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The impact of advancing the standard of care in radiotherapy on operational treatment resources
No full textPURPOSE: To demonstrate the impact of implementing hypofractionated prescription regimens and advanced treatment techniques on institutional operational hours and radiotherapy personnel resources in a multi-institutional setting. The study may be used to describe the impact of advancing the standard of care with modern radiotherapy techniques on patient and staff resources.
METHODS: This study uses radiation therapy data extracted from the radiotherapy information system from two tertiary care, university-affiliated cancer centers from 2012 to 2021. Across all patients in the analysis, the average fraction number for curative and palliative patients was reported each year in the decade. Also, the institutional operational treatment hours are reported for both centers. A sub-analysis for curative intent breast and lung radiotherapy patients was performed to contextualize the impact of changes to imaging, motion management, and treatment technique.
RESULTS: From 2012 to 2021, Center 1 had 42 214 patient plans and Center 2 had 43 252 patient plans included in the analysis. Averaged over both centers across the decade, the average fraction number per patient decreased from 6.9 to 5.2 (25%) and 21.8 to 17.2 (21%) for palliative and curative patients, respectively. The operational treatment hours for both institutions increased from 8 h 15 min to 9 h 45 min (18%), despite a patient population increase of 45%.
CONCLUSION: The clinical implementation of hypofractionated treatment regimens has successfully reduced the radiotherapy workload and operational treatment hours required to treat patients. This analysis describes the impact of changes to the standard of care on institutional resources
Temporal Trends in Infrainguinal Bypass Outcomes: A Comparative Analysis Across Three Eras
No full textObjectives: The declining volume of infrainguinal bypass (IIB) has raised concerns over contemporary outcomes compared to earlier periods. This study compares the outcomes of IIB in the contemporary era to earlier periods when IIB was more widely practiced. Methods: Patients undergoing IIB for peripheral artery disease (PAD) between 2003-2021 were identified in the Vascular Quality Initiative (VQI). Patients were stratified into three groups based on treatment era: early era (2003-2007, E1), intermediate era (2009-2013, E2), and contemporary era (2015-2019, E3). Mantel-Haenszel (MH) test for linear trend was used to test for a linear relationship between era and outcomes. Multivariate Cox regression was used to evaluate the independent association of treatment era with the outcomes of primary patency, reoperation, major amputation, and mortality. Results: A total of 39,538 patients received IIB during this time period. The average number of IIB performed per center dropped from 47.8 IIB/year to 25.3 IIB/year between 2003-2020 (Fig 1). Patients in the latter period (E3) were more likely to have a previous ipsilateral infrainguinal peripheral vascular intervention (P \u3c.001), ipsilateral minor amputation (P \u3c.001), and undergo emergent surgery (P \u3c.001). Over the three time periods, there was a significant decrease in venous conduit use (E1, 71.3%; E2, 60.8%; E3, 55.2%; P \u3c.001). Worse outcomes at 1-year for primary patency (E1, 88.6%; E2, 86.1%; E3, 84.4%; P \u3c.001) and higher rates of reintervention (E1, 12.4%; E2, 15.0%; E3, 15.8%; P =.002) and major amputation (E1, 9.4%; E2, 9.1%; E3, 10.4%; P =.009) were observed. On multivariate Cox- regression, compared to E1 patients, higher hazard of loss of primary patency was observed for both E2 (HR, 1.72; 95% CI, 1.51-1.95) and E3 (HR, 3.67; 95% CI, 3.23-4.17) patients (Table I). In addition, higher re-intervention was observed for both E2 (HR, 1.38; 95% CI, 1.17-1.62) and E3 (HR, 1.41; 95% CI, 1.21-1.66) patients. No difference was seen regarding major amputation and 30-day mortality between the three eras. Conclusions: There is a decline in the mean rate of IIB performed across the centers in the VQI. Patients undergoing IIB for lower extremity PAD in the contemporary era have decreased primary patency compared to those in earlier eras. This decline may stem from decreased technical proficiency associated with lower bypass volume, increased complexity of disease, and decreased use of vein conduits. This study emphasizes the need for further investigation into the factors contributing to the changing landscape of IIB outcomes. [Formula presented] [Formula presented
Brachial Artery to Axillary Vein Dialysis Graft Creation for Salvage After Failed Upper Extremity Dialysis Access
No full textObjectives: Maintaining hemodialysis (HD) access can be challenging in patients with a history of multiple accesses in the ipsilateral extremity. Much effort has been directed at finding reliable alternative access, one of which being a brachial artery to axillary vein graft. Certain techniques have described the axillary vein as the point of outflow in arteriovenous graft (AVG) creation, but questions have been raised in relation to the precise anatomic location of the venous anastomosis. In this clinical case series, we report 20 patients who underwent brachial artery to anatomic axillary vein graft creation with venous outflow medial to the teres major for HD access following failed fistulas and recorded their primary and secondary patencies. Methods: This is a single-institution case series of patients undergoing dialysis graft creation from the brachial artery to the anatomic axillary vein operated on by a single practitioner from 1990 to 2020. The technique of axillary vein exposure required an infraclavicular incision with division of the pectoralis minor tendon. Patient demographics and comorbidities were recorded, and frequency distributions were constructed and presented in the form of percentages. Kaplan-Meier analyses were performed on (a) primary patency (n = 20), and (b) secondary patency (n = 13). Results: The primary patency of brachial artery to axillary vein grafts was 62% at 6 months, 45.7% at 12 months, and 17.1% at 24 months (Fig 1). The secondary patency was 79.3% at 6 months, 51% at 12 months, and 24% at 24 months (Fig 2). On average, patients undergoing this brachial artery axillary vein graft creation had 3.3 ± 0.56 interventions after AVG creation. Conclusions: Brachial artery to axillary vein grafts provide a proximal option for dialysis access when considering an access in the contralateral extremity or a HERO graft. As this technique has been performed in a small series, further data is needed to extrapolate outcomes on a prospective basis. [Formula presented] [Formula presented
Temporal evolution of living donor liver transplantation recipient outcomes – a UNOS registry study
No full textBackground: Living donor liver transplantation (LDLT) is a curative treatment option for several liver diseases and has the potential to eliminate the wait list duration and its associated mortality. We aim to evaluate (1) temporal changes of overall survival (OS), (2) independent predictors for mortality and (3) differences of risk factors over time. Methods: Adult LDLT patients from the United Network for Organ Sharing (UNOS) registry up to 2020 were included. Groups in 5 year intervals were formed. Kaplan-Meyer and multivariate stepwise backward elimination logistic regression analysis were performed. Results: 5,506 LDLT patients (median age 54.0years, 56% male, 81% non-Hispanic White, BMI 26.1kg/m2, 47% blood type O and MELD of 15 at time of transplant) were selected. The cold ischemic time was 1.5hours with in 86.4% a right lobe graft used. The median follow-up was 4.0years. The OS was significantly different between time periods (log-rank p\u3c0.001) (Figure 1). Comparing 1996-2000 to 2016-2020 OS has relatively improved at 1-year by +13% and at 3-year by +17%. Temporal significant changes of the independent predictors for mortality of recipient and donor age, hepatocellular carcinoma with cirrhosis, cholangiocarcinoma, previous transplantation, creatinine, albumin, INR, encephalopathy and length of stay were noted. Conclusions: LDLT is a safe procedure with good short-, middle- and long-term survival rates. Its efficacy has significantly improved despite a temporal increase of risk parameters. These findings suggest that the limit for LDLT in the United States has yet to be met, as this evolving therapeutic option pushes its boundaries. [Formula presented
Robotic distal ureterectomy for high-risk distal ureteral urothelial carcinoma: A retrospective multicenter comparative analysis (ROBUUST collaborative analysis)
No full textIntroduction & Objectives: The role of kidney-sparing surgery (KSS) in patients with high-risk upper urinary tract urothelial carcinoma (UTUC) is controversial. The aim of this study was to assess the outcomes of distal ureterectomy in patients with high-risk distal ureteral tumors. Materials & Methods: The ROBUUST (ROBotic surgery for Upper Tract Urothelial Cancer Study) multicenter international (2015-2022) dataset was used for this retrospective cohort analysis. After identifying high-risk patients with tumors of the distal ureter, the study population was divided into two subgroups according to surgical procedure, robot-assisted distal ureterectomy (RADU) or robot-assisted nephroureterectomy (RANU). A survival analysis of the primary endpoint recurrence-free survival (RFS), defined as the time elapsed between diagnosis and disease recurrence, was performed. Secondary endpoints were metastasis-free survival (MFS), as the time between diagnosis and metastasis onset, and overall survival (OS), as the time between diagnosis and death by any cause. After adjusting for clinical features of the high-risk prognostic group, Cox proportional hazard model was plotted to evaluate significant predictors of time-to-event outcomes. Results: Overall, 477 patients with distal ureteral high-risk UTUC were retrieved, of which 58 received RADU and 419 RANU, respectively, with a mean (±SD) follow-up of 29.6 months (±2.6). No significant difference in terms of baseline features was observed between the two treatment groups, including preoperative serum creatinine (SCr) (p=0.6) and estimated glomerular filtration rate (eGFR) (p=0.1). Mean (±SD) tumor size was significantly higher in the RANU group (2.9 ±2 vs 2.3 ±1.6, p=0.03), even though no difference was observed in the proportion of lesions of ≥2 cm (66.1% vs 58.5%, p=0.3). Likewise, a comparable number of patients had cT≥2 (12.4% vs 8.6%, p=0.4) tumors. At survival analysis a RFS of 8.2 months (±2.6) and 9.3 months (±4) was observed for RADU and RANU, respectively, with no significant difference between the treatment modalities (p=0.6). The two cohorts were comparable also in terms of MFS (p=0.5) and OS (p=0.7). At Cox regression analysis, in each model for the different time-to-event outcomes, the type of surgery was never a significant predictor of worse oncological outcomes. At last follow-up patients undergoing RADU had significantly better post-operative renal function in terms of mean (±SD) eGFR (60.7 ±2.4 vs 52.3 ±4.9, p=0.01). Conclusions: Within the limitations related to the retrospective study design, our findings suggest comparable outcomes in terms of RFS, MFS and OS between RADU and RANU patients, and an advantage of in terms of post-operative renal function preservation. KSS might be considered as a potential option for selected high-risk patients
The role of cytoreductive nephrectomy in metastatic clear cell carcinoma: Analisys of an other-cause mortality matched population from the contemporary immunotherapy era
No full textIntroduction & Objectives: In the recent randomized CARMENA trial, performing cytoreductive nephrectomy (CN) did not improve overall survival in metastatic renal cell carcinoma (RCC) patients treated with Sunitinib. However, this trial raised concerns about possible selection bias of patients with higher metastatic burden and consequent poor prognosis. Conversely, population-based studies showed how patients referred to CN usually have better health status, which reflects in lower risk for any cause of death. We aimed to evaluate the role of CN on cancer-specific mortality (CSM) within an immunotherapy-era cohort of metastatic RCC patients matched for their other-cause mortality (OCM) risk. Materials & Methods: The Surveillance, Epidemiology and End Results Registry was queried to identify \u3e 18 years patients diagnosed with metastatic RCC, between 2010 and 2017. We included only patients treated with immunotherapy. A Cox regression model including treatment type (CN versus no surgery of the primary site) was used to calculate the other-cause mortality (OCM) risk. Therefore, a 1:1 propensity score match was used to create a cohort of metastatic RCC patients, treated or not with CN, having the same OCM risk. Cumulative incidence curves were depicted to assess CSM and OCM, while Fine-Gray regression tested the impact of CN on CSM. Patients were further stratified according to number of metastasis (1, 2 or more than 2 sites) and the same aforementioned analyses were repeated for these sub-cohorts. Results: We identified 3138 patients with metastatic RCC treated with immunotherapy, of whom 1597 (51%) were treated with CN. In the unmatched cohort, 3-years CSM and OCM rates were 80.8% and 15.5% for non-surgery arm respectively, versus 54.3% and 8.4% for CN patients (all p\u3c0.001). Our Cox Regression model matching yielded to 1662 patients equally distributed, with no difference in OCM rate (11.7% vs 10.8%, p=0.8). In the matched cohort, the 3-years CSM was 54.1% for CN patients vs 80.3% in non-surgery arm (p\u3c0.001). At multivariable analysis, patients who did not receive surgery had 1.79-fold higher CSM risk, when compared with those who underwent CN (95% CI: 1.56-2.06, p\u3c0.001). When stratifying patients for metastases sites, patients who did not undergo CN had higher CSM rates when they harboured metastasis in 1 (84.5% vs 70.0%) or 2 sites (87.8% vs 73.4%, all p\u3c0.001). Conversely, no difference in CSM rate where observed for patients with 3 or more metastases sites, regardless of nephrectomy receipt (89.1% vs 86.8%, p=0.06). Conclusions: We evaluate the role of CN in a immunotherapy-era cohort of metastatic RCC, using OCM risk matching as a proxy of similar health status. In this setting, performing CN yielded a survival advantage in patients with low-to intermediate metastatic burden. Conversely, CN did not CSM for patients with widespread metastases
774 Hospital-level variation in cesarean birth after nulliparous term induction of labor
No full textCANCER LETTERS 581 (2024) 216528 216563 TARGETING MITOCHONDRIA IN EOC TO IMPROVE IMMUNITY
No full textSBI Tech Michigan: Optimizing Implementation of Screening and Brief Intervention for Excessive Alcohol Use Among Women of Reproductive Age
No full textAim: Excessive alcohol use has been increasing among women and is associated with negative health outcomes among pregnant and non-pregnant women. Health systems play an important role in addressing alcohol use through their ability to reach non-treatment-seeking women with the help of Screening and Brief Intervention (SBI). Technology-delivered SBI can help mitigate implementation challenges related to traditional, provider-delivered SBI. We describe a program that implemented technology based SBI (eSBI) within women’s health clinics in a large, integrated healthcare system. Methods (Optional): Patients (age 18-45) receiving routine care at Henry Ford Health Women’s Health clinics were offered the option to complete eSBI, which included universal screening for alcohol use and other substance use, in one of two ways: 1) via iPad in clinic waiting areas; 2) via link sent through the patient portal in advance of a visit to complete on their own device. Screening results are populated into the electronic health record for providers to view. Patients who screened positive had the option to connect with a behavioral health clinician. Outcomes of interest include number of clinics adopting eSBI, proportion of patients completing eSBI, and proportion of positive screens receiving brief intervention. Factors impacting implementation were also assessed. Results (Optional): Seven clinics adopted eSBI; however, completion rates were low (8%). Among patients who completed eSBI (n = 333), 29% reported alcohol misuse, 10% reported binge drinking, 28% reported cannabis use, 18% reported tobacco use, 3% reported prescription drug misuse, and 1% reported other drug use. Approximately 60% of those who completed screening opted to receive the brief intervention. Implementation barriers included a lengthy security compliance review process and substantial demands on clinic staff including but not limited to the COVID-19 pandemic. Conclusions: Despite advantages, several barriers impacted widespread adoption of eSBI. Efforts to integrate and streamline staff tasks may help to improve uptake and impact of eSBI. Financial Support: Centers for Disease Control and Prevention (NU84DD000001
Vitreous Metastasis from Cutaneous Melanoma: Diagnosis and Management
No full textPurpose: To report the clinical findings, treatments, and outcomes in a series of patients with vitreous metastasis from cutaneous melanoma.
Methods: This single-center, retrospective, interventional case series included patients with biopsy-confirmed vitreous metastasis from cutaneous melanoma diagnosed between 1997 and 2020. Standard 23- or 25-gauge pars plana vitrectomy was performed for diagnostic sampling. Sclerotomies were treated with double or triple freeze-thaw cryotherapy. Perioperative intravitreal injections of melphalan (32 μg/0.075 mL) were administered, when indicated. Visual acuity, intraocular pressure, and systemic and ocular treatment responses were reported.
Results: Five eyes of five patients with unilateral vitreous metastasis from cutaneous melanoma were identified. The median age at diagnosis was 84 (range, 37–88) years. The median follow-up after ophthalmic diagnosis was 28 (8.5-36) months; one patient did not have a follow-up. The initial visual acuity ranged from 20/30 to hand motions. Baseline clinical findings included pigmented or non-pigmented cellular infiltration of the vitreous (5/5), anterior segment (4/5), and retina (3/5). Four patients had secondary glaucoma. Systemic therapy included checkpoint inhibitor immunotherapy (n=3, all with partial/complete response), systemic chemotherapy (n=2), surgical resection (n=3), and radiation (n=2). The median time from primary diagnosis to vitreous metastasis was 2 (2–15) years. One patient had an active systemic disease at the time of vitreous metastasis. The final visual acuity ranged from 20/40 to no light perception. Ophthalmic treatment included vitrectomy in all five patients, intravitreal administration of melphalan in three, and intravitreal administration of methotrexate in one. One patient required enucleation, and histopathology revealed extensive invasion by melanoma cells.
Conclusions: Vitreous metastasis from cutaneous melanoma can present as a diffuse infiltration of pigmented or non-pigmented cells into the vitreous and may be misdiagnosed as uveitis. Diagnostic pars plana vitrectomy and periodic intravitreal chemotherapy may be indicated