Characterizing MCID and assessing the role of preoperative PROMIS scores in predicting outcomes for reverse total shoulder arthroplasty at 2-year follow-up

BackgroundThe Patient-Reported Outcomes Measurement Information System (PROMIS) has gained more ground as a reliable and efficient means of collecting patient outcomes in different shoulder surgeries. The purpose of this study is to determine if preoperative PROMIS scores are able to predict improvement in postoperative PROMIS scores and anchor this data to determine if a patient will achieve MCID after reverse total shoulder arthroplasty (RTSA). We hypothesize that preoperative PROMIS will significantly correlate, with anchor questions allowing clinicians to predict which patients are most likely to achieve MCID after RTSA.MethodsThree PROMIS CAT forms (PROMIS Upper Extremity Physical Function CAT v2.0 (“PROMIS-UE”), PROMIS Pain Interference v1.1 (“PROMIS-PI”), and PROMIS Depression v1.0 (“PROMIS-D”)) were provided to all patients scheduled to undergo RTSA by board-certified shoulder and elbow surgeons at 1 institution. Demographic data was collected, including age, median household income, zip code, body mass index, sex, smoking status, and race. All patients enrolled in the study were contacted and asked the same 3 anchor questions pertaining to the 3 PROMIS CAT forms above.ResultsA total of 71 patients (52.1% male) were included in our cohort with an average age of 67.8 years (standard deviation, 8.4). Mean follow-up time point was 21.4 months (standard deviation, 9.9) after surgery. Neither preoperative PROMIS-UE, nor preoperative PROMIS-PI showed any significant predictive ability to achieve their respective domain MCIDs (AUC: 0.564 and 0.631, respectively). PROMIS-UE and PROMIS-PI improved to a significant degree at an average 21.4 months postoperatively from 29.2 ± 5.8 and 63.8 ± 4.8 to 39.8.9 ± 8.9 and 50.0 ± 9.7, respectively. Improvements in PRMOIS-D scores were insignificant at average 21.4 months (Baseline: 49.8 ± 8.0 vs. 44.5 ± 9.4 at final follow-up). Using anchor-based analysis to determine MCID, we found the following MCID values for PROMIS-UE, PROMIS-PI, and PROMIS-D: 7.0, -6.6, and -3.9, respectively. ROC analysis revealed MCID values for PROMIS-UE, PI, and D as 7.0, -6.6, and -3.9 respectively (AUC: 0.743, 0.805, 0.601). SCB values for PROMIS-UE, PI, and D were identified as 8.4, -12.1, and -4.0, respectively (AUC: 0.883, 0.932, 0.652).ConclusionsPROMIS-UE and PROMIS-PI questionnaires can adequately assess the symptoms and outcomes of RTSA patients out to two years postoperatively. Preoperative baseline PROMIS-UE, PROMIS-PI, and PROMIS-D scores cannot adequately predict achievement of MCID in patients indicated for primary RTSA when using anchor-based methods at final follow-up, and should not be used to counsel patients on surgery or guide postoperative treatment.Level of EvidenceLevel II; Retrospective Cohort Study     

Fibrosing cholestatic hepatitis after kidney transplantation from HCV‐viremic donors to HCV‐negative recipients: A unique complication in the DAA era

Fibrosing cholestatic hepatitis (FCH) posttransplantation can lead to graft failure and death. In the era of direct acting antiviral therapy (DAA), several studies have demonstrated the efficacy and safety of transplanting hepatitis C virus (HCV)–positive allografts into HCV‐negative recipients. In this case series, we present two cases of HCV‐negative recipients who underwent kidney transplantation from viremic donors and developed FCH. Both patients presented after transplant with abnormal liver function tests and HCV viral loads of greater than 100 000 000 IU/mL. FCH was diagnosed by histology and/or clinical data. Both patients were started on DAA therapy within 24 hours of admission with improvement in LFTs. One patient has undetectable HCV 12 weeks after completing treatment and the other patient has undetectable HCV after completing DAA treatment. The introduction of DAAs has changed the landscape of solid organ transplantation with the potential to expand the donor pool and increase access to organs. While HCV viremic organs have tremendous potential to increase access to a scarce resource, FCH is a potentially fatal complication and therefore clinicians must maintain a high index of suspicion for this unique complication.     

Perioperative Outcomes of Melanoma Patients Undergoing Surgery After Receiving Immunotherapy or Targeted Therapy

World Journal of Surgery - Traditional chemotherapy agents adversely affect wound healing and need to be held prior to or after surgery. Immune checkpoint inhibitors (ICIs) and targeted agents are...     

Optimal cannula positioning of HeartMate 3 left ventricular assist device

Cannula position in HeartMate II and HeartWare left ventricular assist devices (LVADs) is associated with clinical outcome. This study aimed to investigate the clinical implication of the device positioning in HeartMate 3 LVAD cohort. Consecutive patients who underwent HeartMate 3 LVAD implantation were followed for one year from index discharge. At index discharge, chest X-ray parameters were measured: (a) cannula coronal angle, (b) height of pump bottom, (c) cannula sagittal angle, and (d) cannula lumen area. The association of each measurement of cannula position with one-year clinical outcomes was investigated. Sixty-four HeartMate 3 LVAD patients (58 years old, 64% male) were enrolled. In the multivariable Cox regression model, the cannula coronal angle was a significant predictor of death or heart failure readmission (hazard ratio 1.27 [1.01-1.60], P = .045). Patients with a cannula coronal angle ≤28° had lower central venous pressure (P = .030), lower pulmonary capillary wedge pressure (P = .027), and smaller left ventricular size (P = .019) compared to those with the angle >28°. Right ventricular size and parameters of right ventricular function were also better in the narrow angle group, as was one-year cumulative incidence of death or heart failure readmission (10% vs. 50%, P = .008). Narrow cannula coronal angle in patients with HeartMate 3 LVADs was associated with improved cardiac unloading and lower incidence of death or heart failure readmission. Larger studies to confirm the implication of optimal device positioning are warranted.     

Pre-Antiretroviral Therapy Serum Selenium Concentrations Predict WHO Stages 3, 4 or Death but not Virologic Failure Post-Antiretroviral Therapy

A case-cohort study, within a multi-country trial of antiretroviral therapy (ART) efficacy (Prospective Evaluation of Antiretrovirals in Resource Limited Settings (PEARLS)), was conducted to determine if pre-ART serum selenium deficiency is independently associated with human immunodeficiency virus (HIV) disease progression after ART initiation. Cases were HIV-1 infected adults with either clinical failure (incident World Health Organization (WHO) stage 3, 4 or death by 96 weeks) or virologic failure by 24 months. Risk factors for serum selenium deficiency (<85 μg/L) pre-ART and its association with outcomes were examined. Median serum selenium concentration was 82.04 μg/L (Interquartile range (IQR): 57.28–99.89) and serum selenium deficiency was 53%, varying widely by country from 0% to 100%. In multivariable models, risk factors for serum selenium deficiency were country, previous tuberculosis, anemia, and elevated C-reactive protein. Serum selenium deficiency was not associated with either clinical failure or virologic failure in multivariable models. However, relative to people in the third quartile (74.86–95.10 μg/L) of serum selenium, we observed increased hazards (adjusted hazards ratio (HR): 3.50; 95% confidence intervals (CI): 1.30–9.42) of clinical failure but not virologic failure for people in the highest quartile. If future studies confirm this relationship of high serum selenium with increased clinical failure, a cautious approach to selenium supplementation might be needed, especially in HIV-infected populations with sufficient or unknown levels of selenium.     

Graft-versus-tumor response in patients with multiple myeloma is associated with antibody response to BCMA, a plasma-cell membrane receptor

Donor lymphocyte infusions (DLIs) induce effective graft-versus-tumor responses in patients with multiple myeloma who relapse after allogeneic hematopoietic stem-cell transplantation. The graft-versus-myeloma response is presumably mediated primarily by donor T cells, but recent studies have also demonstrated the presence of antibodies specific for a variety of myeloma-associated antigens in patients who achieve complete remission after DLI. One of the B-cell antigens identified in these studies was B-cell maturation antigen (BCMA), a transmembrane receptor of the tumor necrosis factor (TNF) superfamily that is selectively expressed by mature B cells. The present studies were undertaken to characterize the functional significance of antibodies to BCMA in vivo. Using transfected cells expressing BCMA, antibodies in patient serum were found to react with the cell-surface domain of BCMA. Post-DLI patient serum was able to induce complement-mediated lysis and antibody-dependent cellular cytotoxicity (ADCC) of transfected cells and primary myeloma cells expressing BCMA. BCMA antibodies were only found in post-DLI responders and not in other allogeneic transplant patients or healthy donors. These results demonstrate that BCMA is a target of donor B-cell immunity in patients with myeloma who respond to DLI. Antibody responses to cell-surface BCMA may contribute directly to tumor rejection in vivo.