Background: Convalescent plasma increases SARS-CoV-2 clearance in COVID-19, especially in patients lacking pre-existing antibodies.Research Question: In hospitalized COVID-19 patients receiving convalescent plasma, does conversion to a positive SARS-CoV-2 IgG status provide mortality benefit in patients who lacked SARS-CoV-2 IgG.Study Design and Methods: This observational study included consecutive hospitalized patients with COVID-19 who received convalescent plasma under the Expanded Access Program from April to August of 2020.SARS-CoV-2 N-based IgG antibody ELISA measurements before and after transfusion were recorded.Outcomes of patients without preexisting antibodies who seroconverted immediately after receipt of convalescent plasma were compared to those who did not seroconvert.Hospital mortality was the primary outcome.Results: 275 hospitalized patients received convalescent plasma during the study period.SARS-CoV-2 IgG was collected from 234 patients.110 (47%) patients were seropositive and 124 (53%)were seronegative prior to transfusion.Among the seronegative group, 63 (50.8%) patients seroconverted after plasma transfusion, while 61 (49.2%) remained seronegative despite transfusion.Age, gender, BMI, SOFA scores and receipt of high titer plasma were similar across all subgroups.Seroconversion after transfusion was not associated with survival at hospital discharge (OR 1.9 [CI 0.7-4.9],p = 0.17).Interpretation: Serologic response after transfusion of convalescent plasma is not associated with hospital survival in COVID-19 patients without pre-existing SARS-CoV2 IgG antibodies.

BackgroundTransvenous endomyocardial biopsy is an invasive procedure which is used to diagnose rejection following an orthotopic heart transplant. Endomyocardial biopsy is widely regarded as low risk with all-cause complication rates below 5% in most safety studies. Following transplant, some patients require therapeutic anticoagulation. It is unknown whether anticoagulation increases endomyocardial biopsy bleeding risk.MethodsRecords from 2061 endomyocardial biopsies performed for post-transplant rejection surveillance at our institution between November 2016 and August 2022 were reviewed. Bleeding complications were defined as vascular access-related hematoma or bleeding, procedure-related red blood cell transfusion, and new pericardial effusion. Relative risk and small sample-adjusted 95% confidence interval was calculated to investigate the association between bleeding complications and anticoagulation.Results and ConclusionsThe overall risk of bleeding was 1.2% (25/2061 cases). There was a statistically significant increase in bleeding among patients on intravenous (RR 4.46, CI 1.09-18.32) but not oral anticoagulants (RR .62, CI .15-2.63) compared to patients without anticoagulant exposure. There was a trend toward increased bleeding among patients taking warfarin with INR >= 1.8 (RR 3.74, CI .90-15.43). Importantly, no bleeding events occurred in patients taking direct oral anticoagulants such as apixaban. Based on these results, intravenous rather than oral anticoagulation was associated with a significantly higher risk of bleeding complications following endomyocardial biopsy.

BACKGROUND:Insulin pump use is increasing in frequency among pregnant individuals with type 1 diabetes (T1D). Automated insulin delivery (AID) technologies have not been studied extensively in pregnancy.METHOD:We present a retrospective case series of eight individuals with T1D who used the Tandem t:slim X2 insulin pump (Tandem Diabetes Care, Inc., CA, USA) during pregnancy. Weekly continuous glucose monitor and insulin pump data were analyzed from electronic medical records and data-sharing portals. Safety, glycemic control, and pregnancy outcomes were examined with both the control IQ (CIQ) and basal IQ (BIQ) algorithms.RESULTS:Six CIQ and two BIQ users were studied. The mean glycated hemoglobin (A1C) during pregnancy was 6.1%, and the average time in pregnancy-recommended glycemic range (TIR; 63-140mg/dL) was 67.9%. There were no instances of diabetic ketoacidosis or severe hypoglycemia. CIQ users had a higher mean sensor glucose (127.6 mg/dL) compared to BIQ participants (118.4 mg/dL). However, the average time below range (<63 mg/dL) was 6.1% in BIQ participants compared to 1.5% in CIQ participants. CIQ participants used several strategies to achieve glycemic targets, including daytime use of sleep activity. An increased basal-to-bolus insulin ratio was negatively correlated with TIR (r=-0.415).CONCLUSIONS:Tandem t:slim X2 insulin pumps were safely used during pregnancy in eight individuals with T1D, with variable success in achieving recommended glycemic targets. Further research is needed to understand differences in CIQ and BIQ use in pregnancy. AID device manufacturers must additionally develop further methods to target lower glucose for pregnant users.

Over the last few decades, there has been an increase in the use of a minimally invasive (MIS) approach for complex hernias involving component separation. A robotic platform provides better visualization and mobilization of tissues for component separation. We aim to assess the outcomes of open and robotic-assisted approaches for large VHR utilizing the ACHQC national database. A retrospective review of prospectively collected data from the Abdominal Core Health Quality Collaborative (ACHQC) was performed to include all adult patients who had primary and incisional midline ventral hernias larger than 10 cm and underwent elective open and robotic hernia repairs with mesh from January 2013 to March 2023. Univariate and multivariate analyses were performed comparing Open and Robotic approaches. The ACHQC database identified 5,516 patients with midline hernias larger than 10 cm who underwent VHR. The open group (OG) had 4,978 patients, and the robotic group (RG) had 538. The RG had a higher median BMI (33.3 kg/m2 (IQR 29.8–38.1) vs 32.7 (IQR 28.7–36.6) (p < 0.001). Median hernia width was 15 cm (IQR 12–18) in the OG and 12 cm in the RG (10–14) (p < 0.001). Sublay positioning of the mesh was the most common. The fascial closure was higher in the RG (524; 97

Social media has numerous academic and professional benefits and is increasingly valued within healthcare. MedTwitter is an online community of medical professionals on the X platform (formerly Twitter). Despite MedTwitter’s numerous benefits and far-reaching users, few medical schools teach students about this resource. We addressed this educational gap by implementing a MedTwitter curriculum designed for medical students. Utilizing the principles of Adult Learning Theory (ALT), we developed a 10-h, virtual, self-paced curriculum introducing medical students to MedTwitter and its applications within medicine and education. The curriculum included primary literature, expert commentary, select MedTwitter content, original slideshows, and hands-on MedTwitter activities. Surveys collected qualitative and quantitative data regarding interest, knowledge, perceptions, and comfort with MedTwitter before and after course completion. Forty-three pre-clinical students voluntarily registered; only 26

Background:Cytologically indeterminate thyroid nodules (ITN) pose a management challenge. Here we analyze if adding ultrasound characteristics to Afirma Genome Sequence Classifier (GSC) results increases GSC diagnostic performance. Methods:We retrospectively analyzed 237 GSC-tested Bethesda III/IV ITNs between July 2017 and December 2019 and classified them by American Thyroid Association (ATA) and the Thyroid Imaging Reporting and Data System (TIRADS) of the American College of Radiology. Results:The benign call rate was higher in Bethesda III ITNs with TIRADS <5 vs TIRADS 5 (89% vs 68%. P = .015). The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of GSC in ATA high-risk Bethesda III ITNs vs lower were 100% vs 80% (P = 1), 89.5% vs 91.5% (P = .67), 66.7% vs 25% (P = .13), and 100% vs 99.2% (P = 1), respectively, and for TIRADS 5 vs <5 were 100% vs 80% (P = 1), 88.2% vs 91.4% (P = .65), 71.4% vs 23.5% (P = .06), and 100% vs 99.3% (P = 1). The sensitivity, specificity, PPV, and NPV of GSC in high-risk ATA Bethesda IV ITNs vs lower were 66.7% vs 100% (P = .42), 83.3% vs 85.7% (P = 1), 66.7% vs 64.3% (P = 1), and 83.3% vs 100% (P = .3), respectively, and for TIRADS 5 vs <5 were 66.7% vs 90% (P = .42), 88.9% vs 83.8% (P = 1), 66.7% vs 60% (P = 1), and 88.9% vs 96.9% (P = .39). Conclusion:Sensitivity, specificity, NPV, and PPV of GSC were not significantly different in ATA high-risk and TIRADS 5 ITNs compared to ATA < high-risk and TIRADS 1-4 ITNs.

OBJECTIVE The primary goal of this study was to establish the current microbial trends in vertebral osteomyelitis/ discitis (VOD) amid the opioid epidemic and to determine if intravenous drug use (IVDU) predisposes one to a unique microbial profile of infection. METHODS The authors performed a retrospective cohort study consisting of 1175 adult patients diagnosed with VOD between 2011 and 2022 at a single quaternary center. Data were acquired through retrospective chart review, with pertinent demographic and clinical information collected. RESULTS Staphylococcus aureus was the most cultured organism in both the IVDU and non-IVDU groups at 56.1% and 40.7%, respectively. In the IVDU cohort, Serratia marcescens was the next most prevalently cultured organism at 13.9%. CONCLUSIONS The present study demonstrates that in the IVDU population S. marcescens is an organism of high concern. The potential for Serratia spp. infection should be accounted for when selecting empirical antimicrobial therapy in VOD patients.

INTRODUCTION:We assessed differences in the post-transplant outcomes between COVID-19 vaccinated and unvaccinated Kidney transplant (KTx) recipients.METHODS:We conducted a retrospective, single-center study of 400 KTx from 2/1/2021 to 4/30/2022 with 6-21 months follow-up. Primary outcomes included differences in the incidence of post-transplant COVID-19, ICU admission for COVID-19, death, and graft failure between the two groups. Secondary outcomes were inpatient floor admission, outpatient-management, length of hospital stay during COVID-19 admission. We also reported rejection, DGF, CMV needing treatment, and BK PCR >10 000 in baseline characteristics.RESULT:70.5% (282/400) were fully vaccinated, and 29.5% (118/400) were unvaccinated. 33% (92/282) of vaccinated and 39% (46/118) of unvaccinated patients developed COVID-19 (p-value .03). In both groups, 16% received outpatient treatments for COVID-19. 3% (12/282) of the vaccinated and 8% (11/118) unvaccinated were admitted to the general floors (p-value .06), and 1% (3/282) of the vaccinated and 3.3% (4/118) of the unvaccinated patients needed admission to the ICU (p-value .2). The length of stay was 12 days in both groups. 13/282 (4.6%) vaccinated patients and 7/118 (5.93%) unvaccinated patients died during the follow-up period (p-value = .3). COVID-19 was deemed the etiology of death in 5/13 cases in the vaccinated and 3/7 in the unvaccinated. DGF, rejection, CMV requiring treatment, and BK PCR >10 000 were comparable between groups.CONCLUSION:The incidence of COVID-19 was higher in unvaccinated than in vaccinated KTx. The two groups were not statistically different for other primary outcomes, including the need for hospital admissions (outpatient, general floor, ICU), length of hospital stay, death, and graft failure.

Purpose Transvenous endomyocardial biopsy (EMB) is an invasive procedure which is routinely used in the diagnosis of transplant rejection in patients with orthotopic heart transplant (OHT). EMB is generally regarded as safe, but bleeding complications have been described. It is unknown whether concomitant use of oral anticoagulants (OAC) increases the risk of bleeding in patients undergoing EMB, thus current clinical practice is variable regarding periprocedural anticoagulant continuation. The purpose of this study is to retrospectively evaluate bleeding complications amongst patients undergoing EMB while taking OAC. Methods Patients who underwent EMB for transplant rejection surveillance at The Ohio State University Cardiac Catheterization Laboratory from November 2016 to August 2022 were studied. Patients taking OAC at the time of procedure were identified. Bleeding complications for the entire cohort were determined by reviewing the medical records for access-related hematoma or bleeding, new pericardial effusion, or red blood cell transfusion directly related to the EMB procedure without another cause of bleeding. Results Records of 2,196 EMB amongst 248 post-OHT patients were reviewed. Of these biopsies, 133 were excluded due to aborted procedure or multiple procedures. OAC were administered to 68 patients during the study period (14.4%), with 259 biopsies occurring in patients taking OAC. Of these patients, 142 patients were noted to be taking warfarin. The most common indications for anticoagulation were venous thromboembolism (83.5%) and atrial fibrillation (13.5%). Chart review revealed 25 bleeding events, occurring in 1.2% of all cases. Of the 25 bleeding events, 88% occurred within the first 3 months post-transplant. In the OAC group, two bleeding events were observed compared to 21 events in patients without anticoagulant use (RR 0.65, CI -0.80 - 2.10). Both bleeding events in the OAC group occurred in patients taking warfarin. Complications were also observed in two patients receiving intravenous heparin. In patients taking warfarin, INR ≥ 1.8 was associated with significantly increased bleeding risk (RR 3.82, CI 2.34-5.30) compared to patients without OAC use. Conclusion Based on this retrospective data, the rate of bleeding from EMB is low, occurring in just over 1% of cases. Bleeding risk appears to be highest in the first 3 months following transplant. An INR ≥1.8 was associated with significantly increased risk of bleeding, therefore EMB should be performed only when the risk of delay outweighs bleeding risk in patients taking warfarin with INR ≥1.8.

INTRODUCTION:Alcohol related liver disease (ALD) affects diverse communities with individual and social characteristics that can impact outcomes. The social vulnerability index (SVI) assigns a score between 0 and 1, where higher scores represent an increased risk of social vulnerability. We sought to assess the impact of SVI on outcomes of patients hospitalized with ALD with access to social support services. METHODS AND MATERIALS:Hospitalizations for ALD at our institution between March and August 2019 were reviewed. All patients were assigned an SVI score based on their residential census tract. Per our standard practice, patients were screened by care coordinators to identify needs for rehabilitation counseling, and care coordination after discharge. Demographics, hepatic decompensation, critical care needs, readmission, and mortality were compared. RESULTS:Among 73 patients admitted for alcoholic hepatitis, 32 had a low SVI and 42 had a high SVI. African American patients were more likely to have a higher SVI (35% vs 0%, p=<0.001). No significant difference in outcomes based on SVI was noted. There were 393 patients admitted for alcoholic cirrhosis including 166 with a low SVI and 227 with a high SVI. Patients that were African American (23.6% vs 5.5%, p=<0.001) or disabled (41.4% vs 29.5%, p = 0.008) had a higher SVI. No significant difference in outcomes based on SVI was noted. CONCLUSION:Most patients admitted for ALD had a high SVI; however, SVI did not impact hospitalization outcomes.

Robotic ventral hernia surgery may provide better patient outcomes. Whether it is provided equitably based on race remains unknown. We examined whether patients from the Abdominal Core Health Quality Collaborative who were Black had equitable access to robotic surgery for ventral hernia repair with permanent mesh compared to white counterparts from 2013 to 2023. We performed propensity-score matching to address confounding and then chi-squared testing to examine access to robotic, laparoscopic, and open approaches. Secondary outcomes included 30-day readmissions, complications, and death and 1- and 2-year hernia recurrence and quality of life measured by HerQLes Summary and PROMIS Pain T-Scores analyzed with chi-squared, Fisher exact, and Wilcoxon testing. 2397 patients identified as Black, and 21,900 identified as white. Our propensity-score matched cohort included 2374 Black patients and 7122 white. Black and white groups had the same rates of laparoscopy (15

Background: Morbid obesity, with a body mass index 35 kg/m2, is a commonly used cutoff for denying elective transversus abdominis release. Although obesity is linked to short -term wound morbidity, its effect on long -term outcomes remains unknown, calling into question if a cutoff is justified. We sought to compare 1-year recurrence rates after transversus abdominis release based on body mass index and to evaluate short- and long -term outcomes. Methods: Patients undergoing open, clean transversus abdominis release from August 2014 to January 2022 at our institution with 1-year follow-up completed were identified. Univariate and multivariable analyses were performed to determine the association of body mass index with 90 -day wound events, 1-year hernia recurrence, and hernia-specific quality of life. Covariates included body mass index, diabetes, recurrent hernia, hernia width, fascial closure, surgical site occurrence requiring procedural intervention, previous abdominal wall surgical site infection, infiammatory bowel disease, mesh weight, and mesh-to-hernia size ratio. Results: A total of 1,089 patients were included. Increasing body mass index was associated with surgical site infection (adjusted odds ratio = 1.59; 95% confidence interval, 1.14-1.77; P < .01) and surgical site occurrence (adjusted odds ratio = 1.42; 95% confidence interval, 1.13-1.74; P < .01) but was not associated with surgical site occurrence requiring procedural intervention. Hernia width was associated with surgical site occurrence (adjusted odds ratio = 1.4; 95% confidence interval, 1.08-1.82; P < .01) and surgical site occurrence requiring procedural intervention (adjusted odds ratio = 1.4; 95% confidence interval, 1.08-1.82; P = .01). Hernia recurrence rate at 1 year was lower for the body mass index >= 35 kg/ m2 group (7% vs 12%; P = .02). Hernia width (odds ratio = 1.33; 95% confidence interval, 1.02-1.74; P = .04) was associated with recurrence; body mass index was not (P = .11). Both groups experienced significant improvement in hernia-specific quality of life at 1 year. Conclusion: Morbid obesity is associated with 90 -day wound morbidity; however, short -term complications did not translate to higher reoperation or long -term recurrence rates. The impact of body mass index on hernia recurrence is likely overstated. An arbitrary body mass index cutoff of 35 kg/m2 should not be used to deny symptomatic patients abdominal wall reconstruction. (c) 2023 Elsevier Inc. All rights reserved.

IntroductionSarcoid-like reactions (SLRs) to immune checkpoint inhibitors (ICIs) are a rare but increasingly recognized immune-related adverse event of which the clinical significance is unclear.MethodsWe conducted a retrospective cohort study at a tertiary academic center of consecutive patients who received at least one dose of ICI from 2013-2020. Patient characteristics, risk factors, and outcomes were compared between patients with and without SLR following ICI treatment.ResultsA total of 2963 cancer patients received at least 1 dose of ICI between 2013-2020, and 7 patients (0.24%) developed SLR. There were no significant demographic differences between patients with and without SLR following ICI. SLRs occurred in 5 of 451 (1.07%) melanoma patients and 2 of 840 (0.24%) non-small cell lung cancer patients. Two of the 7 patients had multi-organ SLR, and both were symptomatic requiring systemic corticosteroids and permanent ICI discontinuation, while single organ SLR patients did not require immune suppression. Development of SLR did not appear to have negative impact on cancer progression or overall survival; in fact, a trend towards improved progression-free and overall survival was observed (median time: 1363 days vs 127 days, p = 0.091; 1387 days vs 428.5 days, p= 0.19, respectively).ConclusionsSLRs are a known but understudied complication associated with ICI therapy. Multisystem SLR patients were more symptomatic and required ICI discontinuation and immune suppression. Larger studies are needed to fully evaluate the impact of SLR on cancer outcomes.

Background. Community-acquired respiratory viruses (CARVs) are an important cause of morbidity and mortality in lung transplant (LTx) recipients. Despite routine mask-wearing, LTx patients remain at a higher risk of CARV infection than the general population. In 2019, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the causative agent of COVID-19 and a novel CARV, emerged leading federal and state officials to implement public health nonpharmaceutical interventions (NPIs) to curb its spread. We hypothesized that NPI would be associated with the reduced spread of traditional CARVs. Methods. A single-center, retrospective cohort analysis comparing CARV infection before a statewide stay-at-home order, during the stay-at-home order and subsequent statewide mask mandate, and during 5 mo following the elimination of NPI was performed. All LTx recipients followed by and tested at our center were included. Data (multiplex respiratory viral panels; SARS-CoV-2 reverse transcription polymerase chain reaction; blood cytomegalovirus and Epstein Barr virus polymerase chain reaction; blood and bronchoalveolar lavage bacterial and fungal cultures) were collected from the medical record. Chi-square or Fisher exact tests were utilized for categorical variables. A mixed-effect model was used for continuous variables. Results. Incidence of non-COVID CARV infection was significantly lower during the MASK period than during the PRE period. No difference was noted in airway or bloodstream bacterial or fungal infections, but cytomegalovirus bloodborne viral infections increased. Conclusions. Reductions in respiratory viral infections, but not bloodborne viral infections nor nonviral respiratory, bloodborne, or urinary infections, were observed in the setting of public health COVID-19 mitigation strategies, suggesting the effectiveness of NPI in preventing general respiratory virus transmission.

The incidence of early-onset obesity-related cancers (diagnosed < 50 years) is increasing in the U.S. We examined the reported historical body mass index (BMI) of adults with early and later-onset cancers to explore relation to obesity. We queried the 1999–2018 NHANES database for adults diagnosed with obesity-related cancers (colorectal, non-colorectal gastrointestinal, uterine, breast). We classified early and late-onset cancer based on a diagnosis age of < 50 and ≥ 50 years, respectively. Propensity-weighted analysis was used to compare prior historical BMIs between the matched groups. After weighing, we included 2,966,528 patients with obesity-related cancers, 846,211 (28

Background:Permanent synthetic meshes such as polypropylene (PP) have been utilized for hernia repair for decades, but concerns remain regarding potential long-term, mesh-related complications. A resorbable polymer such as poly-4-hydroxybutyrate (P4HB) represents an alternative with high initial strength, that gradually resorbs, leaving an abdominal wall that is at least as strong as it would be in its native state. We aimed to compare early wound morbidity and clinical outcomes associated with P4HB to traditional, permanent PP in umbilical and small to medium, routine ventral hernias using data from the Abdominal Core Health Quality Collaborative (ACHQC).Methods:Inclusion criteria for the umbilical cohort included: all Centers for Disease Control and Prevention (CDC) wound classes, all Ventral Hernia Working Group (VHWG) hernia grades, and hernia defects <3 cm. The small to medium, routine ventral hernia cohort was limited to CDC class I wounds, VHWG hernia grades I and II, and hernia defects <5 cm. The study group was comprised of P4HB meshes; the comparator group was an aggregate of PP meshes. Clinical outcomes were assessed at 30 days.Results:There was no significant difference in early wound morbidity, readmission, or reoperation between the P4HB and PP cohorts. A small number of patients experienced SSO, with ≤4% requiring procedural intervention. None of the patients (0% in all cases) experienced skin/soft tissue necrosis, infected seroma, infected hematoma, exposed/contaminated/infected mesh, enterocutaneous fistula, graft failure, or pain requiring intervention at 30-days. However, P4HB was associated with significantly greater operative time, length of stay, and use of myofascial release compared to PP (p < 0.05 in all cases).Conclusions:Short-term clinical outcomes associated with resorbable P4HB mesh are comparable to permanent synthetic PP mesh in umbilical and small to medium, routine ventral hernia repairs, despite significant differences in operative time and length of stay. Longer-term follow-up is needed to expand on the clinical relevance of these short-term findings.

Introduction/AimsExome sequencing (ES) has proven to be a valuable diagnostic tool for neuromuscular disorders, which often pose a diagnostic challenge. The aims of this study were to investigate the clinical outcomes associated with utilization of ES in the pediatric neuromuscular clinic and to determine if specific phenotypic features or abnormal neurodiagnostic tests were predictive of a diagnostic result.MethodsThis was a retrospective medical record review of 76 pediatric neuromuscular clinic patients who underwent ES. Based upon clinical assessment prior to ES, patients were divided into two groups: affected by neuromuscular (n = 53) or non-neuromuscular (n = 23) syndromes.ResultsA diagnosis was made in 28/76 (36.8%), with 29 unique disorders identified. In the neuromuscular group, a neuromuscular condition was confirmed in 78% of those receiving a genetic diagnosis. Early age of symptom onset was associated with a significantly higher diagnostic yield. The most common reason neuromuscular diagnoses were not detected on prior testing was due to causative genes not being present on disease-specific panels. Changes to medical care were made in 57% of individuals receiving a diagnosis on ES.DiscussionThese data further support ES as a powerful diagnostic tool in the pediatric neuromuscular clinic and highlight the advantages of ES over gene panels, including the ability to identify diagnoses regardless of etiology, identify genes newly associated with disease, and identify multiple confounding diagnoses. Rapid and accurate diagnosis by ES can not only end the patient's diagnostic odyssey, but often impacts patients' medical management and genetic counseling of families.

Manual ability may be an important consideration when measuring cognition in children with CP because many items on cognitive tests require fine motor skills. This study investigated the association of fine motor dependent (FMD) and fine motor independent (FMI) items within the cognitive domain (COG) of the Bayley Scales of Infant Development-Third Edition (Bayley-III) and Manual Ability Classification System (MACS) in children with cerebral palsy. Children aged 2 to 8 (3.96 ± 1.68) years were included in this study. MACS levels were assigned at baseline. COG was administrated at baseline (n = 61) and nine months post-baseline (n = 28). The 91 items were classified into FMD (52) and FMI (39). Total raw score, FMD, and FMI scores were calculated. The association between MACS and cognitive scores (total, FMD, and FMI) were evaluated using linear regression and Spearman correlation coefficients. We found total, FMD, and FMI scores decrease significantly as the MACS level increases at the baseline. Both FMD and FMI scores decreased as MACS levels increased (worse function). There was a significant difference between the two slopes, with the FMD scores having a steeper slope. Similar patterns were observed nine months post-baseline. Children with lower manual ability scored lower in the cognitive domain at baseline and 9 months post-baseline. The significant difference in the performance of FMD items and FMI items across MACS levels with a steeper slope of changes in FMD items suggests fine motor skills impact cognition.