Publications by Year: 2025

BACKGROUND: The Society for Cardiovascular Angiography & Intervention (SCAI) SHOCK stages classification schema risk-stratifies patients with cardiogenic shock (CS). The updated 2022 SCAI SHOCK stages removed the use of respiratory support, either noninvasive (NIV) or invasive mechanical ventilation (IMV), as a criterion. We sought to investigate the impact of receiving respiratory support on in-hospital mortality for patients with CS stratified by SCAI SHOCK stages.

METHODS: Utilizing a nationally representative database, adults aged ≥18 years admitted from 2015 to 2023 with a diagnosis of CS were used to assess for the association between respiratory support, either NIV or IMV, on the first day of admission, with in-hospital mortality stratified by SCAI SHOCK stages B through E. We utilized inverse probability treatment weighting, adjusting for demographic characteristics, comorbidities, hospital characteristics, and vasoactive/mechanical circulatory support.

RESULTS: We identified 317,325 patients with CS, including 2.4%, 39.0%, 34.2%, and 24.5% with SCAI stages B through E, respectively. Respiratory support was utilized in 38.0% (n = 120,594) of patients, with 5.4% receiving NIV, 33.8% receiving IMV, and 1.1% receiving both on the first day of admission. After inverse probability treatment weighting, respiratory support use remained associated with an increased mortality overall (weighted mean mortality increase of 18.3%; 95% CI, 17.9%-18.7%), when stratified by each SCAI SHOCK stage and in several key sensitivity analyses.

CONCLUSIONS: Compared with patients not receiving respiratory support, the use of respiratory support was associated with an increased mortality for each SCAI stage of CS and could be a simple, easily identifiable CS risk modifier.

Care for patients with chronic limb-threatening ischemia (CLTI) is complex, and it is most effective when conducted with collaboration across multiple specialties. A recent upward trend in major limb amputation among patients with CLTI warrants a renewed effort to optimize care for this multifaceted condition. The Vascular InterVentional Advances (VIVA) Foundation, a not-for-profit 501(c)(3) organization, convened a Vascular Leaders Forum in 2024 to initiate an open, multispecialty discussion about the state of CLTI care in the United States and current challenges around delivery and access to such care. The forum comprised representatives from vascular surgery, interventional cardiology, interventional radiology, vascular medicine, podiatry, regulators, medical device manufacturers, patient advocacy, and the CLTI and CLTI caregiver population. This article explores the central themes of challenges in CLTI care and ways in which collaboration across specialties and care settings could improve CLTI outcomes. In summary, it was recommended that integrated CLTI care teams extend beyond vascular surgery, interventional cardiology, and interventional radiology to include vascular medicine, podiatry, wound care, diabetology, and dietetics. Meeting the increasing demand for CLTI revascularization will require these teams to span tertiary care hospitals, community hospitals, outpatient revascularization clinics, and primary care settings.

BACKGROUND AND OBJECTIVE: Alzheimer's disease and related dementias (ADRDs) are progressive conditions that substantially impact individuals and families. Timely diagnosis and early support are critical for long-term adjustment. However, current dementia care models do not meet needs of patients and families. Dementia care specialists treating individuals with dementia offer unique insight into care needs of diverse groups of patients, families, and healthcare systems that can be used to identify opportunities to improve care. To understand dementia care specialists' impressions of factors impacting ADRD diagnosis and postdiagnosis support, we aimed to identify factors that impact (1) timely and accurate diagnosis, (2) diagnostic disclosure and provision of postdiagnosis support, and (3) patient and care-partner adjustment after diagnosis.

RESEARCH DESIGN AND METHODS: We recruited dementia care specialists treating persons living with dementia (n = 19) from two academic medical centers. Participants completed 60-min qualitative focus groups or individual interviews. Data were analyzed using a hybrid inductive-deductive approach to thematic analysis.

RESULTS: We identified subthemes within three overarching a priori determined themes. Participants highlighted the presence of delays in referrals, time constraints, specialist discomfort, and lack of training as factors impacting the timeliness and accuracy of diagnosis. They also highlighted information needed in disclosure visits, ways of coordinating care, and identifying early support needs. Finally, participants highlighted factors impacting adjustment including families' insight and acceptance, distress, and available resources.

DISCUSSION AND IMPLICATIONS: Our study highlights the challenges dementia care specialist specialists face in delivering early support for individuals and families impacted by ADRDs and suggests avenues for revising existing care models.

BACKGROUND: The significance of foreign body (FB) ingestion in children with Intestinal Failure (IF) is unknown. We aimed to characterize differences in procedural management and clinical outcomes related to gastrointestinal FB removal in pediatric patients with IF compared to children without this condition.

MATERIAL AND METHODS: This ten-year retrospective review utilized electronic healthcare data from a single pediatric center. We evaluated patients who underwent post-esophageal gastrointestinal FB removal procedures between 2011 and 2020 and compared medical history, presentation, procedure type, and procedure outcomes in children with and without IF.

RESULTS: There were 12 patients with IF and 185 controls. All FBs ingested by IF patients carried low intrinsic risk of perforation or obstruction. Esophagogastroduodenoscopy (EGD) was the most common removal procedure in both groups. Patients with IF were more likely to have FBs removed from a post-pyloric location (100 vs. 20.5 %, p < 0.0001), require lower endoscopy (41.7 vs. 9.7 %, p = 0.006), require multiple procedures for definitive removal (41.7 vs. 8.6 %, p = 0.0041), involve > 1 endoscopist or pediatric surgeon (66.7 vs. 7.0 %, p < 0.0001), and require hospital admission (83.3 vs. 28.6 %, p < 0.0001).

CONCLUSION: FB ingestion by children with IF is associated with increased risk of procedural complexity and hospital admission, even when the object's intrinsic risk of gastrointestinal hazard is low. These differences may be related to altered intestinal anatomy and dysmotility. Physicians should consider involvement of an advanced proceduralist during removal. Education to prevent ingestion should be part of routine IF care.

BACKGROUND: Postoperative delirium is a serious yet underrecognized complication affecting diverse surgical populations, with profound implications for morbidity, mortality, and long-term cognitive function. Its prediction remains imprecise, and screening practices vary widely.

METHODS: We conducted a retrospective analysis of the 2021-2023 data from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP). The study included 217,783 adult surgical patients with documented delirium assessment. Patients were categorized as delirium, non-delirium, or unscreened, with an additional 2.7 million unscreened patients analyzed to assess selection bias in screening. The primary outcome was the incidence of delirium. Other outcomes included surgical and medical complications, mortality, length of stay, functional decline, discharge destination and conditions, and perioperative lab values. Multivariable regression models were used to identify independent predictors of delirium and its associated outcomes.

FINDINGS: Delirium screening was performed exclusively in patients aged ≥75 years, accounting for 7.3% of all surgical patients. Screening rates declined with advancing age (44% of patients aged 90+ vs 56% aged 75-79), while the proportion screening positive increased sharply (3.1% at 75-79 years vs 12.8% at ≥90 years). Delirium occurred in 10.6% (n = 23,100) of screened patients. Compared with non-delirium patients, those with delirium were older (mean 81.3 vs 79.9 years, p < 0.0001), more functionally dependent, and had higher ASA class and comorbidity burden. Dementia (37% vs 7.9%, p < 0.0001), recent falls (40% vs 18%, p < 0.0001), and urgent/emergency surgery (55% vs 26%, p < 0.0001) were strongly associated. Each 10-min increase in operative time was seen to independently be associated with 2.3% raised odds of delirium (p < 0.0001). Delirium was independently associated with higher 30-day mortality (OR 3.2, 95% CI 2.9-3.5), reoperation (OR 2.3, 95% CI 2.1-2.5), surgical complications (OR 1.8, 95% CI 1.6-1.9), loss of independence (OR 1.6, 95% CI 1.5-1.7), and reduced odds of home discharge (OR 0.5, 95% CI 0.4-0.5).

INTERPRETATION: Postoperative delirium is an independent predictor of adverse surgical outcomes yet remains substantially under-screened, with disparities across patient groups. These findings underscore the need for standardized, routine screening and targeted prevention strategies to improve perioperative care.

FUNDING: No funding was received for this study.

BACKGROUND: Accurate classification of glioma subtypes is essential for personalized treatment, yet current diagnostic approaches rely on invasive procedures to determine molecular profiles. This study aims to enhance non-invasive glioma classification by integrating metabolic imaging with advanced unsupervised learning.

METHODS: Whole-brain 3D Magnetic Resonance Spectroscopic Imaging (MRSI) was performed at 3 Tesla. From 26 scanned patients, 12 gliomas (5 astrocytomas, 5 oligodendrogliomas, 2 glioblastomas) that passed strict quality-control criteria were included for analysis. Spectral decomposition was performed using Global Non-Negative Matrix Underapproximation (G-NMU), and tumor subtype classification was achieved with Uniform Manifold Approximation and Projection (UMAP) followed by K-means clustering.

RESULTS: The proposed framework was able to classify tumor types with an accuracy of 99.65% and an AUC of 99.07. Clear subtype-specific metabolic fingerprints were validated by hierarchical clustering and UMAP embeddings, emphasizing 2HG, serine, and inositol as important classification drivers.

CONCLUSIONS: This study demonstrates that whole-brain MRSI spectral decomposition based on G-NMU is a reliable non-invasive method for classifying gliomas. In contrast to spectral fitting on prior-knowledge basis sets, G-NMU accurately separates astrocytoma, oligodendroglioma, and glioblastoma by extracting metabolic features without making assumptions about the tumor metabolic composition. These results suggest that integration of metabolic imaging and unsupervised learning into clinical workflows may improve molecular stratification for noninvasive glioma diagnosis.

INTRODUCTION: Point-of-care ultrasound (POCUS) is a valuable tool for clinicians, but little data exists regarding the perceptions of ideal POCUS utilization, as compared to actual use, amongst urologists. We aim to assess how perceptions align or diverge with actual practice.

METHODS: An institutional review board (IRB)-approved survey was developed and disseminated by email to 6 of 8 American Urologic Association Sections, program directors via the Society of Academic Urologists, and to 2 residency programs. The primary outcome was to assess differences in current and perceived optimal use. Data was collected via the University of Iowa RedCap system. Descriptive statistics and Chi-squared analyses were performed.

RESULTS: 184 non-trainees and 41 trainees completed the survey. Rates of current POCUS use were significantly lower than perceived optimal usage for renal (58% to 88%, p < 0.001), testis (37% to 74%, p < 0.001), and penile (19% to 37%, p < 0.001) application amongst the urologic organs. Current use was also lower than perceived optimal use with regard to utilization in the emergency room (16% to 39%, p < 0.001) and for diagnostic purposes (53% to 81%, p < 0.001), regardless of organ focus. Sub-analysis found that trainees, compared to non-trainees, identified the inpatient unit (54% to 18%, p < 0.001) and emergency room (81% to 35%, p < 0.001) as optimal locations for use.

CONCLUSIONS: Perceptions of POCUS use differ between trainees and non-trainees, especially the location of use. These results help identify areas for which training could be focused, as well as highlight the need for further research on generational variation in desired POCUS use.

BACKGROUND: In rural KwaZulu-Natal Province, South Africa, less than 25 % of persons with hypertension have controlled blood pressure. We conducted a formative evaluation of current clinic-based care to identify barriers and facilitators that could impact effective implementation of a community-based hypertension intervention (IMPACT-BP).

METHODS: We conducted individual interviews and group discussions with clinic managers, nurses, community health workers (CHWs), community leaders, and patients to identify barriers and facilitators experienced in clinic-based hypertension care, which could affect the acceptability, feasibility, and implementation of the IMPACT-BP intervention. The Conceptual Model of Implementation Research and the Theoretical Framework of Acceptability guided the design of data collection instruments and analysis. Qualitative data collection was performed by trained social science research assistants, recorded, transcribed, translated, and analyzed using thematic analysis.

RESULTS: Forty-one participants (92 % women) participated in group discussions (n = 32) or individual interviews (n = 9). Barriers to intervention acceptability and feasibility included inadequate levels of staffing, high patient volumes, distrust of CHWs' work at clinics and in the community, and insufficient training and equipment for CHWs. Facilitators included home delivery of medications by CHWs.

CONCLUSIONS: Our findings allowed us to identify specific adaptations to the intervention implementation strategy to make the proposed community-based intervention acceptable and feasible in this setting. Adaptations included employing dedicated CHWs and nurses for trial-related activities, developing an expanded CHW training module on hypertension knowledge, teaching CHWs to measure blood pressure and subsequently train patients to do the same, and training CHWs to educate patients about hypertension management.

DANFLU-1 was an open-label, pragmatic feasibility trial which randomized persons aged 65 to 79 years to high-dose inactivated influenza vaccine (HD-IIV) or standard-dose inactivated influenza vaccine (SD-IIV). The trial found that HDIV was associated with a reduced incidence of death and hospitalization for influenza or pneumonia as compared to SDIV. Bayesian analysis offers a framework for probabilistic interpretation of trial data and provides a method for incorporating prior information into the analysis. This study presents a post-hoc, Bayesian re-analysis of the DANFLU-1 trial. We conducted a Bayesian re-analysis of the DANFLU-1 trial, which randomly assigned 12,477 adults (65-79 years) 1:1 to HDIV or SDIV during the 2021/2022 season. The trial used Danish nationwide registers for data collection including baseline and follow-up data. This re-analysis applied neutral non-informative, evidence-based, and neutral skeptical priors. The evidence-based priors were informed solely by randomized trials published before DANFLU-1. Relative vaccine effectiveness (rVE) with 95% credible intervals (CrI), and posterior probabilities were estimated using Bayesian log-binomial regression models. Probabilities of rVE >0%, 10% and 20% were estimated. The findings were consistent across different priors. There was a greater than 95% probability of any benefit (i.e. rVE >0%) for all-cause mortality and hospitalization due to pneumonia/influenza, regardless of the prior used. For pneumonia/influenza hospitalization, the probabilities of rVE >10% were at least 95% with the non-informative and evidence-based priors, while it was 93.2% with the skeptical prior. For all-cause mortality, the probabilities of rVE > 10% ranged from 91.1% to 98.4% across priors. For the remaining outcomes, including cardiorespiratory hospitalization and any hospitalization, the probabilities of of rVE >10% ranged from 25.0% to 59.0% across priors. This Bayesian re-analysis of DANFLU-1 demonstrated robust results, with high probabilities of any benefit (rVE >0%) for all-cause mortality and hospitalization due to pneumonia/influenza. We also found high probabilities of an rVE > 10% for both outcomes, indicating robust findings supportive of clinical benefit. As a feasibility trial, the findings warrant further Bayesian investigation of adequately powered trials.