score system might stratify patients with different risks of relapse, which could guide treatment.

Arsenic level in bladder tumor of patients from an exposed population: association with progression and prognosis

Aims: To elucidate the impact of arsenic on progression and prognosis of bladder cancer. Patients & methods: Total arsenic in 145 tumors (80 non-muscle-invasive [NMIBC] and 65 muscle-invasive bladder cancer [MIBC]) was measured and associated with Ki67 expression, tumor-clinicopathological parameters and patient outcome. Results: Tumor arsenic concentration was higher in exposed than unexposed patients (256 μg/kg vs 77 μg/kg; p < 0.0001) and positively correlated (r = 0.65; p < 0.0001) with arsenic content of patient's drinking water. Arsenic concentration showed significant association with Ki67-overexpression (p = 0.001) and advanced tumor stages (NMIBC vs MIBC; p = 0.0009). In NMIBC, high tumor arsenic (>100 μg/kg) and Ki67 overexpression was established as predictors for recurrence (hazard ratio [HR]: 4.68; p = 0.005 and HR: 3.91; p = 0.018) and progression (HR: 6.04; p = 0.023 and HR: 6.87; p = 0.013). In MIBC, association of high arsenic remained significant with increased risk of recurrence (HR: 4.58; p = 0.04). Conclusion: In NMIBC, high arsenic and Ki67 overexpression and in MIBC, only high arsenic showed prognostic importance in predicting poor patient outcome.

Impact of weekend admission and changes in treating team on patient flow and outcomes in adults admitted to hospital with community-acquired pneumonia

BACKGROUND

The effect of workflow factors, such as timing of admission and changes in treating team, on patient outcomes remains inconclusive.

AIMS

To investigate the impact of weekend admission and changes in treating team on four pre-defined outcomes in patients admitted to hospital with community-acquired pneumonia (CAP).

METHODS

We performed an observational cohort study by utilising prospective longitudinal data collected during the IMPROVE-GAP trial, a stepped-wedge randomised study investigating an evidence-based bundle of care in the management of CAP. We assessed the effect of two exposure variables, day of admission and change of treating team, on four pre-specified outcomes: (i) length of stay; (ii) time to clinical stability; (iii) readmission within 30 days; and (iv) mortality at 30 days. Our analysis was restricted to patients with a primary diagnosis of CAP and employed multivariable Cox regression and logistic regression to adjust for potential measured confounders.

RESULTS

Of 753 participants, 224 (29.7%) were admitted on the weekend and 71 (9.4%) changed treating team during admission. Weekend admissions had significantly longer hospital stays than weekday admissions (hazard ratio (95% confidence interval; P-value) 0.82 (0.70-0.98; 0.03)) and took longer to reach clinical stability (0.80 (0.68-0.95; 0.01)). Change of treating team doubled the odds of readmission at 30 days (odds ratio 1.95 (1.08-3.58; 0.03)).

CONCLUSIONS

These results suggest workflow factors can negatively impact both health service and patient outcomes. Systems interventions aimed at improving out of hours service and reducing changes in treating team should be considered.

Leveraging the Hyperledger Fabric for Enhancing the Efficacy of Clinical Decision Support Systems

Adopting and implementing the Clinical Decision Support System (CDSS) technology is a critical element in an effort to improve national quality initiatives and evidence-based practice at the point of care. CDSS is envisioned to be a potential solution to many current challenges in the healthcare sphere, which includes information overload, practice improvement, eliminating treatment errors, and reducing medical consultation costs. However, the CDSS did not manage to achieve these goals to the desired levels and provide context-appropriate alerts, although integrated with the electronic health records (EHRs) (1). Clinical decision support alerts can save lives, but frequent ones can cause increased cognitive burden to clinicians, worsen alert fatigue, and increase the duplication of tests. This ultimately increases health care costs without refining patient outcomes. Studies show that 49-96% of clinical alerts are ignored, raising questions about the effectiveness of CDSS (1). Blockchain, a decentralized, distributed digital ledger that contains a plethora of continuously updated, time-stamped, and highly encrypted virtual record, can be a key to addressing these challenges (2). The blockchain technology if integrated with the CDSS can serve as a potential solution to eliminating current drawbacks with CDSS (3). This article addresses the most significant and chronic problems facing the successful implementation of CDSS and how leveraging the Hyperledger Fabric can alleviate the clinical alert fatigue and reduce physician's burnout using patient-specific information. The proposed architecture framework for this study is designed to equip the CDSS with overall patient information at the point of care. This then empowers the physicians with the blockchain-integrated CDSS, which holds the potential to reduce clinician's cognitive burden, medical errors, and costs and ultimately enhance patient outcomes. The research study broadly discusses how the blockchain technology can be a potential solution, reasons for selecting the Hyperledger Fabric, and elaborates on how the Hyperledger Fabric can be leveraged to enhance the efficacy of CDSS.

Overcoming the barriers to dissemination and implementation of quality measures for gastrointestinal endoscopy: European Society of Gastrointestinal Endoscopy (ESGE) and United European Gastroenterology (UEG) position statement

The European Society of Gastrointestinal Endoscopy (ESGE) has developed performance measures and established a framework for quality assessment for gastrointestinal endoscopy in Europe. Most national societies actively undertake initiatives to implement and explicitly endorse these quality indicators. Given this, the ESGE proposes that, at a national level, strong leadership should exist to disseminate and implement quality parameters. Thus, understanding the potential barriers that may vary locally is of paramount importance. The ESGE suggests that each national society should prioritise quality and standards of care in gastrointestinal endoscopy in their activities and should survey/understand which measures area local priority to their members and make measuring quality intrinsic to daily endoscopy practice.

Association of Changes in Acute Gastrointestinal Injury Grade with Prognosis in Critically Ill Patients: A Prospective, Single-Center, Observational Study

Purpose

To investigate the association between the change of acute gastrointestinal injury (AGI) grade and the outcome in critically ill patients.

Methods

This was a prospectively observational study. All patients admitted in the ICU from October 2013 to June 2015, with the duration of ICU > 72 h and age >18 years, were enrolled in this study. The AGI grade and gastrointestinal symptoms were evaluated during ICU stay following the 2012 ESICM recommendation. The ICU mortality, duration of ICU stay, mechanical ventilation (MV) use, vasoactive drug use, and continuous renal replacement therapy of patients were recorded accordingly.

Results

A total of 320 patients were included, and 265 of them were diagnosed with AGI. The overall ICU mortality was 11.88%, while it was 13.58% in patients with AGI. In logistic regression analyses, the decreasing trend of AGI grade was identified as a protective factor for ICU death (odds ratio (OR), 0.484; 95% confidence interval (CI), 0.26–0.90), while the max AGI grade was a risk factor (OR, 3.464; 95% CI, 2.71–8.47) for ICU death.

Conclusion

The changes of AGI grades in critically ill patients were associated with their clinical outcomes. The ICU-acquired AGI patients associated with longer ICU stay days.

Patient-Related Outcomes of Arthroscopic Resection of Ganglion Cysts of the Wrist

Background  Ganglion cysts of the wrist can cause pain and loss of functionality. No consensus exist on optimal treatment. Arthroscopic resection shows promising results but is poorly studied. Furthermore, only few studies have used patient-related outcomes to evaluate arthroscopic treatment. Purpose  The purpose of this study was to assess patient-related outcomes following arthroscopic resection of wrist ganglion cysts. Patients and Methods  This was a retrospective study of all consecutive patients that underwent arthroscopic resection of a dorsal or volar wrist ganglion. Minimum follow-up was 6 months. The primary outcome was the patient-rated wrist evaluation (PRWE). Secondary outcomes were recurrence rate and complications. Results  A total of 53 patients were included with a mean follow-up of 13 months (interquartile range: 6-23 months). Twenty-six patients (49%) presented with a recurrence following prior treatment. Mean PRWE was 13 (standard deviation [SD] = 1.8), with no difference between patients with dorsal or volar ganglion cysts. There were five recurrences (9%), of which three occurred in the first five patients who were operated. There were three patients with complications (6%), consisting of neuropraxia, extensor carpi ulnaris tendinitis, and painful scar tissue. Conclusion  Arthroscopic resection results in good patient-related outcome and low complication and recurrence rates when performed by an experienced surgeon. Recurrence and complication rates are similar to arthroscopic resections described in literature and superior to open resection and needle aspiration. Well-designed randomized clinical trials will be necessary to confirm these findings. Level of Evidence  This is a level IV, retrospective study.

Can a brief assessment of social support predict outcomes after bariatric surgery?

Social support is important to optimize bariatric surgery outcomes, but limited tools exist for brief and effective assessment preoperatively. The aims of the study were to determine the extent to which two ratings of social support can predict bariatric surgery outcomes, and to examine any associations between these two methods.In this retrospective study, patients were included for whom the Cleveland clinic behavioral rating system (CCBRS) and Flanagan quality of life scale (FQoLS) scores were obtained as part of their preoperative psychosocial evaluation. They were followed up for 6 to 24 months after bariatric surgery. Linear and logistic regressions were performed with patients' CCBRS and FQoLS scores as independent variables, and percent excess weight loss (%EWL), length of stay (LOS), complications, readmissions and loss to follow-up as dependent variables. The prediction of CCBRS ratings from FQoLS social support items was also evaluated. A total of 415 patients were included in the analysis. There were significant associations between the CCBRS and three of the four relevant FQoLS self-ratings. As CCBRS and FQoLS scores increased, complications decreased significantly. The CCBRS alone additionally predicted decreased length of hospital stay and approached significance for predicting decreased readmission rates. There were no associations between %EWL and behavior ratings. The degree of patients' social support is associated with important bariatric surgery outcomes. It is possible to obtain this valuable information via the administration of brief assessments prior to bariatric surgery.

Neuroblastoma: the association of anatomical tumour site, molecular biology and patient outcomes

BACKGROUND

Numerous factors have been identified as carrying prognostic value in neuroblastoma (NB) and therefore incorporated in risk stratification of disease. Here, we investigate the association of anatomical site of NB with molecular biology and clinical outcomes.

METHODS

A total of 117 patients with NB were studied over a 30-year period. Tumour location was confirmed with computed tomography/magnetic resonance imaging. Data on molecular biology were obtained as testing became available. Chi-squared, Fisher's exact test and Kaplan-Meier log-rank tests were used for statistical analysis.

RESULTS

Tumour originated in the thoracic region (thoracic NB, TNB) in 15 patients (13%), adrenal gland (adrenal NB, ANB) in 88 patients (75%) and abdominal/paravertebral chain (paravertebral NB, PVNB) in 14 patients (12%). Overall survival (OS) for ANB was significantly lower (38%; P = 0.015). ANB cases were more frequently diagnosed at stage IV (69%; P = 0.001). MYCN amplification was noted in 33% of ANB cases and associated with lower OS (17% versus 62% MYCN non-amplified ANB; P = 0.01). The vast majority of TNB and PVNB were non-MYCN amplified (100% and 86%, respectively) and carried better prognosis (OS 86% and 83%, respectively). Forty-two percent of ANB cases were diploid and had lower OS (20% versus 71% hyperdiploid ANB; P = 0.079). TNB and PVNB were found to be mostly hyperdiploid (86% and 100%, respectively) with better OS (83% and 33%, respectively). Segmental chromosomal alterations had prognostic significance in those with PVNB (P = 0.03).

CONCLUSION

TNB tumours have better outcomes than adrenal tumours. This may be due to varied factors reported here including non-metastatic disease at presentation, non-amplification of the MYCN oncogene and overall favourable molecular biology characteristics.

Anthropometric Outcome of Primary Unilateral Cleft Lip Repair in Indonesia

OBJECTIVE

This study aimed to measure and analyze the outcome of primary unilateral cleft lip repair.

DESIGN

Observational cohort study.

SETTING

Surabaya Cleft Lip and Palate (CLP) Center, a major referral center for the Eastern part of Indonesia, affiliated with a tertiary center.

PATIENTS, PARTICIPANTS

From 69 patients who met the inclusion criteria, we excluded 31 patients who were more than 2 years of age and were operated on by junior residents under supervision.

INTERVENTIONS

We performed anthropometric measurements of the patients on photographs taken before, immediately after, and a year after the surgery.

MAIN OUTCOME MEASURE(S)

This study measured nasal width, vertical lip height, horizontal lip length, and philtral height ratios.

RESULTS

While nasal width and philtral height ratios decreased significantly (P = .000 and P = .000, respectively) reaching symmetry immediately after surgery, the horizontal lip length, and vertical lip height ratios remained unchanged (P = .862 and P = .981, respectively). A year after surgery, the nasal width and horizontal lip length ratios increased significantly (P = .017 and P = .006, respectively), while philtral height and vertical lip height ratios remained unchanged (P = .927 and P = .138, respectively). There was no difference in the ratios based on the initial size and completeness of the cleft.

CONCLUSION

In Surabaya CLP Center, the symmetry of nasal width, philtral height, horizontal lip length, and vertical lip height were achieved by the unilateral cleft lip repair despite the initial size and completeness of the cleft.

Molecular Characterization of Ovarian Yolk Sac Tumor (OYST)

Simple Summary

Ovarian yolk sac tumors (OYSTs) are rare and specific therapeutic strategies are needed after the failure of platinum-based first-line and salvage regimens. This retrospective study included ten patients with OYST, including patients with relapsed disease and disease-free patients. Three patients (33.3%) harbored oncogenic mutations in KRAS, KIT and ARID1A, which may be used as a target. Our series shows that relapsed patients with molecular analysis had clinically relevant molecular alterations. Future research with dedicated trials and multicenter international collaborations are needed to demonstrate the efficacy of specific therapeutic strategies after failure of platinum-based first-line and salvage regimens.

Abstract

Most patients with malignant ovarian germ cell tumors (MOGTCs) have a very good prognosis and chemotherapy provides curative treatment; however, patients with yolk sac tumors (OYSTs) have a significantly worse prognosis. OYSTs are rare tumors and promising results are expected with the use of specific therapeutic strategies after the failure of platinum-based first-line and salvage regimens. We initiated a project in collaboration with EORTC SPECTA, to explore the molecular characteristics of OYSTs. The pilot project used retrospective samples from ten OYST relapsed and disease-free patients. Each patient had a molecular analysis performed with FoundationOne CDx describing the following variables according to the Foundation Medicine Incorporation (FMI): alteration type (SNV, deletion), actionable gene alteration, therapies approved in EU (for patient’s tumor type and other tumor types), tumor mutational burden (TMB), and microsatellite instability (MSI) status. A total of 10 patients with OYST diagnosed between 2007 and 2017 had a molecular analysis. A molecular alteration was identified in four patients (40%). A subset of three patients (33.3% of all patients) harbored targetable oncogenic mutations in KRAS, KIT, ARID1A. Two patients at relapse harbored a targetable mutation. This retrospective study identifies clinically relevant molecular alterations for all relapsed patients with molecular analysis. Dedicated studies are needed to demonstrate the efficacy of specific therapeutic strategies after the failure of platinum-based first-line and salvage regimens and to explore the potential relationship of a molecular alteration and patient outcome.

Clinical use of Convalescent Plasma in the COVID-19 pandemic: a transfusion-focussed gap analysis with recommendations for future research priorities

BACKGROUND AND OBJECTIVES

Use of convalescent plasma for coronavirus disease 2019 (COVID-19) treatment has gained interest worldwide. However, there is lack of evidence on its dosing, safety and effectiveness. Until data from clinical studies are available to provide solid evidence for worldwide applicable guidelines, there is a need to provide guidance to the transfusion community and researchers on this emergent therapeutic option. This paper aims to identify existing key gaps in current knowledge in the clinical application of COVID-19 convalescent plasma (CCP).

MATERIALS AND METHODS

The International Society of Blood Transfusion (ISBT) initiated a multidisciplinary working group with worldwide representation from all six continents with the aim of reviewing existing practices on CCP use from donor, product and patient perspectives. A subgroup of clinical transfusion professionals was formed to draft a document for CCP clinical application to identify the gaps in knowledge in existing literature.

RESULTS

Gaps in knowledge were identified in the following main domains: study design, patient eligibility, CCP dose, frequency and timing of CCP administration, parameters to assess response to CCP treatment and long-term outcome, adverse events and CCP application in less-resourced countries as well as in paediatrics and neonates.

CONCLUSION

This paper outlines a framework of gaps in the knowledge of clinical deployment of CPP that were identified as being most relevant. Studies to address the identified gaps are required to provide better evidence on the effectiveness and safety of CCP use.

Does a delay in surgery for distal radial fractures affect patient outcome?

Current guidelines from the British Orthopaedic Association state that if fractures of the distal radius are operated on then this should take place within 3 days of injury for intra-articular fractures, 7 days for extra-articular fractures and 3 days when a trial of conservative management has failed. This retrospective cohort study aimed to assess whether there was any difference in outcome between patients receiving timely or delayed surgery, using the Patient-Rated Wrist Evaluation score at >12 months after injury as the primary outcome measure. Data from 380 patients treated at two district general hospitals over a 5-year period were obtained using electronic databases to capture the demographics and treatment details and postal questionnaires to assess current function. The study showed no statistical or clinical differences in outcome measures between the timely or delayed cohorts in any of the three treatment groups.Level of evidence: III.

The impact of biomarkers of acute kidney injury on individual patient care

Acute kidney injury (AKI) remains a common clinical syndrome associated with increased morbidity and mortality. In the last several years there have been several advances in the identification of patients at increased risk for AKI through the use of traditional and newer functional and damage biomarkers of AKI. This article will specifically focus on the impact of biomarkers of AKI on individual patient care, focusing predominantly on the markers with the most expansive breadth of study in patients and reported literature evidence. Several studies have demonstrated that close monitoring of widely available biomarkers such as serum creatinine and urine output is strongly associated with improved patient outcomes. An integrated approach to these biomarkers used in context with patient risk factors (identifiable using electronic health record monitoring) and with tests of renal reserve may guide implementation and targeting of care bundles to optimize patient care. Besides traditional functional markers, biochemical injury biomarkers have been increasingly utilized in clinical trials both as a measure of kidney injury as well as a trigger to initiate other treatment options (e.g. care bundles and novel therapies). As the novel measures are becoming globally available, the clinical implementation of hospital-based real-time biomarker measurements involves a multidisciplinary approach. This literature review discusses the data evidence supporting both the strengths and limitations in the clinical implementation of biomarkers based on the authors' collective clinical experiences and opinions.

BCL2 Expression at Post-Induction and Complete Remission Impact Outcome in Acute Myeloid Leukemia

Advances in acute myeloid leukemia (AML) genomics and targeted therapies include the recently approved BCL2 inhibitor venetoclax. The association between BCL2 expression and patient outcome was analyzed in a series of 176 consecutive AML patients at diagnosis (Dx), post-induction (PI), complete remission (CR) and relapse (RL). Levels increased significantly at relapse (mean 1.07 PI/0.96 CR vs. 2.17 RL, p = 0.05/p = 0.03). In multivariate analysis, high BCL2-Dx were marginally associated with worse progression-free survival, while high PI levels or at CR had an independent negative impact on outcome (PI: HR 1.58, p = 0.014; CR: HR 1.96, p = 0.008). This behavior of high PI or CR BCL2 levels and increased risk was maintained in a homogeneous patient subgroup of age <70 and intermediate cytogenetic risk (PI: HR 2.44, p = 0.037; CR: HR 2.71, p = 0.049). Finally, for this subgroup, high BCL2 at relapse indicated worse overall survival (OS, HR 1.15, p = 0.05). In conclusion, high BCL2 levels PI or at CR had an independent negative impact on patient outcome. Therefore, BCL2 expression is a dynamic marker that may be useful during AML patient follow up, and BCL2 levels at PI and/or CR may influence response to anti-BCL2 therapy.

Role of EEG in Predicting Outcome of Hepatic Encephalopathy Patients

Introduction: A retrospective analysis of 151 patients with hepatic encephalopathy (HE) who were admitted to the liver intensive care unit (LICU) and liver transplant intensive care unit (TICU) and underwent electroencephalographic (EEG) testing was performed. We describe a method of grading the EEGs of patients with HE and predicting their subsequent outcomes. Methods: All liver failure patients with HE who underwent routine EEG testing in the LICU or TICU between October 1, 2018 and March 31, 2019, at the Institute of Liver and Biliary Sciences (ILBS) were enrolled in this analysis. The data was analyzed using Statistical Package for the Social Sciences (SPSS). The patients were divided into four grades of HE based on established EEG criteria (HE-EEG). Results: One hundred fifty-one patients [127 Male (84%), 24 Female (16%)] with HE who underwent EEG testing were enrolled. Ages ranged from 3 to 74 years, with a mean age of 48.34 years and median interquartile range (IQR) of 49 years (38-60 years). Ninety-five patients (62.9%) had grade 1 and 2 hepatic encephalopathy, with a statistically significant, worse outcome seen in grades 3 and 4 HE patients. Seizures were seen in 30 (20.1%) of HE patients. Fifteen of 30 patients with seizures (50%) were in the ethanol and nonalcoholic steatohepatitis (NASH) groups. Forty-four of 59 (74.6%) MRIs and 35 of 60 (58.3%) CTs demonstrated some type of brain abnormality in these patients. Imaging abnormalities and the presence of seizures did not contribute to a statistically worse outcome. Conclusion: EEG has an important role in predicting the outcome and prognosis in HE. Patients with grade 3 or 4 HE-EEG, or with progressive worsening of HE-EEG grading were associated with the highest mortality rates.

A Comparison of Conservative and Operative Management of Thumb Ulnar Collateral Ligament Avulsion Fractures in Children

Background: The optimal management of pediatric thumb ulnar collateral ligament (UCL) avulsion fractures remains poorly defined. The purpose of this study was to elucidate patient outcomes based on initial management and fracture characteristics. Methods: A retrospective study of all patients younger than 18 years of age presenting with a thumb UCL avulsion fracture was performed. Patients were grouped by their initial management. The primary outcome of the study was time to return to full activity. Fractures were characterized by articular surface involvement, displacement, and rotation. Results: Forty-seven patients with thumb UCL avulsion fractures were identified. Ten patients underwent surgery as initial treatment; all healed without complication, with a mean recovery time of 6.2 ± 1.8 weeks. Thirty-seven patients were treated conservatively; although most healed, the recovery time was longer (9.2 ± 8.3 weeks, adjusted hazard ratio = 2.3, 95% confidence interval = 1.0-5.5). Four cases (11%) required conversion to surgery that all healed without complications. Fractures treated with immobilization alone were significantly smaller, less displaced, and less rotated than those initially treated with surgery; however, 19 fractures that would have met criteria for surgery were treated with immobilization and successfully healed within 7.1 ± 2.9 weeks. Fracture characteristics did not predict which patients would fail conservative treatment or have prolonged recovery times. Conclusions: While surgery provided definitive treatment without delay in recovery, immobilization may not be an unreasonable treatment choice even for patients with large or displaced fractures. In cases where patients failed immobilization, surgery as a second-line treatment had good results.

The prognostic significance of ALDH1A1 expression in early invasive breast cancer

AIMS

Aldehyde dehydrogenase family 1 member A1 (ALDH1A1) is reportedly a key ALDH isozyme linked to the cancer stem cells (CSC) of many solid tumours, where it is involved in self-renewal, differentiation and self-protection. In this study, the prognostic significance of ALDH1A1 expression in early invasive breast cancer (BC) and its role as a BC stem cell (BCSC) were evaluated.

METHODS AND RESULTS

ALDH1A1 expression was assessed, using immunohistochemistry and tissue microarrays, in a large well-characterised BC cohort. ALDH1A1 mRNA expression was also assessed at transcriptomic levels, utilising data from the Molecular Taxonomy of Breast Cancer International Consortium. The associations of ALDH1A1 with clinicopathological parameters, other stem cell markers and patient outcomes were determined. ALDH1A1 was expressed in 71% of BC cases at both the protein and mRNA levels. High ALDH1A1 expression was associated with poor prognostic features, including high grade, poor Nottingham Prognostic Index (NPI), lymph node metastasis and highly proliferative ER⁺ (luminal B) and triple-negative (TNBC) subtypes. ALDH1A1 expression was positively correlated with the expression of CD44, CD24, TWIST, SOX9, EPCAM and CD133. The high immunoexpression of ALDH1A1 was significantly associated with poor BC-specific survival (P < 0.001), and specifically in the luminal B and TNBC subtypes (P = 0.042 and P = 0.003, respectively). The immunoexpression of ALDH1A1 was an independent predictor of poor prognosis (P = 0.015).

CONCLUSIONS

ALDH1A1, as assessed using immunohistochemistry, seems to act as a BCSC marker associated not only with other BCSC markers but also with poor prognostic characteristics and poor outcomes, particularly in the luminal B and TNBC subtypes.

Lyme Disease Patient Outcomes and Experiences; A Retrospective Cohort Study

Lyme disease is a vector-borne illness caused by Borrelia spp. bacterium spread by ticks to humans and other mammals. Despite being prevalent in many regions of the world, there remains considerable uncertainty surrounding many aspects of the disease, and consensus on the most appropriate and effective means of treating the illness remains to be achieved. Recommendations published by the Infectious Diseases Society of America (IDSA) and the International Lyme and Associated Diseases Society (ILADS), the primary guidelines followed by health care professionals treating Lyme disease, diverge in many of their key recommendations, including treatment duration. Given this lack of consensus, surprisingly little research has been conducted on patient outcomes following different treatment approaches. In this study, patient outcomes were evaluated from a cohort of 210 Canadian Lyme disease patients seeking treatment at one US Lyme disease clinic following a treatment regimen conforming to the ILADS treatment guidelines. It was found that the majority of Lyme disease patients at the clinic responded positively to treatment and a significant (p < 0.05) decrease in symptoms was observed over time. This study, along with related studies, may help to guide physicians to provide their patients with the most effective care.

Preliminary Radiology Report Discordances and Patient Outcomes

RATIONALE AND OBJECTIVES

At our institution, resident and fellow radiologists issue preliminary reports for off-hours imaging studies, which are overread by attending radiologists the next day using structured discrepancy templates. In this study, we examined the impact on patient management and outcome of studies with major discordance.

MATERIALS AND METHODS

For our retrospective observational study, preliminary reports between March and June 2017 that received major discordance were identified through report text search. Electronic medical records were reviewed for patient management change and patient outcome.

RESULTS

Of the 199 cases, 52 cases (26%) had management change and 119 cases (60%) did not have management change. In 25 cases (13%), the preliminary report was proven correct on subsequent management. Three cases (2%) were lost to follow-up. In only one case was adverse outcome directly related to the discordant finding. In cases with patient management change, there was higher proportion of perceptual error compared with those without management change (73% versus 59%). In 47 cases (24%), the discordant finding or diagnosis was known to the clinical team, and better history could have avoided the major change.

CONCLUSION

Adverse outcome from the discordant imaging finding was low (0.5%). Major change in preliminary report could be reduced with better clinical history. Patient management change was more frequently seen with perceptual errors, placing greater emphasis on strategies to reduce them.

Reversal Treatment in Oral Anticoagulant-Related Intracerebral Hemorrhage-An Observational Study Based on the Swedish Stroke Register

Introduction: Intracerebral hemorrhage (ICH) is the most serious adverse effect of oral anticoagulant (OAC) treatment. The effect of OAC reversal therapy on outcome is uncertain. We compared 90-day survival and functional outcome in patients with OAC-ICH who received OAC reversal therapy with those who did not. Methods: Data from The Swedish Stroke Register (Riksstroke) for all registered cases of OAC-ICH during 2017 (572 patients) were used to obtain information on reversal (n = 369) and non-reversal (n = 203) treatment receiving patients. Univariate and multivariate Cox regression analysis stratified for level of consciousness (LOC) on admission, and adjustment for relevant baseline variables, was used to compare 90-day Hazard Ratios (HR) for mortality. Results: Sixty-five percent of patients received reversal treatment. These patients were younger, more often pre-stroke independent and alert at presentation. Withholding reversal treatment was associated with an increased death rate (HR = 1.47; 95% CI: 1.08-2.01) in a Cox regression model stratified for LOC and adjusted for baseline imbalances. Additional factors associated with an increased 90-day death rate were male sex (HR = 1.42; 95% CI: 1.06-1.92), age (HR = 1.05; 95% CI: 1.02-1.07), and intraventricular hemorrhage (HR = 2.41; CI: 1.77-3.29). Conclusion: In this large observational study 35% of patients with OAC-ICH did not receive reversal treatment. Patients receiving OAC-reversal treatment had an improved 90-day mortality outcome compared to those not receiving treatment. Mortality was strongly related to LOC. Further, and larger, studies are required to determine which patient groups may benefit from reversal therapy and in whom non-reversal is adequate.

Impact of South Korea's Comprehensive Nursing Service Policy on Nurse and Patient Outcomes

In some Asian and African countries, caregivers of patients are permitted to reside in hospital rooms and support the daily tasks of patient care. To solve the various problems that this system could cause, the Korean government has established a comprehensive nursing service, whereby caregivers are no longer permitted in the hospital and, instead, nurses provide all the patient care. This study aimed to identify and evaluate the effectiveness of the comprehensive nursing service, by surveying 1348 nurses to evaluate nursing outcomes-specifically, the Nurses' Assessment of Quality Scale, job satisfaction, and turnover intention. A total of 396 patients were also surveyed to determine patient outcome, in particular patient satisfaction. In the comprehensive nursing service ward, the total score on the Nurses' Assessment of Quality Scale, job satisfaction, and patient satisfaction scores were higher than in the non-comprehensive nursing service ward. Moreover, turnover intention was lower. All differences were statistically significant. The results of this study demonstrate that the decision to implement policy-based comprehensive nursing services has thus far been beneficial. In the future, the government should revise and supplement its policies through various socioeconomic assessments.

Considerations for Postacute Rehabilitation for Survivors of COVID-19

Coronavirus disease (COVID-19), the infection caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), was first reported on December 31, 2019. Because it has only been studied for just over three months, our understanding of this disease is still incomplete, particularly regarding its sequelae and long-term outcomes. Moreover, very little has been written about the rehabilitation needs of patients with COVID-19 after discharge from acute care. The objective of this report is to answer the question "What rehabilitation services do survivors of COVID-19 require?" The question was asked within the context of a subacute hospital delivering geriatric inpatient and outpatient rehabilitation services. Three areas relevant to rehabilitation after COVID-19 were identified. First, details of how patients may present have been summarized, including comorbidities, complications from an intensive care unit stay with or without intubation, and the effects of the virus on multiple body systems, including those pertaining to cardiac, neurological, cognitive, and mental health. Second, I have suggested procedures regarding the design of inpatient rehabilitation units for COVID-19 survivors, staffing issues, and considerations for outpatient rehabilitation. Third, guidelines for rehabilitation (physiotherapy, occupational therapy, speech-language pathology) following COVID-19 have been proposed with respect to recovery of the respiratory system as well as recovery of mobility and function. A thorough assessment and an individualized, progressive treatment plan which focuses on function, disability, and return to participation in society will help each patient to maximize their function and quality of life. Careful consideration of the rehabilitation environment will ensure that all patients recover as completely as possible.

Difference in Profiles of the Gut-Derived Tryptophan Metabolite Indole Acetic Acid between Transplanted and Non-Transplanted Patients with Chronic Kidney Disease

BACKGROUND

Uremic toxins have emerged as potential mediators of morbidity and mortality in patients with chronic kidney disease (CKD). Indole-3-acetic acid (IAA, a tryptophan-derived uremic toxin) might be a useful biomarker in patients with CKD. The objectives of the present study were to (i) describe IAA concentrations in a cohort of non-transplanted patients with CKD and a cohort of transplanted patients with CKD, and (ii) investigate the possible relationship between IAA levels and adverse outcomes in the two cohorts.

METHODS

Levels of free and total IAA were assayed in the two prospective CKD cohorts (140 non-transplanted patients and 311 transplanted patients). Cox multivariate analyses were used to evaluate the association between IAA levels and outcomes (mortality, cardiovascular events, and graft loss).

RESULTS

In the non-transplanted CKD cohort, free and total IAA increased progressively with the CKD stage. In the transplanted CKD cohort, free and total IAA levels were elevated at the time of transplantation but had fallen substantially at one-month post-transplantation. Indole acetic acid concentrations were lower in transplanted patients than non-dialysis non-transplanted patients matched for estimated glomerular filtration rate (eGFR), age, and sex. After adjustment for multiple confounders, the free IAA level predicted overall mortality and cardiovascular events in the non-transplanted CKD cohort (hazard ratio [95% confidence interval]: 2.5 [1.2-5.1] and 2.5 [1.3-4.8], respectively). In the transplanted CKD cohort, however, no associations were found between free or total IAA on one hand, and mortality, CV event, or graft survival on the other.

CONCLUSION

We demonstrated that levels of IAA increase with the CKD stage, and fall substantially, even normalizing, after kidney transplantation. Free IAA appears to be a valuable outcome-associated biomarker in non-transplanted patients, but-at least in our study setting-not in transplanted patients.

Comparison of the Outcome of Patient Management with Physician Extenders Only and with both Residents and Extenders

This was a retrospective study that aimed to determine the treatment outcome of patients seen in the trauma unit of the Johnson City Medical Center (JCMC). The study included 2844 patients in the trauma registry and evaluated age, sex, injury severity score (ISS), length of stay (LOS) in the intensive care unit (ICU), overall hospital lengths of stay (LOS), ventilator days, discharge disposition, and complications between one group managed by extenders only and the second managed by both residents and extenders. The sample size of the two groups was similar (group one = 1446 and group two = 1398) and the proportions of males and females in the two groups were identical (males = 65%, females = 35%). Both groups had similar mechanisms of injury, although group one had a higher percentage of falls (32.9% vs. 22.03%) and group two had a higher proportion of motor vehicle crash (MVC) traumas (40.41% vs 30%). There was no significant difference in those discharged home and deaths between the two groups. (χ²(1, N = 2258) = 0.04, p = 0.82). Complications showed statistical significance when looking at extenders vs. residents plus extenders for all complications (χ²(7, N = 196) = 38.73, p ≤ 0.0001). It is possible that having extenders only versus both extenders and residents had no significant difference among the patient outcomes based on the variables age, sex, ISS, ICU days, overall hospital LOS, and ventilator days; however, when observing complications between the two groups, it is possible that patients are more likely to have complications due to overall hospital LOS in the residents plus extenders group.