Buffalo General Medical Center

Background:Return to play and performance following elbow ulnar collateral ligament (UCL) reconstruction or repair in Major League Baseball (MLB) position players have not been well studied.Purpose:To evaluate return to play and return to performance using modern advanced analytics at 1 and 2 seasons following UCL surgery in MLB position players.Study Design:Cohort study; Level of evidence, 3.Methods:A retrospective analysis was performed on all 33 MLB position players who underwent primary UCL surgery between March 1, 2014, and November 1, 2024. Incidence, risk factors, and return-to-play rates were recorded. Return-to-performance analysis was conducted for 25 players who met the inclusion criteria and were compared to preoperative levels and 50 uninjured matched controls. Performance data were collected for all MLB position players using public sources. Binary logistic regression was also conducted.Results:Incidence of UCL surgery in MLB position players over the full 11-season period (2014-2024) was 2.9 ± 1.4 surgeries per season in our cohort, with an even greater average in the past 5 full seasons compared to 2014 to 2019 (P = .21) and 1984 to 2014 (P < .05). Cases had a significantly greater whiff percentage and fewer outs above average. A total of 81.8% returned to play at 1.5 years postoperatively (mean of 317 ± 111 days). UCL repairs (n = 8) resulted in 121 fewer days missed on average compared to reconstructions (n = 25; P < .01). Notably, position players provided significantly less value (FanGraphs wins above replacement [fWAR]) after returning. There were otherwise no differences in any mean offensive or defensive metric. Controls had higher proportions meeting prior performance levels in nearly every metric for the first and second seasons back. Preinjury weighted runs created plus (wRC+) in cases was the only predictor for returning to performance in fWAR postoperatively.Conclusion:Annual UCL surgery rates in MLB position players have tripled in recent seasons. Less contact and defensive ability were associated with getting UCL surgery. Over 80% of players returned to play by 1.5 years postoperatively, with those who underwent UCL repairs returning faster. Most performance metrics return at high rates, but the significant decline in player value after returning can likely be explained by decreased workload and possibly a slight decline in offensive performance.

Lenalidomide is the preferred treatment for patients with lower-risk MDS and transfusion-dependent anemia. Lenalidomide is not considered a cure for MDS but it has proven to be an effective treatment for lower-risk MDS. We present a patient with lower-risk MDS and transfusion-dependent anemia who not only responded well to lenalidomide therapy but has been transfusion-independent for over 6 years since her treatment with lenalidomide was stopped. Her blood erythrocyte count (hemoglobin level) has been normal since and we consider this to be the first report of a case with MDS being cured by lenalidomide therapy.

IntroductionAntipsychotics are frequently used in hospitalized older adults to manage agitation and delirium, despite limited supporting evidence and known risks. While guidelines recommend low doses and short durations, high doses remain common. This study evaluated the efficacy and safety of low-versus high-dose antipsychotics in hospitalized adults aged ≥ 65 years.MethodsThis retrospective cohort study included patients from two hospitals within a single health system between August 2021 and August 2023. Patients were included if they received inpatient administration of haloperidol, olanzapine, quetiapine, risperidone, or ziprasidone and excluded for prior antipsychotic use, benzodiazepine use, psychiatric comorbidities, or prolonged intensive care unit (ICU) admission. Patients were stratified into low- and high-dose groups. Low doses were haloperidol 0.5–1 mg, olanzapine 2.5–5 mg, quetiapine 12.5–25 mg, risperidone 0.25–1 mg, or ziprasidone 10–20 mg, and doses were considered high if they were above the criteria for a low dose. The primary outcome was a surrogate marker of efficacy: antipsychotic redosing within 6 h. Secondary outcomes included length of stay (LOS), antipsychotic continuation at discharge, and possible antipsychotic-associated adverse events through 90 days post discharge as assessed through index and readmission records. Multivariable logistic regression was used to assess factors associated with antipsychotic redosing within 6 h.ResultsA total of 305 patients were included (low dose: n = 176; high dose: n = 129). Redosing within 6 h occurred at similar rates in low versus high groups (n = 25 [14.2%] versus n = 18 [14.0%], p = 0.950). Multivariable regression showed haloperidol use (compared with quetiapine) was associated with higher odds of redosing. Adverse event rates were numerically higher in the high-dose group, including a greater incidence of inpatient pneumonia and mortality, though most deaths occurred in patients receiving palliative care.ConclusionsLow- and high-dose antipsychotics demonstrated similar short-term efficacy, but higher doses may carry increased risk of adverse events in hospitalized older adults. Clinicians should prioritize low-dose regimens and evaluate the necessity of antipsychotic use in this vulnerable population.

Beta-blockers are recommended in the first 24 hours after ST-segment elevation myocardial infarction (STEMI) except in those at risk of cardiogenic shock. This retrospective cohort study aimed to assess if early beta-blocker use was associated with cardiogenic shock development in STEMI patients. Cardiogenic shock was assessed in adult patients with STEMI undergoing percutaneous coronary intervention (PCI) with guideline defined risk factors for shock (age above 70 years, systolic blood pressure below 120 mmHg, and heart rate above 120 bpm or below 60 bpm) who did or did not receive a beta-blocker within 24 hours of PCI. Multivariable logistic regression was used to assess the association between cardiogenic shock development and early beta-blocker administration. A total of 216 patients were included, 85 with early beta-blocker administration and 131 without. Patients who received an early beta-blocker versus those who did not had a median (interquartile range) age of 63 (52-71) versus 66 (54-76; P = .2260) and peak troponin of 58.3 (15.0-132.4) ng/mL versus 51.6 (16.6-139.5; P = .9884). Cardiogenic shock occurred in 4.7% (n = 4) patients with early beta-blocker use versus 12.2% (n = 16; P = .0909) without. After backward stepwise logistic regression, early beta-blocker use was not associated with cardiogenic shock (adjusted odd ratio [aOR] 0.334, 95% confidence interval (CI) 0.106-1.047; P = .0599), but those with a peak troponin over 56 ng/mL had an over three-fold increased risk of developing cardiogenic shock (aOR 3.434, 95% CI 1.191-9.902; P = .0224) regardless of beta blocker administration. Early beta-blocker administration in STEMI patients may not be associated with shock development.

This case report presents a rare and intriguing clinical scenario involving a 63-year-old male with recurrent left-sided hydroureteronephrosis, hypertension, and hyperlipidemia presenting with fatigue, dyspnea, and weight loss. Laboratory findings revealed anemia, basophilic stippling, spherocytosis, and nucleated red blood cells on the peripheral blood smear, raising concerns for hemolysis. Concomitant iron deficiency anemia led to further investigations, revealing gastritis and a colonic mass. A CT scan revealed splenomegaly with an accessory spleen. The histopathological evaluation identified splenic marginal zone lymphoma (MZL) - a diagnosis supported by flow cytometry. Simultaneously, the patient was found to have a moderately differentiated colorectal adenocarcinoma on colonoscopy. This unique case highlights a rare synchronous occurrence of invasive colonic adenocarcinoma with splenule MZL, an unprecedented finding in medical literature.

Enoxaparin is a hydrophilic drug with obesity having little effect on its apparent volume of distribution, therefore patients with obesity receiving standard 1mg/kg dosing may be at a higher risk of supratherapeutic dosing. Conversely, dose reducing patients with obesity could place already at risk patients at higher risk of a thrombotic event. Data and recommendations are variable for the most appropriate weight-based dose of therapeutic enoxaparin in obese patients, particularly those a weight > 100kg or a body mass index (BMI) ≥ 40kg/m2. The purpose of this systematic review was to globally evaluate these data to surmise optimal dosing recommendations for patients with obesity. A systematic review of English language studies was conducted and identified articles via Pubmed, EMBASE, and the Cochrane Central Register of Controlled Trials (CENTRAL) searches. Studies were included if they reported therapeutic enoxaparin use in adult patients with a BMI ≥ 40kg/m2 or body weight > 100kg and the percentage of patients achieving a therapeutic anti-Xa based on a weight-based dose or the weight-based dose required to produce a therapeutic anti-Xa level. Therapeutic attainment of anti-Xa levels were assessed across enoxaparin weight-based dosing categories including a very low dose group: < 0.75mg/kg, low dose group: 0.75-0.85mg/kg, and standard dose group: ≥ 0.95mg/kg. Rates of bleeding and thrombosis were also evaluated. A total of eight studies were included. For anti-Xa level assessment, 682 patients were included. A total of 62% of anti-Xa levels were therapeutic in the very low dose group, 66% in the low dose group, and 42% in the standard dose group. Overall rates of total bleeding and thrombosis were assessed in 798 patients. A total of 29 bleedings (3.6%) occurred, and 27 reported a relationship to dose. Most bleedings, 85.2% (n = 23/27), occurred with doses in the standard dose group (≥ 0.95mg/kg). Thrombosis occurred in 5 patients (0.6%). Utilization of a reduced weight-based dosing strategy for therapeutic enoxaparin in obese patients may increase the percentage of patients with a therapeutic anti-Xa level.