A Comparative Analysis of Effect of HIV Infection on Outcomes of Cervical Cancer Treated with Radiotherapy

PURPOSE/OBJECTIVE(S)

There is paucity of data on management of human immunodeficiency virus (HIV) positive cervical cancer and its clinical outcomes in Indian women. The primary objective of this study was to compare disease free survival (DFS) and overall survival (OS) between HIV-positive and HIV-negative patients receiving radiotherapy (RT) for cervical cancer. The secondary endpoints were toxicity and various factors affecting DFS and OS.

MATERIALS/METHODS

Patients diagnosed with cervical cancer on histopathology and treated with RT with or without concomitant chemotherapy (CT) at an institution between 2015 and 2020 were included in this retrospective analysis. On the basis of HIV serology test, 70 patients were included in each arm, Arm A had HIV-negative patients and Arm B had HIV-positive patients. In both the arms, external beam radiotherapy (EBRT) in adjuvant or radical setting was given with a total dose of 46-50 Gy to whole pelvis and iliac nodes; 2 Gy/fraction daily as 5 fractions/week by conventional four-field box technique or conformal 3-dimensional radiotherapy (3DCRT) or Intensity modulated radiotherapy (IMRT). Concurrent cisplatin was administered as weekly 40mg/m2 to patients with ECOG< = 2, creatinine clearance >40mL/min in radical and adjuvant patients as indicated. CD4 counts ≥200 cells/mm3 was a prerequisite for concurrent cisplatin in Arm B. Intracavitary or interstitial brachytherapy was delivered as indicated. Statistical analysis was done using statistical software. Kaplan-Meier method used for all survival analysis. Log rank test was used to calculate statistical significance for various prognostic factors followed by Cox regression test for multivariate analysis.

RESULTS

Median age was 46.5 years (range: 30-76). In Arm A, 62 patients (88.57%) and 5 patients (7.14%) received radical and adjuvant RT. In Arm B 61 patients (87.14%) and 2 patients (2.85%) were given radical and adjuvant RT. 66 patients (94.28%) in Arm A and 52 patients (74.28%) in Arm B received concurrent cisplatin. At a median follow up of 33.8 months (range: 1.2 to 85.4), 2-year DFS was 88.9% for Arm-A and 86.5% for Arm-B (p = 0.134) and 2-year OS was 91.4% and 82.9% for Arm-A and Arm-B (p = 0.001), respectively. Grade III/IV skin toxicity was seen in and 4 patients (5.71%) in Arm A and 12 patients (17.14%) in Arm B (p = 0.34). Grade III/IV gastrointestinal toxicity was seen in 2(2.85%) patients and 4(5.7%) patients in Arm A and Arm B respectively (p = 0.40). 14(20%) patients in Arm A and 27(38.5%) patients in Arm B had Grade III/IV hematologic toxicity (p = 0.016). On multivariate analysis, anemia (Hb≤12 gm/dl) and OTT ≥56 days were associated with unfavorable DFS (p = 0.03 and p = 0.001) and OS (p = 0.04 and p = 0.01) in Arm B.

CONCLUSION

In view of comparable DFS outcomes in both the arms, HIV-positive cervical cancer patients can be managed with the standard treatment protocol as HIV-negative patients. HIV-positive patients are more likely to experience poorer DFS and OS. However, results need to be validated on prospective study.

Correlation of Dose Volume Parameters with Dysphagia and Pharyngeal Constrictor Muscle Thickness in Dysphagia Optimized IMRT

PURPOSE/OBJECTIVE(S)

Reduced radiation dose to the pharyngeal constrictor muscles (PCM) using dysphagia optimized intensity-modulated RT (DO-IMRT) is associated with improved swallowing outcomes in oropharyngeal cancers (OPCs). Purpose was to evaluate the relationship between dose of radiation delivered and acute dysphagia in patients with OPC treated with IMRT, after delineation of PCM.

MATERIALS/METHODS

Twenty-five patients with newly diagnosed OPC who underwent definitive IMRT with concurrent cisplatin were included in the study. PCM mean dose < 50 Gy was used as the dose constraint. Target volume was divided into high, intermediate and low risk areas receiving doses in the range of 60-66 Gy, 54-58 Gy, 51-56 Gy in 30-33 fractions over 6-6.5 weeks, respectively. PCM dose-volume parameters were collected and logistic regression was used to analyze these data relative to percent weight loss during RT and duration of feeding tube use. Thickness of constrictor muscle in pre-treatment and 3 months post-therapy CT scan were assessed. Weekly assessment of dysphagia was based on RTOG toxicity gradings. Aim of the study was to evaluate the correlation between dysphagia grades with dose-volume parameters and PCM thickness.

RESULTS

Median age was 55.0 years (mean 54.3) with 24 males and stage II:III-16:9 patients. Dmean to PCM was 49.86 Gy (range 48.22 -57.63) with median Dmax of 70.24 Gy. For patients with dysphagia (grade ≥1), V50 ranged from 48.2-57.23%, while in those with no dysphagia, it ranged from 47.92-52.18 % (Mean 51.36%). Nine patients needed feeding tube after RT end. Median feeding tube duration was 64 days. The correlation between Dmean ≥ 50 Gy and dysphagia at 1st, 2nd, 3rd and 6th month was found statistically significant (p < 0.01). Table 1 shows the Pearson correlation and P-value of the dosimetric parameters with dysphagia. The correlation of V50 was found statistically significant with grade of dysphagia at 3rd and 6th month post-treatment (p<0.001). The mean thickness range and median thickness of constrictors before and 3 months after treatment were 1.8-3.2 mm, 2.4 mm, and 2.8-6.2 mm,4.1 mm, respectively. The increase in thickness of constrictor muscle correlated significantly (p<0.05) with dysphagia grades and also with V50, V60 and Dmean (p<0.001) but no statistical significance was seen with Dmax (p = 0.232). With a median follow-up of 18 months (range 7-24), 1-year actuarial local control was 92%.

CONCLUSION

DO-IMRT may prove beneficial in the OPC by preventing dysphagia and aspiration post therapy and hence improving the quality of life of patients. Dmean ≥ 50Gy, V50 > 51.4% and V60 > 35.5% are the parameters correlating significantly with dysphagia (p<0.001) and change in mean thickness of PCM (p<0.001).

The effects of the DASH dietary pattern on clinical outcomes and quality of life in adults with uncontrolled asthma: Design and methods of the ALOHA Trial

BACKGROUND

Poor diet quality is an important risk factor for increased asthma prevalence and poor asthma control. To address the question of whether adults with asthma can benefit from following a healthy diet, this trial will test the efficacy and mechanisms of action of a behavioral intervention promoting the Dietary Approaches to Stop Hypertension (DASH) dietary pattern with sodium reduction among patients with uncontrolled asthma.

METHODS

In this 2-arm randomized clinical trial, 320 racially/ethnically and socioeconomically diverse adults with uncontrolled asthma on standard controller therapy will be randomized to either a control or an intervention group and assessed at baseline, 3, 6 and 12 months. Control and intervention participants will receive education on lung health, asthma, and other general health topics; additionally, the intervention group will receive DASH behavioral counseling over 12 months. The primary hypothesis is that the DASH behavioral intervention, compared with the education-only control, will lead to significantly more participants with minimum clinically important improvement (responders) in asthma-specific quality of life at 12 months. Secondary hypotheses will test the intervention effects on other asthma (e.g., asthma control, lung function) and non-asthma outcomes (e.g., quality of life). Additionally, therapeutic (e.g., short chain fatty acids, cytokines) and nutritional biomarkers (e.g., dietary inflammatory index, carotenoids) will be assessed to understand the mechanisms of the intervention effect.

CONCLUSION

This trial can substantially advance asthma care by providing rigorous evidence on the benefits of a behavioral dietary intervention and mechanistic insights into the role of diet quality in asthma.

CLINICALTRIALS

gov #: NCT05251402.

Effect of concurrent beta-blocker use in patients receiving immune checkpoint inhibitors for advanced solid tumors

PURPOSE

Stress-induced adrenergic signaling can suppress the immune system. In animal models, pharmacological beta-blockade stimulates CD8 + T-cell activity and improves clinical activity of immune checkpoint blockade (ICB) in inhibiting tumor growth. Herein, we investigated the effect of BB on clinical outcomes of patients receiving ICB in advanced solid tumors.

METHODS

We retrospectively evaluated patients with solid tumors treated with ICB at our institution from January 1, 2011 to April 28, 2017. The primary clinical outcome was disease control. Secondary clinical outcomes were overall survival (OS), and duration of therapy (DoT). The primary predictor was use of BB. Association between disease control status and BB use was assessed in univariable and multivariable logistic regression. OS was calculated using hazard ratios of BB-recipient patients vs. BB non-recipient patients via Cox proportional hazards regression models. All tests were two-sided at a significance level of 0.05.

RESULTS

Of 339 identified patients receiving ICB, 109 (32%) also received BB. In covariate-adjusted analysis, odds of disease control were significantly higher among BB recipients compared to BB-non-recipients (2.79; [1.54-5.03]; P = 0.001). While we did not observe significant association of OS with the use of BB overall, significant association with better OS was observed for the urothelial carcinoma cohort (HR: 0.24; [0.09, 0.62]; P = 0.0031).

CONCLUSIONS

Concurrent use of BB may enhance the clinical activity of ICB and influence overall survival, particularly in patients with urothelial carcinoma. Our findings warrant further investigation to understand the interaction of beta adrenergic signaling and antitumor immune activity and explore a combination strategy.

A multicenter study assessing survival in patients with metastatic renal cell carcinoma receiving immune checkpoint inhibitor therapy with and without cytoreductive nephrectomy

BACKGROUND

Cytoreductive nephrectomy (CN) for the treatment of metastatic renal cell carcinoma (mRCC) was called into question following the publication of the CARMENA trial. While previous retrospective studies have supported CN alongside targeted therapies, there is minimal research establishing its role in conjunction with immune checkpoint inhibitor (ICI) therapy.

OBJECTIVE

To evaluate the association between CN and oncological outcomes in patients with mRCC treated with immunotherapy.

MATERIALS AND METHODS

A multicenter retrospective cohort study of patients diagnosed with mRCC between 2000 and 2020 who were treated at the Seattle Cancer Care Alliance and The Ohio State University and who were treated with ICI systemic therapy (ST) at any point in their disease course. Overall survival (OS) was estimated using Kaplan Meier analyses. Multivariable Cox proportional hazards models evaluated associations with mortality.

RESULTS

The study cohort consisted of 367 patients (CN+ST n = 232, ST alone n = 135). Among patients undergoing CN, 30 were deferred. Median survivor follow-up was 28.4 months. ICI therapy was first-line in 28.1%, second-line in 17.4%, and third or subsequent line (3L+) in 54.5% of patients. Overall, patients who underwent CN+ST had longer median OS (56.3 months IQR 50.2-79.8) compared to the ST alone group (19.1 months IQR 12.8-23.8). Multivariable analyses demonstrated a 67% reduction in risk of all-cause mortality in patients who received CN+ST vs. ST alone (P < 0.0001). Similar results were noted when first-line ICI therapy recipients were examined as a subgroup. Upfront and deferred CN did not demonstrate significant differences in OS.

CONCLUSIONS

CN was independently associated with longer OS in patients with mRCC treated with ICI in any line of therapy. Our data support consideration of CN in well selected patients with mRCC undergoing treatment with ICI.

Analyzing the impact of close margins and extra-resection margins on failure rates in postoperative oral cavity cancers

BACKGROUND

Postoperative oral cancers with close margins belong to medium- to high-risk category for local failure. During re-surgery for close margins, there is sufficient doubt as to whether the re-excised tissue is from the same region as the close margin. Therefore, we planned a retrospective review of these cases of close margins that were re-excised with extra-resection margins (ERMs).

MATERIAL AND METHODS

Details of 2011 oral cavity patients resected at our hospital were retrieved. Cases with close margins were segregated and the status of ERMs was noted. The postoperative histopathological details, radiotherapy details, and failure patterns in all these cases were documented. The primary objective of the study was to assess the overall survival (OS) and disease-free survival (DFS) in cases with ERMs. The secondary objective was to assess the local and regional control rates and variation with the number and status of close and ERMs. OS, DFS, and local failure rates were defined from the date of registration. Statistical analysis was performed with the SPSS statistical software package. All survival analyses were performed using the Kaplan-Meier method. Log-rank test was used to test the statistical significance. A P-value of 0.05 was considered statistically significant.

RESULTS

Sixty-four cases with a median age of 47 years (range: 29-76) were considered for the final analysis. The median follow-up was 40 months (range: 9.5-56.5). The 2-year OS and DFS rates were 91.5% and 88.5%, respectively. The crude local and regional failure rates were 10.9% and 3.1%, respectively. The 3-year locoregional control rate was 90.2%. The 2-year locoregional control rate for one close margin was significantly better as compared to more than one close margin (P = 0.049). No difference in survival and failure rates was found between the number of ERMs resected (one vs. two) and ≤ vs. > 3 mm close margin status. Two patients developed bone metastases.

CONCLUSION

The survival rates and locoregional control rates did not differ much between the groups that had one or more ERMs. However, the locoregional control rates were better in cases with one close margin as compared to those with more than one close margin. A larger study with longer follow-up is needed to detect statistically significant differences in outcomes and identify the factors that portend poor prognosis in these cases with close margins and ERMs.

Direct Measurement of Resonances in ^{7}Be(α,γ)^{11}C Relevant to νp-Process Nucleosynthesis

We have performed the first direct measurement of two resonances of the ^{7}Be(α,γ)^{11}C reaction with unknown strengths using an intense radioactive ^{7}Be beam and the DRAGON recoil separator. We report on the first measurement of the 1155 and 1110 keV resonance strengths of 1.73±0.25(stat)±0.40(syst)  eV and 125_{-25}^{+27}(stat)±15(syst)  meV, respectively. The present results have reduced the uncertainty in the ^{7}Be(α,γ)^{11}C reaction rate to ∼9.4%-10.7% over T=1.5-3  GK, which is relevant for nucleosynthesis in the neutrino-driven outflows of core-collapse supernovae (νp process). We find no effect of the new, constrained reaction rate on νp-process nucleosynthesis.

Calcitriol-mediated hypercalcemia as an immune-related adverse event in a patient receiving nivolumab and ipilimumab for metastatic renal cell carcinoma, case report

BACKGROUND

Severe hypercalcemia is often associated with uncontrolled malignancy through several mechanisms. However, calcitriol-mediated hypercalcemia is a rare etiology for advanced solid tumors.

CASE PRESENTATION

We report a case of calcitriol-mediated hypercalcemia secondary to immune checkpoint inhibition in a responder with metastatic clear cell renal cell carcinoma (ccRCC). In this case, a 68 year old male with metastatic ccRCC to the liver within 4 months of right radical nephrectomy went on to develop hypercalcemia (12.8 mg/dL) shortly following 2 cycles of nivolumab and ipilimumab. Additional testing showed an elevated calcitriol level (142 pg/mL), low parathyroid hormone (PTH) and parathyroid hormone-related protein (PTHrP) levels, and a normal 25-hydroxyvitamin D level. FDG-PET imaging showed hypermetabolic mediastinal, hilar, and intra-abdominal lymphadenopathy, however the subsequent lymph node biopsy only showed reactive lymphoid cells without malignancy or granuloma. The hypercalcemia was resistant to initial therapy with calcitonin, hydration, and zoledronic acid but quickly responded to high-dose prednisone (1 mg/kg), followed by normalization of calcitriol levels. The patient was rechallenged with nivolumab and ipilimumab which provided a partial response after 4 cycles. He was maintained on low dose prednisone (10 mg daily) leading to a sustained resolution of his hypercalcemia.

CONCLUSION

This case suggests calcitriol-mediated hypercalcemia as a novel immune-related adverse event.

Predictors and Barriers to Condom Use in the African Cohort Study

Consistent condom use is an inexpensive and efficacious HIV prevention strategy. Understanding factors associated with condom use and barriers to use can inform strategies to increase condom uptake. The ongoing African Cohort Study prospectively enrolls adults at 12 clinical sites in Uganda, Kenya, Tanzania, and Nigeria. At enrollment, participants are asked about condom use at last sex with a regular partner. Robust Poisson regression models were used to evaluate predictors of self-reported condom use. Participants who reported not using condoms were asked to provide reasons. From January 2013 to September 2019, 2482 participants reported having at least one regular sexual partner in the preceding 6 months. Of those, 1577 (63.5%) reported using a condom at last sex. Condom use was more common among older participants, males, HIV-infected participants, and those with an HIV-infected partner. Married participants, those with a partner of unknown HIV status, and those reporting alcohol use were less likely to report condom use at last sex. Condom use at last sex also varied significantly by clinical site. Partner disapproval or refusal to use a condom was a consistent driver of disparities in condom use among participants who were HIV infected, female, and aged 18-24 years. Effective HIV prevention programs should integrate condom education with the tools necessary to negotiate condom use with regular partners.

Zileuton use and phenotypic features in asthma

Zileuton, a 5-lipoxygenase (5LPO) inhibitor exerts a broad influence in the arachidonic acid (AA) pathway by blocking upstream molecules that otherwise would lead to production of an array of inflammatory leukotrienes (LT) A4-E4. Hence, it has the potential to be a drug suitable to treat complicated asthmatics. Studies have shown modest response rates for zileuton in asthmatics.

OBJECTIVE

We sought to study our hypothesis that response to zileuton varies across specific asthmatic phenotypes.

METHODS

We retrospectively analyzed data from 129 patients with asthma that were prescribed zileuton at the University of Pittsburgh's Comprehensive Lung Clinic. A total of 75 patients from the above population had requisite lung function data and zileuton usage that would help assess a drug response effect. A zileuton responder was defined as having at least or greater than 5% annualized increase in post-bronchodilator FEV1% from baseline. Using a multivariate logistic regression analysis, we determined the association between responder status and the underlying phenotypic characteristics.

RESULTS

Using generalized estimating equations (GEE) analysis of 331 individual lung function test data-points as well as logistic regression analysis for predictors of 5% or more annualized increase in FEV1%, 21 of 75 patients (28%) met criteria for having a differential response to zileuton. Severe asthma was associated less often with responder status (OR 0.12; p 0.004). Obesity was less often associated with responder status, however did not reach significance (OR 0.46; p 0.15).

CONCLUSION

In this retrospective study, zileuton response varies across asthmatics, with poorer response rates being associated with those with severe asthma and possibly obesity. Although prescription trends for zileuton may predominate amongst severe asthmatics, this tendency does not seem to mirror the actual likelihood to respond. As against the trivial role for zileuton per current GINA algorithms, our study brings forward a notion that zileuton may well be considered along with LTRAs (like montelukast) for non-severe asthma.

Characterization of sick visits at an enhanced oncology urgent care center

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Background: The Oncology Care Unit (OCU) is an urgent care center open during after-hours and weekends for patients with cancer and blood disorders at the Mount Sinai Hospital. This 6-bed, nurse practitioner-run unit aims to decrease the need for emergency room (ER) visits and hospitalization in this high risk patient population. Herein we characterize utilization of this unit for urgent clinical management (“sick visits”). Methods: We identified all patients treated in the OCU between 5/12/17 and 4/8/18, and collected information on diagnosis, treatment, and utilization of the ER or hospitalization. We used descriptive statistics to identify characteristics of those patients treated in the OCU. Results: Of the 1,934 visits to the OCU, 100 (5%) were coded as “sick visits”. Of this cohort, 39% had solid tumors, 44% liquid tumors, and 17% benign hematologic conditions. Among the oncology patients, the average number of prior treatment lines was 4.6 and average time since diagnosis was 51.3 months. Of all cancers, 84% were classified as advanced stage or high-risk. Treatments for the entire group included: transfusion (T, 20%), hydration (H, 20%), and infusion (I, 13%). Similarly, 39% of visits were for H+I, 3% for T+H, 4% for T+I, and 1% for T+H+I. 5% of patients had a repeat, unplanned OCU sick visit in the next 7 days. Among the sick visits, 28% resulted in hospitalization, with a 14-day average length of stay. Further results are shown in Table 1. Conclusions: The OCU provides enhanced diagnostic and therapeutic services for high-risk hematology/oncology patients. These services often exceed the capabilities of a busy practice and would otherwise prompt an ER visit and/or hospitalization. We now aim to study the effect of the OCU on ER utilization and admission rates as well as to analyze its cost effectiveness. [Table: see text]

Nonrestorative Treatments for Caries: Systematic Review and Network Meta-analysis

The goal of nonrestorative or non- and microinvasive caries treatment (fluoride- and nonfluoride-based interventions) is to manage the caries disease process at a lesion level and minimize the loss of sound tooth structure. The purpose of this systematic review and network meta-analysis was to summarize the available evidence on nonrestorative treatments for the outcomes of 1) arrest or reversal of noncavitated and cavitated carious lesions on primary and permanent teeth and 2) adverse events. We included parallel and split-mouth randomized controlled trials where patients were followed for any length of time. Studies were identified with MEDLINE and Embase via Ovid, Cochrane CENTRAL, and Cochrane Database of Systematic Reviews. Pairs of reviewers independently conducted the selection of studies, data extraction, risk-of-bias assessments, and assessment of the certainty in the evidence with the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach. Data were synthesized with a random effects model and a frequentist approach. Forty-four trials (48 reports) were eligible, which included 7,378 participants and assessed the effect of 22 interventions in arresting or reversing noncavitated or cavitated carious lesions. Four network meta-analyses suggested that sealants + 5% sodium fluoride (NaF) varnish, resin infiltration + 5% NaF varnish, and 5,000-ppm F (1.1% NaF) toothpaste or gel were the most effective for arresting or reversing noncavitated occlusal, approximal, and noncavitated and cavitated root carious lesions on primary and/or permanent teeth, respectively (low- to moderate-certainty evidence). Study-level data indicated that 5% NaF varnish was the most effective for arresting or reversing noncavitated facial/lingual carious lesions (low certainty) and that 38% silver diamine fluoride solution applied biannually was the most effective for arresting advanced cavitated carious lesions on any coronal surface (moderate to high certainty). Preventing the onset of caries is the ultimate goal of a caries management plan. However, if the disease is present, there is a variety of effective interventions to treat carious lesions nonrestoratively.

PFO closure in high-risk patient with paradoxical arterial embolism, deep vein thrombosis, pulmonary embolism and factor V Leiden genetic mutation

Occurrence of paradoxical arterial embolism may cause the first symptoms in patients with a coexisting hypercoagulable state and patent foramen ovale (PFO). This can result in significant morbidity and mortality depending on the location of the embolism. The risks and benefits of closure of small PFOs have not been well elucidated in prior studies. We describe a patient with a history of Factor V Leiden heterozygosity who presented with left arm pain secondary to arterial embolism. The patient was a 51-year-old male who initially presented to the emergency department after awaking from sleep with progressive, severe, burning left arm pain. He had also noted intermittent shortness of breath over the 2 weeks prior to admission. Temperature was 97.4 F, pulse 86, respiratory rate 20 and blood pressure 121/87. Oxygen saturation was 94% on supplemental oxygen. He had a cool left upper extremity and the patient described subjective paresthesias in this extremity. Left radial pulse was difficult to palpate. Physical exam was otherwise unremarkable. Troponin I was mildly elevated at 0.217 ng/l. White blood cell count was 11.8 and INR 1.1. EKG showed sinus tachycardia with non-specific T abnormalities in the anterior leads. His past medical history was notable for only hypertension and hyperlipidemia. Current recommendation is for antiplatelet or anticoagulation for those with hypercoaguable states who suffer a stroke; there is currently no absolute indication for closure device. We describe the case of a 51-year-old male who had presented with left arm pain and shortness of breath. The computed tomography (CT) angiography of chest showed pulmonary emboli with heavy clot burden bilaterally. Heparin was started, but patient was found to have occlusion along large arteries of the left arm. Emergent left axillary, brachial, radial and ulnar embolectomy for acute critical arm ischemia were performed. The transthoracic echocardiogram done the next day with bubble study was positive for patent foramen ovale. Hypercoaguability showed factor V Leiden heterozygosity. Decision was made for the patient to initiate long-term anticoagulation with rivaroxaban and closure was performed. Patient was advised that closure is off label but opted to proceed with closure in light of hypercoaguable state.

Minimizing prostate cancer admissions via enhanced outpatient care: A model for savings

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Background: Hospitalization is a major contributor to cost in oncology. Minimizing avoidable admissions can lead to substantial savings. Methods: We studied Medicare claims data from 160 admissions for prostate cancer (PCa) patients from 1/2012 to 5/2015. Admissions with the lowest 50th percentile of charges were assessed for being potentially avoidable by 2 independent chart reviews; remaining admissions were assumed to be unavoidable due to medical complexity. Common admitting diagnoses were targeted by theoretical care pathways designed to minimize avoidable admissions via expedited outpatient follow-up. We compared the cost of the avoidable admissions to that of implementing 3 such pathways then estimated the financial impact. Results: Total cost for all 160 admissions was $1,979,200. 25% of these admissions, accounting for $494,800, were deemed potentially avoidable. Our model exchanged each of these admissions for a routine clinic visit which led to an estimated $464,800 in savings, or a 23% improvement in total cost. The most common admitting diagnoses were fever (18%), pain (12%), and dehydration (8%). On review, 3/9 fever admissions in this set were deemed avoidable with 1 extra clinic visit, 3 with 3 visits, and 3 were unavoidable, yielding a 53% reduction in cost for this diagnosis. Similar analyses led to cost reductions of 75% and 66% for pain and dehydration admissions, respectively. Combining just these 3 theoretical interventions led to an estimated savings of $146,955, or a 7.4% improvement in total cost. Conclusions: A sizable portion of PCa admissions can be avoided, with ample savings, if a system is in place to provide the additional care that often exceeds the capabilities of a busy practice. [Table: see text]

Study of key resonances in the 30P(p,γ)31S reaction in classical novae

Among reactions with strong impact on classical novae model predictions, 30P(p,γ)31S is one of the few remained that are worthy to be measured accurately, because of their rate uncertainty, as like as 18F(p,α)15O and 25Al(pγ)26Si. To reduce the nuclear uncertainties associated to this reaction, we performed an experiment at ALTO facility of Orsay using the 31P(3He,t)31S reaction to populate 31S excited states of astrophysical interest and detect in coincidence the protons coming from the decay of the populated states in order to extract the proton branching ratios. After a presentation of the astrophysical context of this work, the current situation of the 30P(p,γ)31S reaction rate will be discussed. Then the experiment set-up of this work and the analysis of the single events will be presented.