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Factors associated with lost to follow-up and delayed follow-up in patients with choroidal nevus
No full textBACKGROUND/OBJECTIVES: Choroidal nevus necessitates regular monitoring due to its potential for malignant transformation. We identified features associated with lost to follow-up (LTFU), delayed follow-up (DFU), and appropriate follow-up (AFU) in choroidal nevus patients.
SUBJECTS/METHODS: This retrospective cohort study analysed 825 adults diagnosed with choroidal nevus between January 1, 2006, and December 31, 2015, in Olmsted County, Minnesota. Patient demographics, tumour features, and clinical outcomes were assessed according to follow-up status.
RESULTS: Among the patients, 82 (9.9%) were LTFU, 317 (38.4%) had DFU, and 426 (51.6%) had AFU. Comparing groups (LTFU vs. DFU vs. AFU), LTFU patients were younger (mean age 44.5 vs. 53.3 vs. 59.7 years, p \u3c 0.001) and primarily diagnosed by optometrists (64.6% vs. 64.4% vs. 41.1%, p \u3c 0.001) on routine visits (56.1% vs. 69.7% vs. 45.8%, p \u3c 0.001). They had lower Charlson comorbidity index (0.4 vs. 0.5 vs. 0.7, p = 0.005) and less systemic cancer history (9.5% vs. 15.7% vs. 22.7%, p = 0.013). LTFU and DFU had better visual acuity (\u3e20/50) compared to AFU (93.9% vs. 94.6% vs. 88.5%, p = 0.019). AFU had larger tumour dimensions (basal diameter: 2.5 mm vs. 2.3 mm vs. 2.8 mm, p = 0.003; thickness: 0.1 mm vs. 0.1 mm vs. 0.2 mm, p \u3c 0.001). More LTFU patients had a mean initial recommended follow-up time of 12 months compared to DFU and AFU (80.5% vs. 78.9% vs. 74.2%, p \u3c 0.001).
CONCLUSIONS: Factors associated with LTFU in choroidal nevus patients include younger age, lower comorbidity index, absence of cancer history, optometrist diagnosis, routine visit diagnosis, better visual acuity, less suspicious tumour features, and longer follow-up recommendation
The Role of Cytoreductive Nephrectomy in Contemporary Metastatic Renal Cell Carcinoma: An Other-Cause Mortality Match Population-Based Study
No full textOBJECTIVE: A post-hoc analysis of CARMENA trial revealed that cytoreductive nephrectomy (CN) might still be beneficial for selected metastatic renal cell carcinoma (mRCC) patients. However, selection bias influences the choice of patients for CN, typically favoring those in better health and with a lower risk of all-cause mortality. We aimed to evaluate the impact of CN on cancer-specific mortality (CSM), using a cohort of mRCC patients matched for other-cause mortality (OCM).
METHODS: The SEER database was queried to identify patients diagnosed with mRCC and treated with immunotherapy between 2010 and 2017. A Cox regression model calculating OCM was used to create a propensity score match cohort. Cumulative incidence curves depicted, and competing risks multivariable regression tested, the impact of CN versus no-surgery on CSM according to number of metastasis sites.
RESULTS: Our match yielded to 1148 patients equally distributed between CN and no-surgery arm, with no difference in OCM (HR: 0.88, 95% CI: 0.53-1.47, P = .6). When stratifying patients for number of metastases sites, nonsurgery arm was associated with higher CSM rates for patients with 1 (HR: 1.93, 95% CI: 1.54-2.41, P \u3c .001) or 2 sites (HR: 1.54, 95% CI: 1.27-1.86, P \u3c .001). Conversely, no difference in CSM were observed for 3 or more sites (HR: 1.35, 95% CI: 0.93-1.97, P = .1).
CONCLUSIONS: In a matched cohort of mRCC patients treated with immunotherapy and comparable OCM risk, CN provided a CSM advantage for patients with up to 2 metastatic sites. This advantage was not observed in case of 3 or more sites
Supervised Exercise Training Improves Quality of Life in Chronic Heart Failure With Preserved Ejection Fraction: A META-ANALYSIS OF RANDOMIZED TRIALS
No full textPURPOSE: Patients with heart failure with preserved ejection fraction (HFpEF) have significant impairments in patient-reported outcomes (PRO) including physical functioning and quality of life (QOL). We conducted a meta-analysis of randomized clinical trials of supervised exercise training (SET) to examine the efficacy of such training.
METHODS: We included six single-blinded SET trials in patients with HFpEF, defined as a left ventricular EF ≥50%, published since 2010 in which participants were randomized to a facility-based exercise training program or usual care. We identified trials from a 2024 Cochrane review of exercise-based cardiac rehabilitation for adults with heart failure as well as other reviews and meta-analyses in PubMed. We used random effects meta-analysis to estimate the respective SET effects for five endpoints: the 36-Item Short Form Survey (SF-36) Physical Functioning Scale (PFS), the SF-36 Physical Component Summary, the Minnesota Living With Heart Failure Questionnaire (MLWHFQ) total score, the Kansas City Cardiomyopathy Questionnaire (KCCQ) Overall Summary Score, and the KCCQ QOL subscale.
RESULTS: The treatment effect estimate favored SET for all five endpoints. However, the SET effect was only statistically significant for the SF-36 PFS (P \u3c .0001) and the MLWHFQ total score (P = .01).
CONCLUSIONS: This meta-analysis demonstrated clear evidence that patient-reported physical functioning, an outcome that patients with HFpEF identify as a prominent disability, is significantly improved with SET. It also showed consistent improvements across several other multi-dimensional measures of QOL
Effectiveness and Safety of Intramyocardial Needle Ablation for Refractory Ventricular Tachycardia and Premature Ventricular Complexes: A Systematic Review and Meta-Analysis
No full textINTRODUCTION: Intramyocardial needle ablation is a novel technique for treating refractory ventricular tachycardia (VT) and premature ventricular complexes (PVC). However, studies defining the effectiveness and safety of this procedure are limited. This meta-analysis aims to evaluate the safety and effectiveness of needle ablation for VT and PVC refractory to standard ablation.
METHODS: Embase, Ovid (includes Medline), and ClinicalTrials.gov were searched from inception to December 31, 2024. Human studies on needle ablation for recurrent VT and PVC were included. Primary outcome was immediate effectiveness (no immediate post-procedural inducible VT or PVC). Secondary outcomes were long-term effectiveness (no clinical VT or PVC at 6 months) and safety (composite measure of peri- and post-procedural complications).
RESULTS: A total of five studies including 180 patients (140 VT; 40 PVC) were analyzed. Mean ages ranged from 54 to 66 years. Among 129 patients with VT, immediate effectiveness was 75% (95% CI, 54-92; I(2) 80%), and cumulative freedom from clinical VT dropped to 43% at 6 months (95% CI, 35-52; I(2) 0%). Among 40 patients with PVC, immediate effectiveness was 82% (95% CI, 67-94; I(2) 0%), and long-term effectiveness was 76% (95% CI, 61-90; I(2) 0%). Safety outcomes were reported in 19% of patients (95% CI, 13-27; I(2) 0%) and 10% of patients (95% CI 1, 23; I(2) 0%) in the VT and PVC arm, respectively. Death related to ablation was report in 7 patients (5.0%) only in the VT studies.
CONCLUSION: Intramyocardial needle ablation is an emerging alternative approach for refractory VT and PVC ablation, showing cautious but promising results and safety profiles. Prospective studies and an international registry could provide valuable insights needed for optimal patient selection and protocol refinement
Heterogeneity in HeartMate 3 implanting center infection management reveals opportunities for quality improvement and best practice initiatives during left ventricular assist device support
No full textBACKGROUND: There is marked variability in device-related (DR) infection frequencies across HeartMate 3 (HM3) centers. The goal is to correlate center driveline (DL) management and infection mitigation practices with DR-infection development, laying foundation for development of best practice recommendations for one facet of HM3 patient care.
METHODS: Coordinators at 30 HM3 centers were surveyed about center practices for infection prophylaxis, intraoperative DL placement and postoperative care, and infection mitigation. Early (≤90 days) and late (\u3e90 day) center DR-infection frequencies were calculated from Society of Thoracic Surgeons Intermacs data linkage. Correlations between center practice patterns and incident DR-infection were examined with multivariable Cox modeling (clustering adjusted hazard ratio [aHR]).
RESULTS: Within Intermacs (3,725 patients), 1-year freedom from DR-infection was 87% (80.6-87.3%). Initially, DL dressing changes were performed daily, weekly, and variably at 48%, 21% and 31% of centers. After 4 weeks, 57% deescalated dressing changes to weekly. Chlorhexidine cleanser with a silver-impregnated dressing (Chl-Sil) was standard at 52.7% of programs; 47.3% used chlorhexidine alone or other supplies. Use of Chl-Sil was associated with reduced early (aHR 0.48, p=0.004) and late (aHR 0.64, p=0.02) DR-infection while frequent dressing changes conferred higher late DR-infection (aHR 1.4, p=0.05). Antibiotic prophylaxis, DL tunneling, and diabetes practices did not correlate with DR-infection.
CONCLUSIONS: Given the burden of DR-infections, best practice recommendations are needed to standardize care. Application of Chl-Sil DL dressings could be a first step in achieving care standardization, while frequent dressing changes following DL incorporation should be avoided
Neutropenic Fever Secondary to Concurrent Clostridioides difficile Infection and Neutropenic Enterocolitis
No full textNeutropenic enterocolitis (NE), also known as typhlitis, is a life-threatening condition that typically occurs in individuals with severe neutropenia, particularly following recent chemotherapy. It carries a high mortality rate, making rapid identification and treatment essential to prevent serious complications or death. The pathogenesis of NE is not fully understood but is believed to be multifactorial. It involves a sequence of events including cytotoxic drug-induced mucosal injury, microbial invasion of the colonic mucosa, and bowel wall necrosis, all occurring in the context of profound neutropenia, ultimately leading to the clinical manifestation of NE. The resulting colonic wall inflammation makes the bowel highly susceptible to infection by various bacterial and/or fungal pathogens. Common clinical features include neutropenic fever, abdominal pain, diarrhea, and rectal bleeding. Early recognition, initiation of appropriate antibiotic therapy, and supportive care are critical for improving outcomes. In this report, we present the case of a patient with newly diagnosed non-Hodgkin lymphoma who presented with persistent watery diarrhea and was found to have neutropenic fever secondary to concurrent Clostridioides difficile infection and NE
Therapy for Stage IV Non-Small Cell Lung Cancer Without Driver Alterations: ASCO Living Guideline, Version 2025.1
No full textLiving guidelines are developed for selected topic areas with rapidly evolving evidence that drives frequent change in recommended clinical practice. Living guidelines are updated on a regular schedule by a standing expert panel that systematically reviews the health literature on a continuous basis, as described in the ASCO Guidelines Methodology Manual. ASCO Living Guidelines follow the ASCO Conflict of Interest Policy Implementation for Clinical Practice Guidelines. Living Guidelines and updates are not intended to substitute for independent professional judgment of the treating clinician and do not account for individual variation among patients. See appendix for disclaimers and other important information (Appendix 1 and Appendix 2). Updates are published regularly and can be found at https://ascopubs.org/nsclc-non-da-living-guideline
Is There an Association Between Nighttime Correction Scale Insulin and Morning Hypoglycemia in Hospitalized Patients?
No full textBackground: Correction scale insulin therapy is commonly used in hospitals. There is limited data evaluating the relationship between correction scale administration timing and morning hypoglycemic episodes.
Objective: To evaluate the association between morning hypoglycemic episodes in patients who receive their correction scale insulin before meals (AC) or before meals and at bedtime (ACHS).
Methods: This is a single-center, retrospective, cohort study of hospitalized patients with a history of diabetes receiving at least 1 long-acting insulin agent. The primary endpoint was the occurrence of hypoglycemia that occurred in the morning. Secondary endpoints included hyperglycemia, hypoglycemia at any time, glycemic variability (quantified as coefficient of variation, CV), and mortality. Since subjects were not randomly assigned to the exposure, inverse probability of treatment weighting (IPTW) was used to balance factors between the study groups. Multivariable analysis for hypoglycemia was conducted using logistic regression weighted by stabilized IPTW.
Results: A total of 614 subjects were included in the study with 556 subjects in the ACHS group and 58 subjects in the AC group. Significant differences in the frequency of morning hypoglycemia were not observed between the ACHS and AC groups (30.6% vs 32.8%, respectively) and this finding persisted after IPTW (OR 0.89, 95% CI 0.63-1.25). Secondary outcomes (after IPTW) showed less morning hyperglycemia (OR 0.39, 95% CI 0.26-0.60) and hyperglycemia at any time (OR 0.2, 95% CI 0.11-0.38) in the ACHS group. No difference was observed in hypoglycemia at any time (OR 0.8, 0.57-1.12), glycemic variability (P = .99), and mortality was infrequent (0.5% vs 0%).
Conclusion: We did not observe an association between ACHS correction scale and morning hypoglycemia. Hyperglycemia was less frequent in the ACHS group. Our results support the continued use of ACHS correction scale insulin