OBJECTIVE:Feminizing frontal cranioplasty (FFC) is an essential technique in feminization of the upper third, often involving the violation of the anterior table of the frontal sinus. Though case reports document frontal sinus complications years after surgery, no studies to date examine the presence of delayed frontal sinus disease on long-term imaging after FFC. STUDY DESIGN:Case series. SETTING:Tertiary care center. METHODS:Adult patients who underwent FFC with type III forehead classification between August 2016 to December 2019 were offered postoperative computerized tomography (CT) scans. Preoperative and postoperative CTs were compared using the Lund-Mackay (LM) scoring system and assessed for frontal sinus disease. Retrospective chart review for demographic data and new diagnoses of sinusitis were extracted. RESULTS:A total of 40 transfeminine patients were included. The average time from surgery to postoperative CT scan was 71 months (median: 67.5 months; range: 56-96 months). The mean preoperative and postoperative total LM scores were 0.98 and 1.05 (P = .83), respectively. The mean frontal sinus-specific preoperative and postoperative LM scores were 0.2 and 0.15 (P = .64), respectively. Though 5 (12.5%) patients exhibited trace frontal sinus mucosal thickening on postoperative CT scans, significant frontal sinus pathology (eg, mucoceles, osteomyelitis, sinocutaneous fistula) was not found in any patient, and none required surgical treatment for sinus-related disease. CONCLUSION:FFC is a relatively safe procedure with low risk for frontal sinus-related complications within the first 6 years after surgery. Continued surveillance should be considered to detect serious frontal sinus pathology that may develop beyond this timeframe.
Background and ObjectivesRecent studies of national stroke door-in-door-out (DIDO) times found that most transfers for acute interventions are not completed within the recommended time frame. There is a critical need for effective emergent transfer protocols to improve outcomes. The Brain Emergency Management Initiative (BEMI) is a stroke transfer protocol connecting patients with acute stroke at spoke sites to a hub center for embolectomy. BEMI has been shown to significantly reduce transfer time metrics through rapid transit activation, CT head/CTA bundling, digital image sharing, standardized documentation, and remote patient admission. In this study, we evaluated the sustainability of BEMI's impact on reduction of these transfer metrics.MethodsWe assessed data for patients transferred for embolectomy in our stroke system. Patients were compared across 3 groups: before the protocol ("pre-BEMI"), the initial year of protocol implementation ("BEMI"), and the contemporaneous 5 years of protocol usage ("BEMI-S") to assess for sustainability. Time metrics assessed include DIDO time, time from treatment decision to groin puncture (TDGP), and a safety outcome of symptomatic ICH (sICH) rate.ResultsFour hundred twenty-nine transfers were evaluated, with a final sample size of 271 patients (pre-BEMI n = 31, BEMI n = 32, BEMI-S n = 208). A significantly shorter median DIDO time was found in the BEMI groups (pre-BEMI median = 143 minutes vs BEMI = 118 minutes, p = 0.015; vs BEMI-S = 97 minutes, p = 2.1e-07). DIDO time also improved significantly from BEMI to BEMI-S groups (118 vs 97 minutes; p = 0.0005). TDGP was significantly reduced in the BEMI and BEMI-S groups compared with the pre-BEMI group (pre-BEMI median = 155 minutes vs BEMI = 130 minutes, p = 0.01; vs BEMI-S = 125 minutes, p = 4.15e-13) but was similar between the BEMI and BEMI-S groups (130 vs 125 minutes, p = 0.89). Symptomatic ICH rates were similar before and immediately after BEMI implementation but significantly reduced in the BEMI-S group (pre-BEMI 12.9%, vs BEMI 15.6%, p = 1, vs BEMI-S 2.4%, p = 0.037; BEMI vs BEMI-S p = 0.014).DiscussionThe BEMI protocol significantly improved transfer (DIDO) time by 46 minutes and treatment time (TDGP) by 25 minutes in our stroke network, showing continuous sustainability. sICH rates significantly lowered by over 10% with continued use of the BEMI protocol. Our protocol builds on similar rapid transfer stroke protocols through incorporating unique features such as air transit, video telestroke specialist evaluation, and rapid on-loading protocols with uniform documentation.
INTRODUCTION:To develop and internally validate electronic health record (EHR)-based machine-learning models to predict worsening heart failure (WHF) events across care settings and all-cause mortality among adults with mild-to-moderate chronic kidney disease (CKD). METHODS:We studied adults with mild-to-moderate CKD [estimated glomerular filtration rate (eGFR) 30-59 ml/min/1.73 m² or eGFR ≥60 with albuminuria] receiving care in a large health system from 2012 to 2021; outcomes were ascertained through 31 December 2022. Primary outcomes were (i) WHF events-outpatient encounters, emergency department (ED)/observation stays, and hospitalizations-identified using a validated natural language processing algorithm, and (ii) all-cause mortality. Models [extreme gradient boosting (XGBoost)] used an 80:20 train-test split and >500 EHR-derived covariates. Discrimination [area under the curve (AUC)] and calibration (slope) were evaluated overall and across subgroups by age, sex, race and ethnicity, and CKD stage. RESULTS:Among 375 495 adults (mean age 64 ± 16 years; 54% women; 53% non-Hispanic White; mean eGFR 76 ± 26 ml/min/1.73 m²), the WHF model achieved AUC 0.887 (95% CI 0.879-0.893) with calibration slope 0.955; the mortality model achieved AUC 0.875 (95% CI 0.868-0.883) with calibration slope 0.914 in the test set. Performance was consistent across age, sex, and race and ethnicity, with a slight decrement as CKD stage worsened. CONCLUSIONS:Electronic health record-based machine-learning models accurately predicted WHF and mortality in mild-to-moderate CKD with strong calibration across key subgroups. These models are positioned for EHR deployment to support risk-stratified cardiovascular-kidney-metabolic care-prioritizing guideline-directed therapies and care pathways for those at highest risk.
Hair Zebras are some of my favorite quiz columns to write because strange hair diagnoses are literally everywhere. This one was inspired by a waiter at a restaurant (pre-COVID, when one could actually go to a restaurant) who had an interesting hair pattern...on his arm! The other was from the desert safari ride in UAE (ISHRS Dubai Regional meeting). Others are combed from the world of online doctor quizzes. Questions 2, 4, and 5 are reproduced from eMPR.com/Haymarket Media, Inc. with permission. None of these will be on the ABHRS exam...test yourself for fun!
BACKGROUND:Despite evidence supporting low-density lipoprotein cholesterol (LDL-C) reduction below 70 mg/dL after a major acute coronary event (MACE), many patients fail to reach this target. METHODS:Retrospective cohort study (baseline 2012-2022) with follow-up through 12/31/2024 (median follow-up: 5.1 years). Participants were 47,416 adults with nonfatal myocardial infarction and/or coronary revascularization discharged on lipid-lowering therapy. Main exposures were LDL-C levels within 1-year postevent and annually for 10 years. Outcomes were incident ASCVD events (myocardial infarction, revascularization, ischemic stroke, CHD death) and composite CVD events (ASCVD, heart failure, peripheral vascular disease, CVD death). RESULTS:The cohort's mean (SD) age was 66 (12) years; 72% were male, and 58% white. In year 1, 12% lacked LDL-C testing; this rose from 44% in year 2% to 64% in year 10. Target LDL-C attainment was 67% in year 1 and 57% to 60% in years 2 to 10. Women and African American patients had lower target attainment. There was a clear upward trend of improved target control over time (58% in 2012, 77% in 2022). Comorbidities, cardiac rehabilitation participation, and adherence to lipid lowering therapy were associated with improved LDL-C control. Achieving LDL-C <70 mg/dL was associated with lower risk of ASCVD (HR 0.79, 95% CI: 0.77-0.82) and composite CVD (HR 0.84, 95% CI: 0.82-0.87); both P < .001. Numbers needed to treat (NNT) to prevent one ASCVD or composite CVD event were 19.7 and 26.3, respectively. CONCLUSIONS:Significant gaps exist in LDL-C monitoring and treatment goal attainment post-MACE. Notable disparities by sex and race/ethnicity were observed. Failure to meet LDL-C targets was associated with a significant increase in ASCVD and CVD risk.
