Disease Control and Toxicity Outcomes after Intraoperative HDR Brachytherapy for Neck Recurrences in Patients Previously Irradiated Head and Neck Cancer

PURPOSE/OBJECTIVE(S)

Despite recent advances in local and systemic therapies for head and neck squamous cell carcinomas (HNSCC), the most common types of treatment failure remain local and regional. Patients with HNSCC also have a higher risk of developing secondary head and neck tumors due to a field cancerization phenomenon. Treatment of these recurrences poses a challenge, particularly in patients having previously received full dose external beam radiotherapy (EBRT) to the head and neck region. This study evaluates the clinical outcomes of intraoperative Harrison-Anderson-Mick applicator (HAM) HDR brachytherapy (BT) after salvage neck dissection for neck recurrences in patients previously irradiated for HNSCC.

MATERIALS/METHODS

All patients having received HAM BT for HNSCC neck recurrences at a single institution were identified. Demographic, treatment, disease control and toxicity data were collected retrospectively. Toxicity was graded as per Common Terminology Criteria for Adverse events version 5. The Kaplan Meier method was used to assess overall survival (OS) and ipsilateral regional control (IRC) from the time of HAM BT.

RESULTS

Nineteen patients with regional recurrence of HNSCC were treated with HAM BT Ir-192 between July 2006 and June 2022, with a median follow-up for survival of 51.4 months (range: 2.5-186.7). The median BT dose was 12.5 Gy delivered intraoperatively at 5 mm tissue depth/1 cm from source. Fifteen patients (78.9%) also received postoperative EBRT to a median dose of 46 Gy in 23 fractions and 13 (68.4%) received systemic therapy. Six patients (31.6%) developed ipsilateral neck recurrences (4 who had adjuvant EBRT and 2 who did not), 2 patients had primary site recurrences and 5 patients developed distant metastases. In terms of acute toxicity, 4 patients had grade 3 dysphagia requiring feeding tube (FT) placement and one patient required surgical intervention for wound necrosis. In terms of late toxicity, 2 additional patients required FT placement and 1 was able to have it removed. No grade 4+ late toxicities were noted. The IRC at the site of HAM BT at 1 year was 71.5% and 63.6% at 5 years. The 1-year OS was 81.3% and 5-year OS was 40.9%.

CONCLUSION

Intraoperative HAM BT resulted in favorable rates of IRC with acceptable toxicity in the reirradiation setting for HNSCC.

Tolerability of Metastasis-Directed Stereotactic Body Radiotherapy with Short-Course Triple-Agent Androgen Annihilation Therapy in Recurrent Oligometastatic Prostate Cancer: Secondary Analysis of a Phase II Study

PURPOSE/OBJECTIVE(S)

A majority of patients with oligometastatic prostate cancer experience relapse within 12 months of metastasis-directed therapy. Intense, triple-agent androgen annihilation therapy (AAT) with leuprolide, abiraterone acetate plus prednisone (AAP), and apalutamide may improve efficacy, but long courses of AAT have been shown to be associated with increased rates of grade≥3 toxicity. The purpose of this secondary analysis of this study is to characterize the tolerability of a short, six-month course of AAT added to metastasis-directed therapy.

MATERIALS/METHODS

All 28 patients enrolled on this phase II study were included in this analysis. All patients had oligometastatic prostate cancer after initial radical prostatectomy, defined by the presence of 1-5 extrapelvic metastases on prostate-specific membrane antigen (PSMA) PET/CT. Patients were started on six months of AAT. After the first month, patients received stereotactic body radiotherapy (SBRT) in 1, 3, or 5 fractions to metastases with or without radiotherapy to the prostate bed and pelvic lymph nodes. Physician-scored toxicities were graded according to Common Terminology Criteria for Adverse Events (CTCAE), Version 5.0.

RESULTS

Median follow-up time was 11.4 months. Twenty patients (71.4%) completed AAT with all three agents. Six patients (21.4%) completed six months of therapy but discontinued at least one agent [4 patients (14.3%) discontinued apalutamide, 1 patient (3.6%) discontinued AAP, and 1 patient (3.6%) discontinued both apalutamide and AAP]. Two patients (7.1%) withdrew from the trial due to adverse events and did not complete therapy. Grade 2 and grade 3 toxicity rates from AAT were each 21.4%. Of the 6 cases of grade 3 toxicity, 3 were skin rashes, 2 were hypertension, and 1 was hepatic toxicity. At the time of SBRT, 1 patient had withdrawn from the study and 1 patient declined radiation therapy. All 26 remaining patients completed SBRT. Grade 2 and grade 3 toxicity rates from SBRT were 7.7% and 0%, respectively.

CONCLUSION

A majority of patients were able to tolerate and complete AAT in combination with metastasis-directed SBRT. Some patients experienced acute grade 3 toxicities, the most common being drug-related skin rashes and hypertension. While efficacy data are needed to evaluate the oncologic benefit, these data suggest a short course of AAT is considerably better tolerated than longer courses of AAT, with grade 3 toxicity rates similar to long courses of single-agent androgen deprivation therapy alone.

High-Dose Rate Brachytherapy Alone for Treatment of Unfavorable Intermediate Risk Prostate Cancer: A Propensity-Score Matched Analysis

PURPOSE/OBJECTIVE(S)

To demonstrate the feasibility of high-dose rate brachytherapy (HDR BT) as monotherapy for unfavorable intermediate risk (UIR) prostate cancer by comparing survival outcomes of HDR BT alone against external beam radiation therapy (EBRT) + HDR BT boost, +/- androgen deprivation therapy (ADT) using propensity-score matched (PSM) data.

MATERIALS/METHODS

This retrospective study queried two data registries collecting patient data from 1991 to present. 633 patients with UIR prostate cancer treated with HDR BT alone, HDR BT+EBRT or HDR+EBRT+ADT were included. HDR BT patients received 42-45Gy/6 fractions (fx) or 27 Gy/2 fx. For HDR BT+EBRT, the HDR dose was 20-24 Gy/2 fx, 24 Gy/4 fx, or 15 Gy/1 fx. EBRT patients received 45 Gy/25 fx to the prostate +/- pelvic nodes. GU/GI toxicities were graded according to the Common Terminology Criteria for Adverse Events (CTCAE) v5.0. Time-to-event analyses were carried out to evaluate the relationship between treatments and five primary endpoints of interest: freedom from biochemical recurrence (FFBC), freedom from distant metastasis (FFDM), freedom from local failure (FFLF), cancer specific survival (CSS), and overall survival (OS) at 5 years. PSM was performed with one-to-n matching. Logistic regression was used to estimate the respective propensity scores. The five potential confounders identified were T-stage, Gleason score, pre-treatment PSA, age, and percent positive cores. Balance was checked using the standardized mean difference of covariates. Univariate and multivariate analyses were conducted on the matched data. Toxicity analysis was performed via association between a change in pre- and post-treatment GU/GI toxicity status and the treatment group, as well as incidence of post-treatment severe GI/GU toxicity (grade 3 or higher) and the treatment group.

RESULTS

Univariate analysis with Kaplan-Meier method and log rank test comparison between the three cohorts demonstrated no significant difference in all survival outcomes FFBC, FFDM, FFLF, CSS, OS (p = 0.15, 0.19, 0.29, 0.57, 0.28, respectively). Multivariate analysis with Cox proportional hazard regression showed no differences in HR for FFBC and OS (p = 0.95, 0.11) with addition of EBRT, or with EBRT+ADT (p = 0.17, 0.24); no fit was obtainable for FFDM, CSS, FFLF. Toxicities between the three cohorts were not significantly different when comparing post-treatment and baseline GI/GU symptoms (p = 0.53/1). No Grade 2 or 3 GI toxicities were identified, while 8%/1% HDR patients, 10%/1% HDR+EBRT patients, and 12%/2% HDR+EBRT+ADT patients experienced Grade 2/3 GU toxicities. The incidence of grade 3 or higher GU toxicities between the three groups was not significantly different (p = 0.91).

CONCLUSION

This propensity-score matched study demonstrates the feasibility of HDR BT alone for effective treatment of UIR prostate cancer when compared to HDR+EBRT or HDR+EBRT+ADT, while potentially minimizing the added toxicities of EBRT and the undesirable side effect profile of ADT.

Long COVID prevalence and associated characteristics among a South Alabama population

OBJECTIVES

Long COVID can significantly impact a patient's quality of life. Defined as persistence or emergence of symptoms 4+ weeks after initial COVID-19 diagnosis, long COVID can result in functional impairments, pulmonary issues, and neuropsychiatric conditions, among others. This study aims to identify long COVID risk factors and prevalence in a south Alabama (US) patient population.

STUDY DESIGN

This was a longitudinal cohort study.

METHODS

Postdiagnosis standardized phone interviews (baseline, 6 months, and 12 months) from April 2020 to July 2021 with patients testing positive through a large healthcare system. Interviews gathered data on sociodemographics, comorbidities, acute illness, and long COVID. Relationships between 1+ ongoing symptoms and variables of interest were assessed using a generalized estimating equation to conduct multivariate analysis.

RESULTS

Of the 516 participants, most were female (65%) and African American (57%, n = 293), with a median (interquartile range) age of 41.1 (25.3-54.6) years. Retention was 70% (n = 359) at 6 months and 58% (n = 301) at 12 months. Participants reporting 1+ persistent symptoms were 20% and 17% at 6 and 12 months, respectively. Illness severity (P < 0.0001) and COVID-related emergency room visit with hospital admission at the time of diagnosis (P = 0.0018) were significantly associated with increased long COVID risk.

CONCLUSIONS

This study found substantial rates of long COVID within our population, with stable rates at 6 and 12 months, indicating illness persistence. Our findings support growing concern for long COVID as a persistent issue within the medical community, with potential to impact patient health for years. Larger, more uniform studies are required to further characterize disease risk factors and clinical course to inform the disease management.

New Zealand and Australian MRI technologists' (radiographers) MRI safety knowledge and confidence levels

INTRODUCTION

The MRI technologist (radiographer) is at the frontline of MRI safety decision-making and has the primary responsibility to provide high quality, efficient and safe patient care in the MRI environment. As MRI technology advances and new safety issues emerge, this study aimed to provide a snapshot of the preparedness of MRI technologists in New Zealand (NZ) and Australia to practise confidently and safely.

METHOD

An online questionnaire, administered via Qualtrics and covering a range of MRI safety topics, was distributed in 2018 via the New Zealand MR Users Group, the MRI Australia-NZ Group Facebook, and relevant professional bodies.

RESULTS

A total of 312 MRI technologists attempted the questionnaire, with 246 surveys being fully completed. Of these, 61% (n = 149) were in Australia, 36% (n = 89) in NZ, and 3% (n = 8) from other countries. Findings indicated that current MRI education is preparing MRI technologists in NZ and Australia to practise safely. However, while these technologists are confident in their MRI safety decision-making, accuracy levels within some groups need addressing.

CONCLUSION

To develop a consistent level of safe practice, it is proposed that a minimum level of MRI-specific education is defined and mandated to practise. Continuing professional development focussing on MRI safety must be encouraged and, if audited as part of registration, could also be mandated. Implementation of a supporting regulatory framework similar to NZ is recommended for other countries.

IMPLICATIONS FOR PRACTICE

All MRI technologists are responsible for the safety of their patients and staff. Employers must support and ensure MRI-specific education has been completed. Ongoing engagement in MRI safety events provided by MRI safety experts, professional bodies and/or universities is essential to remain up-to-date.

Higher Complication Rate in COVID-19 Recovered Patients Undergoing Primary Total Joint Arthroplasty

BACKGROUND

There is limited data reviewing complication risks associated with total joint arthroplasty (TJA) after recovering from COVID-19. This study evaluated complications within 90 days of TJA in patients who had a COVID-19 diagnosis at varying intervals prior to surgery vs a non-COVID-19 cohort.

METHODS

A large national database was used to identify patients diagnosed with COVID-19 in the six months prior to total hip arthroplasty (THA) or total knee arthroplasty (TKA). The incidence of complications within 90 days of surgery was recorded and compared to a COVID-19 negative control group matched 1:3 for age range in 5-year intervals, Charlson Comorbidity Index, and sex. There were 7,780 patients included in the study; 5,840 (75.1%) never diagnosed with COVID-19, 1,390 (17.9%) who had a COVID-19 diagnosis 0 to 3 months prior to surgery, and 550 (7.1%) who had a COVID-19 diagnosis 3 to 6 months prior to surgery.

RESULTS

When compared to their COVID negative controls, patients who had a COVID-19 diagnosis 0 to 3 months prior to surgery had significantly higher rates of re-admission (14.0 vs 11.1%, P=.001), pneumonia (2.2 vs 0.7%, P<.001), deep vein thrombosis (3.3 vs 1.9%, P=.001), kidney failure (2.4 vs 1.4%, P=.006), and acute respiratory distress syndrome (1.4 vs 0.7%, P=.01). Patients who had a COVID-19 diagnosis 3 to 6 months prior to surgery had significantly higher rates of pneumonia (2.0 vs 0.7%, P=.002) and deep vein thrombosis (3.6 vs 1.9%, P=.005) when compared to their COVID negative controls.

CONCLUSION

Patients diagnosed with COVID-19 within three months prior to TJA have an increased risk of 90-day postoperative complications. Risk for pneumonia and deep vein thrombosis remains elevated even when surgery was performed as far as 3 to 6 months after COVID-19 diagnosis.

Upper Extremity Arteriovenous Malformation Masquerading as a Biceps Ganglion Cyst

A 71-year-old male presented to the clinic with two multiloculated cystic masses located over the distal bicep of his left upper extremity, causing discomfort when flexing the extremity. Referral and point-of-care ultrasound at an outside location suggested cystic masses that were consistent with that of a ganglion cyst. Physical exam and clinical presentation were also consistent with this diagnosis. Due to the patient's symptomatic presentation, surgical intervention was proposed, and the patient consented. Intraoperatively, it was discovered that the patient's mass was unexpectedly due to an arteriovenous malformation, revealing the importance of careful workup for cystic masses presenting in unusual locations.

The role of pandemic planning in the management of COVID-19 in England from an infection prevention and control perspective: results of a national survey

OBJECTIVES

This national survey aimed to explore how existing pandemic preparedness plans (PPP) accounted for the demands placed on infection prevention and control (IPC) services in acute and community settings in England during the first wave of the COVID-19 pandemic.

STUDY DESIGN

This was a cross-sectional survey of IPC leaders working within National Health Service Trusts or clinical commissioning groups/integrated care systems in England.

METHODS

The survey questions related to organisational COVID-19 preparedness pre-pandemic and the response provided during the first wave of the pandemic (January to July 2020). The survey ran from September to November 2021, and participation was voluntary.

RESULTS

In total, 50 organisations responded. Seventy-one percent (n = 34/48) reported having a current PPP in December 2019, with 81% (n = 21/26) indicating their plan was updated within the previous 3 years. Around half of IPC teams were involved in previous testing of these plans via internal and multi-agency tabletop exercises. Successful aspects of pandemic planning were identified as command structures, clear channels of communication, COVID-19 testing, and patient pathways. Key deficiencies were lack of personal protective equipment, difficulties with fit testing, keeping up to date with guidance, and insufficient staffing.

CONCLUSIONS

Pandemic plans need to consider the capability and capacity of IPC services to ensure they can contribute their critical knowledge and expertise to the pandemic response. This survey provides a detailed evaluation of how IPC services were impacted during the first wave of the pandemic and identifies key areas, which need to be included in future PPP to better manage the impact on IPC services.

Local Anaesthesia for Enzymatic Debridement of Cutaneous Burns: A Prospective Analysis of 27 Cases

Enzymatic debridement (ED) is increasingly used for cutaneous burns. Compared with surgical debridement, ED has better preservation of viable dermis, less blood loss and autografting, however ED is painful. Current recommendations suggest local anaesthesia (LA) is useful for minor burns, but the evidence base is minimal. In our centre, we routinely use LA with good analgesic effect. This study was a single-centre, prospective analysis conducted at the Queen Victoria Hospital (UK). Patients had at least superficial partial thickness burns and received subcutaneous LA prior to ED during a 1-year period (October 2019-September 2020). Pain was assessed using a numeric scale of 1-10, recorded before, during and after the procedure. In total, 27 patients were included (n=17 males) with a median age of 47 (18-88 years). The mean total burn surface area was 1.5% (0.3-5.0). Treated sites included head and neck (1), trunk (5), upper limb (9) and lower limb (16). The most used LAwas bupivacaine 0.25% (n=25), followed by lidocaine 1% (n=2). Some required additional oral analgesia (n=8) or a regional blockade (n=2). Average pain score during debridement was 1.9 We have found LA effective, with favourable pain scores in comparison to previous studies with oral analgesia or regional blockade. LA is quick and easy to perform, as opposed to nerve blocks, which require trained personnel with ultrasound guidance. LA is a useful analgesic for patients with minor cutaneous burns undergoing ED. In some cases, it is sufficient without additional oral analgesia or regional blockade.

Predictors of long-term survival in 5,680 patients admitted to a UK major trauma centre with thoracic injuries

INTRODUCTION

The long-term outcomes of chest trauma are largely unknown. We sought to determine the predictors of in-hospital and long-term survival in patients admitted to a major trauma centre (MTC) with chest injuries and to evaluate spatial patterns of injury in our network area.

METHODS

Retrospective analysis of data collected on the National Trauma Audit Research Network (TARN) database using multivariate analysis and Cox regression analysis. Spatial analysis was performed using ArcGis 10.7.1.

RESULTS

Some 5,680 patients were admitted with chest trauma between December 1999 and December 2019. Median patient age was 45 years and the median Injury Severity Score (ISS) was 20. The proportion of patients who had an operation was 39.8%. Age, blood transfusion, head injury, shock, emergency thoracotomy and heart disease were predictors of hospital mortality (p < 0.05). However, having an operation on concomitant injuries was protective. ISS and Glasgow Coma Score were discriminators of in-hospital mortality (C-indices 0.76 and 0.80, respectively). The 10-year survival values for patients who survived to discharge from hospital and who were aged <40, 50, 60, 70, 80 and >80 years were 99%, 93%, 95%, 87%, 75% and 43%, respectively. Preadmission lung disease and alcohol/drug misuse were poor predictors of long-term survival (p < 0.05). Hotspot analysis revealed the areas with the highest incidents were all close to the MTC.

CONCLUSIONS

The MTC is geographically central to areas with high numbers of trauma incidents. Although emergency thoracotomy was a predictor of poor in-hospital outcomes, having surgery for concomitant injuries improved outcomes. Patients surviving to discharge have good long-term survivals.

Peripheral Arterial Disease and Prosthetic Joint Infection Resulting in Hip Disarticulation: A Case Report

Introduction

The aim of this study was to report a patient with refractory prosthetic joint infection (PJI) and severe peripheral arterial disease that necessitated hip disarticulation (HD), a rare and aggressive procedure. While this is not the first HD performed due to PJI, this is the first reported incidence that deals with profound infection burden along with immense vascular disease that has failed all other treatment options.

Case Report

We report a case of an elderly patient with a prior history of the left total hip arthroplasty, PJI, and severe peripheral arterial disease who underwent a rare HD procedure and was discharged with minimal complications. Before this major surgery, several surgical revisions and antibiotic regimens were attempted. The patient had also failed a revascularization procedure to treat an occlusion stemming from the peripheral arterial disease and had developed a necrotic wound at the surgical site. Irrigation and debridement of associated necrotic tissue was unsuccessful and due to concerns such as cellulitis, HD was performed with patient consent.

Conclusion

HD is a rare procedure that comprises only 1-3% of all lower limb amputations and is reserved for extremely deleterious indications such as infection, ischemia, and trauma. Complication and 5 year mortality rates have been reported to be as high as 60% and 55%, respectively. Despite these rates, the patient case illustrates a situation, in which early detection of indications for HD prevented further negative outcomes. Based on this case, we believe that HD is a reasonable treatment of choice in patients with severe peripheral arterial disease who fail revascularization and prior moderate treatment options. However, the limited availability of data involving HD and variety of comorbid conditions necessitate further analysis in terms of outcomes.

Novel model for chronic intestinal inflammation in chickens: (2) Immunologic mechanism behind the inflammatory response

Intestinal inflammation in poultry is a complex response that involves immune and intestinal cells which is still not fully understood. Thus, to better understand the mechanisms that drive the chronic intestinal inflammation in fowl we conducted an experiment applying a previously established nutritional model of low-grade chronic intestinal inflammation to evaluate cytokine and chemokine profiles in the chicken intestine. For this, we placed 90 one-day chickens into two treatments: (1) a control group (CNT) fed a corn-soybean diet, and (2) a group fed a diet high in non-starch polysaccharides (NSP). At days 14, 22, 28 and 36 of age, 6 birds from each treatment were euthanized, jejunal and ileal samples were collected for histological examination and cytokine measurements. The cytokines interferon-alpha (IFN-α), IFN-γ, interleukin-16 (IL-16), IL-10, IL-21, IL-6, macrophage-colony stimulating factor (M-CSF), chemokine C-C motif ligand 20 (CCL20), CCL4, CCL5 and vascular endothelial growth factor (VEGF) were quantified in the intestinal tissue. Histologically, both jejunum and ileum of broilers fed NSP diet showed marked infiltration of mononuclear immune cells into the villi. Further, these birds exhibited a significant (P < 0.05) increase in CCL20 concentration in the jejunum at 14d, but a dramatic reduction of M-CSF at 14 and 21d. Later at 28d and 36d, birds fed the NSP diet exhibited increased IL-16 concentration in the jejunum. Since M-CSF is a monocyte stimulatory cytokine and CCL20 a chemokine of T-cells, the reduced M-CSF and increased production of CCL20 may indicate the involvement of the adaptive immune response, specifically driven by T-cells, occurring around the third week of age in the NSP model. Lastly, as a result of the mononuclear cell infiltration and activation of T-cells, IL-16, a pro-inflammatory T-cell cytokine, increased. Therefore, the current work indicates the importance of adaptive immune cells, especially T-cells, in the chronic intestinal inflammation in broiler chicken.