Trinity Hospital of Augusta

ABSTRACT Introduction: Immune thrombocytopenic purpura (ITP) is an autoimmune disorder characterized by thrombocytopenia in the absence of another cause. Our aim is to analyze mortality trends related to ITP in the United States (US) population from 1999 to 2022. Methods: We extracted age-adjusted mortality rates (AAMR) per 100,000 population for ITP-related deaths in the United States from 1999 to 2022 using the CDC Wide-ranging Online Data for Epidemiologic Research (WONDER) database from 1999 to 2022. AAMRs were stratified by year, gender, race or ethnicity, and geographical distribution. Joinpoint regression was used to calculate annual percent change (APC) and average annual percent change (AAPC) through the Joinpoint Regression Program (V 5.1.0, National Cancer Institute). Results: From 1999 to 2022, a total of 17,069 ITP-related deaths occurred in the US. Males exhibited a higher overall AAMR (0.22) in comparison to females (0.17). NH Whites exhibited the highest overall AAMR (0.20). Stratification by geographical location revealed non-metropolitan areas to have a higher overall AAMR (0.24) than metropolitan areas (0.19). The Midwest exhibited the highest overall AAMR (0.22). Vermont (0.37), Rhode Island (0.35), and North Dakota (0.32) were among the states with the highest overall AAMR, whereas states on the other end of the spectrum included Nevada (0.13), the District of Columbia (0.14) and Louisiana (0.15). Conclusion: The disparities identified in our analysis, particularly among NH Whites, the elderly, and residents of the Midwest and rural areas, suggest underlying healthcare access issues, potential genetic predispositions, and regional differences in treatment strategies.

Abstract Background. In the randomized NAPOLI-1 trial, nanoliposomal irinotecan (Nal-Iri) combined with fluorouracil and folinic acid provided considerable survival increase for patients with metastatic pancreatic ductal adenocarcinomas who had received gemcitabine-based therapy. However, patients included in clinical trials often differ from those encountered in practice. A real-world study was required to assess the efficacy and safety of Nal-Iri in patients with poor prognoses for whom quality of life preservation was essential. Methods. We conducted an observational, retrospective national multicenter phase 4 study of patients with advanced pancreatic cancers treated using Nal-Iri combined with fluorouracil and folinic acid in clinical practice. Overall survival (OS) and progression-free survival (PFS) were estimated using the Kaplan-Meier method. We used a nomogram validated from a concordance index of eight clinicobiological variables to predict OS. Results A total of 58 patients with advanced pancreatic adenocarcinomas who received Nal-Iri combined with fluorouracil and folinic acid in three medical centers between March 2020 and September 2022 were included. The median duration of Nal-Iri treatment was 3.6 (range 1.9–8.8) months. The median follow-up time from the start of first-line treatment was 26.2 (16.5–44.8) months. Of all patients, 20.7% received Nal-Iri in a second-line setting, but most (n = 37 patients; 63.8%) received Nal-Iri in a third-line setting. Forty-two patients (72.4%) had previously been treated with irinotecan. The median OS from the time of Nal-Iri initiation was 6.0 (2.6–13.1) months, and the median PFS was 5.8 (3.2–11.4) months. Patients who received Nal-Iri in a second-line setting exhibited significantly better OS than patients who received Nal-Iri in a third-line setting or later (p < 10− 3). Patients who had previously received irinotecan exhibited significantly lower OS compared with patients who were irinotecan-naïve (p < 10− 3).Our nomogram demonstrated excellent prediction of 6-month and 1-year survivals (p < 10 − 3). Conclusions. Nal-Iri combined with fluorouracil and folinic acid was particularly effective in second-line settings and irinotecan non-pre-treated patients. The nomogram demonstrated excellent prediction of survival under real-world conditions.

INTRODUCTION: Endometriosis is characterized by the presence of endometrial-like tissue outside of the uterus. Definitive diagnosis is made by laparoscopic visualization with confirmatory histopathologic biopsy. In some cases, lesions can be ambiguous or difficult to visualize with traditional white light (WL)-illuminated laparoscopy. The study objective is to evaluate whether the use of indocyanine green (ICG) aids in identification and removal of clear or ambiguous endometriosis lesions, not visualized under traditional WL imaging. METHODS: This is a retrospective chart review of patients with symptoms suspicious for endometriosis where ICG is used during laparoscopy to assist in identification of suspected endometriosis lesions. Data collection includes patient demographics, medical history, surgical history, preoperative symptoms, and localization of lesions. Data will be collected from hospital electronic health record system and from a private practice. RESULTS: In total, 211 suspected lesions were excised, of which 115 had histologically proven endometriosis. 196 lesions were detected using ICG and 112 were confirmed to be endometriosis. These results were statistically significant (P=.024) with a sensitivity of 97.4% and a negative predictive value of 80%, demonstrating that ICG can significantly improve the intraoperative detection of endometriosis lesions. Research is ongoing with more data being collected. Our goal is that the additional data will further strengthen the power of our study. CONCLUSION: Our study shows that ICG fluorescence significantly improves the intraoperative detection and resection of ambiguous or clear endometriosis lesions and improves histopathologic diagnosis when compared to WL imaging. Indocyanine green has the potential to increase the detection of endometriosis and improve patient outcomes.

The cause of death in people affected by sickle cell disease (SCD) is often challenging to define as prior studies have used retrospective or administrative data for analysis. We used a prospective longitudinal registry to assess mortality and clinical co-morbidities among subjects enrolled in the Sickle Cell Disease Implementation Consortium (SCDIC) registry. At enrollment, we collected the following data: patient-reported demographics, SCD phenotype, baseline laboratory values, comorbidities, and current medications. Subjects were followed for a median of 4.7 years before the present analysis. The relationship of clinical co-morbidities (at time of enrollment) to mortality was determined using survival analysis, adjusting for SCD phenotype and gender. There was a total of 2439 people with SCD enrolled in the SCDIC registry. One hundred and twenty-eight participants (5%) died during the observation period (2017-2022). Six people died from trauma and were excluded from further analysis. Proximate cause of death was unwitnessed in 17% of the deaths, but commonest causes of death include cardiac (18%), acute chest or respiratory failure (11%), sudden unexplained death (8%). Enrollment characteristics of the individuals who died (n = 122) were compared to those of survivors (n = 2317). Several co-morbidities at enrollment increased the odds of death on univariate analysis. All co-morbidities were included in a multivariable model. After backward elimination, iron overload, pulmonary hypertension, and depression, remained statistically significant predictors of the risk of death. SCD reduces life expectancy. Improved comprehensive and supportive care to prevent end-organ damage and address comorbidities is needed for this population.

Intrathecal administration of amphotericin B represents an important adjunctive therapy for management of severe fungal meningitis. Intrathecal preparations have traditionally used amphotericin B deoxycholate. Liposomal amphotericin B is an alternative formulation with good clinical outcomes as systemic therapy, but scant data exist investigating intrathecal use. The aim of this exploratorystudy was to evaluate outcomes following intrathecal administration of liposomal amphotericin B for treatment of severe fungal meningitis. A national shortage of amphotericin B deoxycholate necessitated revision of institutional protocols at a southwestern neurosurgical center in Spring 2023. A starting intrathecal daily dose of 0.125-0.5 mg liposomal amphotericin B was recommended (dependent on insertion device), with 0.125-0.25 mg slow titration every 48 h and up to a 2 mg maximum daily dose. Four cases of fungal meningitis treated with adjunctive intrathecal amphotericin B liposomal formulation were reviewed. This included three cases of coccidioidal meningitis and one case of presumed Fusarium solani meningitis following an outbreak. All patients had initial disease improvement following initiation of intrathecal amphotericin B and were able to tolerate long-term therapy. One coccidioidal meningitis patient expired of neurologic complications shortly after being moved from the intensive care unit (ICU) to a floor unit. All other patients were successfully discharged from the hospital. New headache was the only reported adverse effect, which was managed with dose reduction and did not require therapy discontinuation. Liposomal amphotericin B may be feasibly administered intrathecally for the adjunctive treatment of severe fungal meningitis.

Burnout among health care professionals contributes to high job turnover. Within the United States, burnout among specialty palliative care (PC) providers will accentuate provider shortage problems. This systematic review was conducted to answer the question "what is known about burnout among specialty PC providers practicing in the United States?" More specifically, it was designed to identify the rate of burnout and factors that influence or mitigate it among PC nurse practitioners (NPs), physician assistants (PA), and physicians and to inform future research. An electronic literature search of studies conducted in the United States between 2012 and September 2022 was completed in Embase, PubMed, CINAHL, and PsycINFO. Analysis of 14 studies showed that there are five primary themes related to burnout among PC providers: (1) the rate of burnout, (2) the physical, psychological, and clinical manifestations of burnout, (3) predictors of burnout, (4) factors of resiliency, and (5) interventions piloted to decrease burnout. The majority of studies have delineated the physician role but have failed to determine the rate and factors of burnout among PC NPs and PAs. As NPs and PAs are integral to the PC provider workforce, future research should be designed to understand more clearly how burnout affects these two PC roles to inform efforts to sustain the PC workforce.

During fetal life some cardiac defects may lead to diminished left heart growth and to the evolution of a form of hypoplastic left heart syndrome (HLHS). In fetuses with an established HLHS, severe restriction or premature closure of the atrial septum leads to left atrial hypertension and remodeling of the pulmonary vasculature, severely worsening an already poor prognosis. Fetal therapy, including invasive fetal cardiac interventions and non-invasive maternal hyperoxygenation, have been introduced to prevent a possible progression of left heart hypoplasia, improve postnatal outcome, or secure fetal survival. The aim of this review is to cover patient selection and possible hemodynamic effects of fetal cardiac procedures and maternal hyperoxygenation in fetuses with an evolving or established hypoplastic left heart syndrome.