Toledo Hospital

ABSTRACT Introduction Liver cirrhosis, a complex and progressive disease, imposes a significant global health burden, characterized by irreversible liver tissue scarring and various life-threatening complications. Traditionally linked to factors like chronic alcohol consumption and viral hepatitis infections, the rising prevalence of obesity introduces a new dimension to its etiology. As obesity rates continue to climb worldwide, the confluence of liver cirrhosis and bariatric surgery has become an increasingly pertinent and clinically relevant topic of inquiry. Methods In this study, we aimed to investigate the impact of liver cirrhosis on patients who underwent bariatric surgery, using data from the 2020 National Inpatient Sample (NIS) database. We compared the outcomes of 82,414 patients who had bariatric surgery, stratifying them based on the presence or absence of liver cirrhosis. We assessed baseline demographic characteristics and comorbidities, in-hospital outcomes, and complications related to the surgery. Results Patients with liver cirrhosis who underwent bariatric surgery demonstrated several distinct trends. On average, they were older (mean age 63 years) and predominantly female (52%) compared to those without cirrhosis (mean age 52, 71% female). Furthermore, comorbidities such as hypertension, diabetes with chronic complications, and alcohol abuse were more prevalent in the cirrhosis group. In terms of outcomes, patients with liver cirrhosis faced significantly higher inpatient mortality rates (4%) compared to those without cirrhosis (1%) with p < 0.001. They also experienced a notably longer average length of hospital stay (2.35 days longer, 95% CI: −3.46 --1.25, p < 0.001) and incurred higher hospitalization costs (add AOR and p value here). Additionally, patients with cirrhosis had increased odds of experiencing acute heart failure (adjusted odds ratio: 1.87, 95% CI: 1.14–2.57, p = 0.01) and requiring blood transfusions (adjusted odds ratio: 1.71,95% CI: 1.13–3.09, p = 0.009). Although the adjusted odds ratio for inpatient mortality was higher in cirrhosis patients (1.58, 95% CI: 0.76–3.30, p = 0.21), it did not reach statistical significance. Conclusion This study highlights the substantial impact of liver cirrhosis on post-bariatric surgery outcomes. Patients with cirrhosis who undergo bariatric surgery face higher inpatient mortality rates and a greater risk of complications, particularly acute heart failure and the need for blood transfusions. The longer hospital stays and increased costs further emphasize the challenges in managing this unique patient population. These findings emphasize the need for careful patient selection, risk assessment, and a multidisciplinary approach when considering bariatric surgery for individuals with both liver cirrhosis and obesity.

Our recent study on rescue therapy (RT) utilized data from the prospective Society of Vascular and Interventional Neurology (SVIN) observational registry. The method of patient admission—whether via interhospital transfer or direct admission—is a recognized factor affecting functional outcomes and could have influenced our results. However, in well-developed systems, the addition of intravenous thrombolysis in transfer patients delays thrombectomy but does not affect outcomes.1 As commonly noted in observational studies and emphasized in our limitations, many confounding factors often go unmeasured or unadjusted. These limitations are inherent to observational studies; therefore, our findings should be interpreted with caution and considered preliminary data useful for informing future randomized trials.\nDue to the lack of current guidelines on antiplatelet therapy for refractory mechanical thrombectomy cases, each of the 14 participating centers followed different protocols. This substantial heterogeneity poses a challenge for performing stratified analyses comparing the various antiplatelet protocols. Although small differences in safety might occur, our study, which is a pragmatic registry, indicates that the overall safety rate is similar across protocols. To address different surgical approaches, we compared rescue stenting versus balloon angioplasty alone within the rescue therapy group. Additionally, within the rescue stenting group, we compared the efficacy of self-expandable stents versus balloon-mounted stents.\nThe superiority of functional outcomes in anterior circulation strokes compared to posterior circulation strokes is well-documented in the literature,2 with underlying pathological and physiological differences extensively published.3, 4 In our article, we stratified safety outcomes between anterior and posterior circulation strokes. Posterior circulation strokes have a distinct natural history, which is why clinical outcomes in this population are measured by the proportion of patients with a modified Rankin Scale (mRS) score of 0 to 3, rather than 0 to 2 mRS. Regarding safety outcomes, we found no significant differences, suggesting that these outcomes are unlikely to have influenced our results. The observed differences are more likely due to the severity of the disease and the small sample size.\nSimilar to the presence of unmeasured confounders, the absence of long-term outcomes of RT, such as arterial patency or stroke recurrence, was also mentioned in our study's limitations. We plan to conduct a randomized trial exploring the effects of RT on intracranial atherosclerosis to determine the true impact of this intervention. We appreciate Dr Xu's highly interesting and important comments. Potential Conflicts of Interest\nNone of the authors have any affiliations with commercial firms whose products or services are utilized in this study.

Cervical cancer is an international public health crisis, affecting several hundred thousand women annually. While not universally protective due to other risk factors, many such cases are preventable with vaccination against high-risk serotypes of the human papilloma virus (HPV 6, 11, 16, 18, 31, 33, 45, 53, 58). Advanced-stage and recurrent cervical cancers are typically lethal and have been the focus in recent years of the integration of immune checkpoint inhibitors (CPIs) to improve survival. We have consolidated information regarding the role of the immune system in both disease progression and disease clearance with the aid of targeted therapies and immunotherapeutic agents. Additionally, we have characterized the treatment modalities currently indicated as the standard of care-such as bevacizumab and the immune CPIs-and those recently approved or in development, including Tivdak, Vigil, and chimeric antigen receptor (CAR) T-cells.

A 62-year-old Caucasian man presented with a comminuted subtrochanteric fracture after a low-energy fall. Physical examination postoperatively revealed a firm hard gluteal compartment in the contralateral buttocks. The patient underwent a fasciotomy, using the Kocher-Langenbeck approach, to release the gluteus maximus and lateral thigh fascia. At the most recent 6-month follow-up, gluteal function was intact with no long-term sequelae from compartment syndrome. Prolonged positioning on a fracture table can result in gluteal compartment syndrome of the contralateral extremity.

BACKGROUND:Coronavirus disease 2019 during pregnancy is associated with adverse maternal and neonatal outcomes.The negative impact on pregnant women is not well understood.Our primary objective was to describe and compare the longitudinal maternal, obstetric, and neonatal outcomes Pre-and Post-COVID-19 pandemic onset within a single healthcare system. METHODS:We performed a retrospective chart review of electronic medical records at 4 hospitals for pregnant women who gave birth between March 1, 2019-March 30, 2022.The data was divided into Pre-COVID-19 (March 1, 2019-February 29, 2020) and Post-COVID-19 (March 1, 2020-March 31, 2022).Outcomes for the two groups were compared using a t-test.P≤0.05 was considered significant. RESULTS:The total number of births is N=18956.There were 6166 pregnant women included in the Pre-COVID-19 group and 12790 in the Post-COVID-19 group.The baseline characteristics, including mean maternal age (28.1 vs 28.2 years, p=0.275) and race, were similar.Notably, Post-COVID-19 there were more pregnancies complicated by: gestational diabetes (2.3% vs 2.9%, p=0.015), preterm birth (22.2% vs 23.5%, p=0.039), preeclampsia (1.4% vs 2.2%, p=0.001),HELLP (0.0% vs 0.1%, p=0.043), excessive bleeding (0.1% vs 0.3%, p=0.042), cephalopelvic disproportion (0.3% vs 0.5%, p=0.022), fetal intolerance to labor (4.2% vs 6.1%, p=0.000), and readmission for vaginal bleeding (4.0% vs 7.2%, p=0.049). DISCUSSION & CONCLUSION:The COVID-19 pandemic is associated with worse maternal and neonatal outcomes even if no diagnosis was made at the delivery episode.The large number of patients included, and the population health approach our study followed, are strengths that allow for counseling on pregnancy outcomes in the Post-COVID-19 era.Our study emphasized the epidemiological impact of the pandemic on the pregnant population at our institution and highlights the need for further studies to delineate its underlying pathophysiology.

IntroductionStrokes secondary to large vessel occlusions (LVO) are frequently caused by either atherosclerotic or thromboembolic sources (1). Both genetic and acquired etiologies can lead to elevated serum homocysteine levels causing LVO as recognized in our patient (2). Measuring homocysteine levels and vitamin B12, B6, and folate replacement can reduce the future risk of stroke by ∼25% (3).MethodsA 42‐year‐old male with acute onset right‐sided facial droop, ataxia, gait instability, nausea, and vomiting. PMH: 11 weeks preterm with subtotal colectomy and short gut syndrome, and mild hypertension. No family h/o blood clots. LKW: >24 hours, initial NIHSS 6, required rapid sequence intubation with repeat NIHSS 28, decreased responsiveness, non‐reactive pupils, and ventilatory compromise. PE: decreased arousal and depressed mentation, facial asymmetry, flaccid right upper and lower extremity.ResultsNon‐contrast head CT: a hyperdense basilar artery (fig 1). CT angiogram of head and neck: Left vertebral artery stenosis with diminutive basilar artery. A diagnostic cerebral angiogram with mechanical thrombectomy was performed with TICI 2b recanalization (fig 2). A subsequent MRI brain further confirmed an acute bi‐cerebellar and left pontine ischemic infarct with diffusion restriction on DWI and ADC reversal (fig 1). Lab work: B12 < 50, homocysteine 50.08, methylmalonic acid 38,038, and folate wnl. A transthoracic, transesophageal ECHO with bubble study and a lower extremity doppler ruled out peripheral sources of stroke. He developed malignant cerebral edema requiring decompressive sub‐occipital craniectomy with external ventricular drain (EVD) placement and remained in the Neuro ICU until discharge.Conclusions•A build‐up of hcy (an intermediate product of methionine and cysteine metabolism) can occur de novo via or iatrogenically •This can cause arterial occlusion leading to ischemic strokes and venous thrombosis as seen in our patient. •Serial monitoring of Hcy, MMA, and replacing the deficient vitamins like B12, B6, and folate in these patients can help prevent the chance of ischemic CNS injuries

SARS-CoV-2 vaccinations were found to be highly effective in phase 3 clinical trials. However, these trials have not reported data regarding the subgroup of liver disease or excluded patients with liver disease. The effectiveness of COVID-19 vaccines among liver cirrhosis (LC) patients is unclear. We conducted this meta-analysis to assess the effectiveness of SARS-CoV-2 vaccination in LC patients. A comprehensive literature search was conducted to include all the relevant studies that compared the outcomes of LC patients who received SARS-CoV-2 vaccines vs. unvaccinated patients. Pooled risk ratios (RRs) with 95% confidence intervals (CIs) were calculated by the Mantel-Haenszel method within a random-effect model. Four studies with 51,834 LC patients (20,689 patients received at least one dose vs 31,145 were unvaccinated) were included. COVID-19–related complications, including hospitalization (RR 0.73, 95% CI 0.59–0.91, P = 0.004), mortality (RR 0.29, 95% CI 0.16–0.55, P = 0.0001), and need for invasive mechanical ventilation (RR 0.29, 95% CI 0.11–0.77, P = 0.01), were significantly lower in the vaccinated group compared to the unvaccinated group. SARS-CoV-2 vaccination in LC patients reduced COVID-19–related mortality, intubation, and hospitalization. SARS-CoV-2 vaccination is highly effective in LC. Further prospective studies, preferably randomized controlled trials, are necessary to validate our findings and determine which vaccine is superior in patients with LC.