Hartford Hospital is an 938-bed acute care teaching hospital located in the South End of Hartford, Connecticut. Hartford Hospital was established in 1854. The hospital campus is located on Seymour Street in Hartford and is directly adjacent to the main campus of the Connecticut Children's Medical Center. Hartford Hospital was ranked #2 in Connecticut by U.S. News Best Hospitals and ranked #1 in the Hartford, Connecticut metro region by the same source. The hospital is a major tertiary care facility for the statewide region and is state designated as a Level I Trauma Center, able to care for the most critically injured of patients. It has 45 operating rooms and one of the largest surgical caseloads in the United States. The emergency room receives over 100,000 visits per year.
Tandem occlusions (TOs)-concurrent extracranial large artery steno-occlusion and intracranial artery occlusion-represent a challenging clinical predicament. Stroke due to TOs is associated with high mortality and morbidity. Because of increased clot burden compared with single occlusions and impaired anterograde flow, intravenous thrombolysis may be less effective, and outcomes are poor without timely intervention. Endovascular thrombectomy (EVT) has become the cornerstone of intracranial revascularization, but the optimal management of the extracranial carotid lesion remains undefined. Evidence from observational studies and early-phase randomized controlled trials (RCTs) is mixed. Currently, no standardized treatment approach is widely accepted, and practice patterns are guided by personal preference and expert opinion. Ongoing RCTs seek to determine whether there is an optimal approach to EVT in the setting of TO with respect to (a) technique and (b) the order of treatment. Even on completion of active RCTs, a dearth of evidence will remain on the optimal antithrombotic therapy, exact device selection, and EVT in dissection-associated TOs and posterior circulation TOs. In the present narrative review, we critically appraise the literature on the endovascular management of TOs and offer considerations for practice that may help to reduce the burden of tandem occlusion strokes.
The β-lactam/β-lactamase inhibitor (BL/BLI) combination drugs, ceftazidime/avibactam, meropenem/vaborbactam, and imipenem/relebactam, have proven especially useful for treating carbapenemase-producing, carbapenem-resistant organisms (CRO), specifically Klebsiella pneumoniae carbapenemases (KPCs). However, non-KPC mechanisms of resistance are rising in prevalence among Gram-negatives and are increasingly challenging to treat. These newer BL/BLIs, including sulbactam/durlobactam, have an array of activity against mechanisms of carbapenem resistance beyond KPC and therefore play an important role in the treatment of non-KPC carbapenem-resistant organisms. This review, the second in a 2-part series, lays out the non-KPC attributes of the newer BL/BLIs with a focus on clinical utility against Burkholderia cepacia complex, Stenotrophomonas maltophilia, Acinetobacter baumannii, and other rare pathogens.
Peripheral T-cell lymphoma, not otherwise specified (PTCL, NOS) rarely occurs in pediatric and young adult populations, where little is known about its clinicopathologic and molecular features. We characterized 16 cases of PTCL, NOS diagnosed in patients ≤21 years old. Seven (44%) cases demonstrated SMARCB1/INI1 loss by immunohistochemistry and SMARCB1/INI1 alterations by next-generation sequencing, including biallelic SMARCB1/INI1 deletion (n = 4), stop codon variant with 1-copy deletion (n = 1) or copy-neutral loss-of-heterozygosity (n = 1), and frameshift variant (n = 1). One case demonstrated biallelic SMARCE1 alterations (a nonsense variant and copy-neutral loss-of-heterozygosity), which, to our knowledge, has not been previously described in a hematopoietic neoplasm. The SWI/SNF-intact group harbored pathogenic TET2, PTEN, EZH2, or TP53 variants. CDKN2A deletions were present in 3 of 7 SWI/SNF-deficient and 0 of 4 SWI/SNF-intact cases. Chromosome 22q11.2 alterations were present on karyotype in 2 of 3 SMARCB1/INI1-deficient cases. SWI/SNF deficiency was associated with intermediate-to-large cell cytomorphology, frequent mitotic (88%; P = .041) and apoptotic (88%) activity, Reed-Sternberg-like cells (63%), necrosis (50%), and fibrosis (50%). All cases expressed CD45 and CD43 at initial diagnosis. SWI/SNF-deficient cases predominantly demonstrated a CD4+/CD8-, TCRab, and PTCL-GATA3 phenotype, whereas SWI/SNF-intact cases predominantly demonstrated a CD8+/CD4-, TCRgd, and PTCL-TBX21 phenotype. A PTCL-TBX21 phenotype was more common in SWI/SNF-intact than in SWI/SNF-deficient cases (P = .041). Cytotoxic markers were expressed in 71% of SWI/SNF-deficient and 88% of SWI/SNF-intact cases. Decreased or absent CD3 expression characterized 88% of SWI/SNF-deficient and 13% of SWI/SNF-intact cases (P = .01). Moreover, 63% of SWI/SNF-deficient cases demonstrated decreased or absent expression of ≥3 pan-T-cell antigens, compared with 13% of SWI/SNF-intact cases. Treatment was heterogeneous. Primary treatment failure or relapse occurred in 4 of 8 SWI/SNF-deficient and 4 of 7 SWI/SNF-intact cases. The median overall survival and event-free survival were 48.7 and 47.5 months for the SWI/SNF-deficient group, and 16.4 and 8.9 months for the SWI/SNF-intact group (P = nonsignificant). Death due to disease or therapy-related complications occurred in 4 of 8 (50%) cases in the SWI/SNF-deficient group and 6 of 7 (86%) of cases in the SWI/SNF-intact group. Our findings expand the knowledge of the clinicopathologic and molecular features of pediatric PTCL and highlight SWI/SNF-deficient T-cell lymphoma as a biologically distinct type of PTCL that is associated with characteristic clinicopathologic features.
IMPORTANCE:There is a gap in objective methods to review applications for advanced medical training. OBJECTIVE:The objective of this study was to evaluate the accuracy of a new machine learning-based residency and fellowship applicant review program, Halsted (Medicratic) in urogynecology fellowship applicant selection compared with program director (PD) review. STUDY DESIGN:This Institutional Review Board-approved study compared PD's standard assessment of fellowship applicants to the Halsted-based assessment at 3 programs in the 2023-2024 application cycle. Each program provided a score for each candidate on a 100-point scale in several domains. After the conclusion of the match, each PD completed a profile within Halsted that identified their preferred qualities in applicants. Halsted scores were obtained, which were compared with PD scores. RESULTS:A total of 126 applications were reviewed, with 59 applicants reviewed by more than 1 program. Program 1 ( r =0.60; P =0.0019) and Program 2 ( r =0.58; P <0.001) exhibited a significantly strong positive correlation between PD-assigned overall application scores and Halsted scores, while Program 3 exhibited a weak positive correlation between scores ( r =0.33; P =0.0225). There were significant differences in the scoring of the same applicant between programs for PD-assigned mean overall scores ( P <0.001) and Halsted scores ( P <0.001). CONCLUSIONS:A significant positive correlation was found between Halsted rankings of applicants and rankings assigned by PDs. In addition, significant differences in interprogram rankings of applicants suggest that there is a range of qualities that each program values and that application review is individualized. Machine learning assistance in application review is a developing tool with the potential to reduce bias and decrease program administrative burden.
