20966 research outputs found
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Stereotactic radiosurgery for patients with brain metastases: current principles, expanding indications and opportunities for multidisciplinary care
No full textThe management of brain metastases is challenging and should ideally be coordinated through a multidisciplinary approach. Stereotactic radiosurgery (SRS) has been the cornerstone of management for most patients with oligometastatic central nervous system involvement (one to four brain metastases), and several technological and therapeutic advances over the past decade have broadened the indications for SRS to include polymetastatic central nervous system involvement (\u3e4 brain metastases), preoperative application and fractionated SRS, as well as combinatorial approaches with targeted therapy and immune-checkpoint inhibitors. For example, improved imaging and frameless head-immobilization technologies have facilitated fractionated SRS for large brain metastases or postsurgical cavities, or lesions in proximity to organs at risk. However, these opportunities come with new challenges and questions, including the implications of tumour histology as well as the role and sequencing of concurrent systemic treatments. In this Review, we discuss these advances and associated challenges in the context of ongoing clinical trials, with insights from a global group of experts, including recommendations for current clinical practice and future investigations. The updates provided herein are meaningful for all practitioners in clinical oncology
A novel process to reduce the cost of admission for treatment of infected shoulder arthroplasty
No full textBACKGROUND: With the rapidly increasing volume of total joint arthroplasty procedures, the incidence of periprosthetic joint infection (PJI) and its associated economic burden are expected to rise. Two-stage reimplantation, a common strategy for PJI management, is costly, as it requires multiple surgeries and hospitalizations, with total costs ranging from 42,000. Given the long hospital stays required for these patients, a quality improvement project was undertaken at the authors\u27 institution to reduce cost of admission (COA) and length of stay (LOS).
METHODS: We conducted a retrospective review of patients treated for PJI of the shoulder at a single hospital within a large health system. Patients were included if they had a biopsy-proven shoulder PJI treated with 1 of 2 protocols: a conventional, inpatient focused approach or a new, outpatient focused approach. Conventional management involved prosthesis explantation with intraoperative cultures, antibiotic spacer placement, inpatient infectious disease consultation, and inpatient peripherally inserted central catheter placement. The new protocol consisted of outpatient infectious disease clinic referral and peripherally inserted central catheter placement prior to explantation and spacer placement. COA and LOS were compared between the 2 groups.
RESULTS: Sixteen patients were included, 8 in each group. Patients managed with the outpatient-focused protocol had a significantly reduced COA (24,233 ± 4967) with a mean difference of $6521, representing a 26.9% cost reduction per patient (P = .006). LOS was significantly reduced in the outpatient-focused group (median: 1.35 days; interquartile range: 1.21-1.89) compared to the conventional protocol group (median: 2.52 days; interquartile range: 1.81-3.21) (U = 10.50; Z = -2.26; P = .024).
CONCLUSIONS: The pilot quality improvement initiative resulted in a 27% reduction in COA and a significantly reduced LOS for patients with shoulder PJI. This has broad implications across orthopedics for the management of periprosthetic joint replacement and potential for tremendous impact of reducing healthcare costs
Rapid Intrathecal Fluorescein Injection During Cerebrospinal Fluid Leak Repair Is Safe and Effective
No full textOBJECTIVE: Intrathecal fluorescein (IF) is effective for localizing nasal cerebrospinal fluid (CSF) leaks along the skull base during endoscopic exploration, with largest studies reporting sensitivities ranging from 66%-93%. Due to reports of intraoperative and postoperative neurologic complications such as seizures and paralysis, surgeons often dilute the fluorescein and inject it intrathecally slowly over a variable amount of time. However, no study has assessed whether rapid IF administration causes the aforementioned risks or whether it affects its accuracy in identifying CSF leaks intraoperatively.
METHODS: A prospective study was conducted from 2015 to 2024, where all patients undergoing endoscopic exploration and/or repair of CSF rhinorrhea had 0.1 mL of 10% fluorescein (10 mg) mixed with 3-5 mL of patients\u27 CSF injected rapidly via the lumbar drain over a few seconds.
RESULTS: Of the 82 included patients, the mean age was 53.8 ± 15.2 years, and 84% were female. Sixty-nine patients underwent successful endoscopic CSF leak repairs, and 13 had negative endoscopic explorations. Rapid IF injection was 80% sensitive (20% false negative rate) and 100% specific for identifying CSF leaks, and it caused no seizures, paralysis, or other neurologic complications.
CONCLUSION: Compared to prior reports of slow low-dose IF injection for CSF leak localization, rapid IF injection yielded similar efficacy (80% sensitivity) with no IF-related complications. Rapid IF injection was safe and effective but should be corroborated by future studies
Ten-Year Update: The State of Sleep Surgery Training for Otolaryngologists
No full textA decade ago, the field of sleep surgery was on the brink of extinction after changes in certification requirements. Though improving, many otolaryngology programs still do not have dedicated sleep faculty, and residents feel they have not received adequate sleep medicine experience. The field of sleep surgery can expand on a pipeline of sleep-trained otolaryngology fellows by increasing residency exposure to faculty with subcertification in sleep medicine and increasing visibility of fellowship opportunities. Mini-mentorship programs for residents without sleep programs/faculty and inclusion of sleep surgery procedures as key indicator cases during residency may increase interest and exposure to sleep procedures. Maintaining current lists of sleep medicine fellowship programs that include Otolaryngology-Head and Neck Surgery faculty is critical to ensuring accessibility and transparency. Without intervention, the field may be limited to selecting sleep surgery fellows from programs with established sleep surgeons and/or training programs, creating a narrow path for future growth
Invasive ductal carcinoma at the site of a cosmetic nipple piercing
No full textWe report a young female patient diagnosed with an invasive ductal carcinoma at the site of a prior cosmetic nipple piercing. She had no significant familial, genetic, or other carcinogenic risk factors to account for her presentation. A review of the literature confirms that trauma can occasionally be associated with invasive breast cancer, but such a connection has not previously been related to nipple piercing procedures
Language and Memory Network Alterations in Temporal Lobe Epilepsy: A Functional and Structural Connectivity Study
No full textBACKGROUND AND PURPOSE: This study evaluated preoperative alterations and postoperative reorganization of the joint language-memory network (LMN) from the perspective of resting-state functional and structural connectivity in Temporal lobe epilepsy (TLE). Graph theory and machine learning approaches were employed to explore automatic lateralization.
MATERIALS AND METHODS: Resting-state fMRI and DTI data were obtained from 20 healthy subjects and 35 patients with TLE. Functional and structural connectivity were calculated within the LMN before and after temporal lobectomy. ANOVA was performed to identify significant connectivity differences between groups. Four local graph measures were extracted from functional and structural connectivity matrices. Standard feature selection techniques and genetic algorithm (GA) methods were applied to select the optimal features. Subsequently, the K-nearest neighbor, support vector machine (SVM), Naive Bayes, and logistic regression classification methods were used to classify healthy controls (HCs) and pre-surgical TLE groups, as well as pre-surgical left TLE (LTLE) and right TLE (RTLE) groups. Also, relationships between psychological scores and the selected features were evaluated using a linear regression method.
RESULTS: The results demonstrated increased functional and decreased structural connectivity in TLE patients before surgery. After surgery, significant connections revealed reduced functional connectivity and increased structural connectivity in TLE patients. Functional analysis identified the left parahippocampal region in LTLE and the right temporal regions in RTLE as key areas. Structural connectivity analysis showed that memory-related areas in the bilateral occipital region and the left language-related area were the origins of alterations. The GA method achieved the highest classification performance using SVM for fMRI and DTI graph measures, with accuracy rates of 97% and 88% for distinguishing LTLE from RTLE, and 93% and 87% for distinguishing TLE from HC, respectively. Moreover, a significant relationship was observed between the best-selected features and memory-assisted cognitive tests.
CONCLUSIONS: Pre-surgical functional hyperconnectivity and post-surgical hypoconnectivity and also newly observed bilateral postsurgical structural connectivity, highlighting functional and structural alterations in the LMN network. Additionally, the study underscores the potential of machine learning for TLE diagnosis and lateralization. A limited sample size, particularly in the postsurgical group was one of the constraints of this study.
ABBREVIATIONS: TLE=Temporal lobe epilepsy; LMN=Language-memory network; GA=Genetic algorithm; HC=Healthy controls; LTLE=Left TLE; RTLE=Right TLE; AUC=Area under the curve
Neoadjuvant chemotherapy prior to radical nephroureterectomy: Survival outcomes and recurrence patterns by pathologic node status
No full textPURPOSE: To evaluate survival outcomes and recurrence patterns by pathologic nodal status in upper tract urothelial carcinoma (UTUC) patients receiving neoadjuvant chemotherapy (NAC) prior to radical nephroureterectomy (RNU) and lymph node dissection (LND).
MATERIALS AND METHODS: Using the international ROBUUST 2.0 database, a retrospective analysis of UTUC patients who underwent robotic/laparoscopic RNU+LND±NAC was performed. Patients were stratified by NAC and pathologic nodal status into pN0, ypN0, pN+, and ypN+ subgroups. Overall (OS), metastasis-free (MFS), and urothelial recurrence-free survivals (RFS) were compared using Kaplan-Meier curves and multivariable Cox regression modeling.
RESULTS: The cohort included 883 patients (15% received NAC). 212 (24%) patients had (y)pN+ disease. Median follow-up was 19 months. Compared to pN+ patients, ypN+ patients had significantly worse 1- (64% vs. 72%), 3- (40% vs. 54%), and 5-year (20% vs. 31%) OS rates. Node-negative patients had similar OS, irrespective of NAC treatment (1-year: 94%; 3-year: 77%-82%). At 1 year, all ypN+ patients had metastases, while 13% of pN+ patients remained metastasis-free. Among ypN+ patients, 89% experienced nodal/regional or distant metastases as the site of initial recurrence, compared to 39% of pN+ patients. Initial nodal/regional or distant metastases occurred in 42% and 18% of ypN0 and pN0 patients, respectively.
CONCLUSION: ypN+ patients have worse survival compared to pN+ patients. Recurrence patterns differ by nodal and NAC status, with ypN+ patients having a significantly higher incidence of nodal/regional or distant metastases as the initial site of recurrence. These survival outcomes and recurrence patterns differences may have important surveillance and treatment implications
Outcomes of Percutaneous Coronary Intervention in Nonagenarians in the United States
No full textBACKGROUND: Although Percutaneous Coronary Intervention (PCI) is the cornerstone treatment acute myocardial infarction (AMI), its use in the elderly, specifically nonagenarians patients, is not well studied. This study sought to compare the outcomes and complications of nonagenarian patients who experienced AMI between those who underwent PCI and those who underwent medical treatment only.
METHODS: We evaluated 301,440 nonagenarian (ages 90-99) patients who presented to the hospital with AMI who were listed in the National Inpatient Sample from 2016 to 2021. AMI was defined according to the ICD-10 Diagnostic Codes. Multivariable logistic regression analysis was used to examine the association of PCI with primary outcomes of mortality and secondary outcomes. The temporal trend of both the incidence of PCI in nonagenarian patients as well as the mortality rate between 2016 and 2021 were expressed as percentages over time.
RESULTS: Of the total (n = 301,440) nonagenarian patients with AMI, 33,035 patients underwent PCI while 268,406 did not undergo PCI and rather, just utilized optimized medical therapy (OMT). Of these, 3290 (9.96%) died in the PCI group, and 43580 (16.24%) died in the OMT group. All of the secondary outcomes were significantly different between the PCI and OMT groups. Comparing the two groups, the PCI group was associated with decreased mortality (OR 0.63 [95% CI, 0.58-0.69]; p \u3c 0.001), acute heart failure (OR 0.88 [95% CI, 0.82-0.95] p \u3c 0.001), and AKI (OR 0.75 [95% CI, 0.70-0.79]; p \u3c 0.001), and increased cardiogenic shock (OR 3.06 [95% CI, 2.77-3.38]. The temporal of PCI in nonagenarian patients showed an increase in frequency from about 8.3 in 2016 to about 13.7% in 2021. Furthermore, comparing the mortality between the PCI and OMT groups showed a significant difference with a decreased mortality in the PCI group.
CONCLUSIONS: Nonagenarian patients experiencing AMI who underwent PCI is associated with a significant mortality decrease compared to those who underwent OMT only. The PCI group was also associated with a significant decrease in multiple secondary complications including acute heart failure, AKI, acute stroke, and an increase in cardiogenic shock. Temporally, we have seen an increase in PCI being used in nonagenarian patients over the interval
Changes in utilization of in-person and virtual outpatient mental health visits before and during the COVID-19 pandemic: An observational cohort study
No full textWhile depression and anxiety increased with the COVID-19 pandemic, mental health (MH) care access plummeted. This accelerated the uptake of virtual visits, but the degree to which these supplanted in-person visits is unknown. This study aims to assess in-person and virtual MH visits prior to and during the pandemic. Visits from HealthPartners (Minnesota, Wisconsin), Henry Ford (Michigan) and Kaiser Washington (Washington, Oregon) from 2018 to 2022 were stratified by site and study period in this observational cohort study. Segmented linear regression analysis identified changes in the trend over time by detecting optimal breakpoints. A total of 1333,966 patients received MH care. Average monthly MH service utilization was 11% higher from September 2020 to December 2022 compared to calendar year 2019, driven by more patients seeking care. At their peak in mid-2020, virtual visits accounted for 25.6% of visits compared to 1.8% pre-pandemic. MH care utilization increased by the end of 2022 compared to pre-pandemic levels, driven by more people seeking care and supported in part by an increase in virtual visits