Endoscopic ultrasound-guided gastrojejunostomy versus robotic gastrojejunostomy for unresectable malignant gastric outlet obstruction

Objectives

Malignant gastric outlet obstruction (GOO) has traditionally been managed with enteral stenting and surgical gastrojejunostomy. Our study aimed to compare outcomes between endoscopic ultrasound-guided gastrojejunostomy (EUS-GJ) using a lumen-apposing metal stent and robotic GJ (R-GJ) for unresectable malignant GOO.

Methods

Patients undergoing EUS-GJ or R-GJ for unresectable malignant GOO were retrospectively analyzed. The primary outcome was clinical success defined by the ability to tolerate oral intake at the time of discharge. Secondary outcomes included technical success, procedure duration, adverse events, and post-procedure length of stay (LOS).

Results

A total of 44 patients met the inclusion criteria. Of the 44, 29 underwent EUS-GJ and 15 underwent R-GJ. Age, gender, malignant etiology, and presence of ascites were similar between the two groups. Patients treated with EUS-GJ had a higher mean Charlson comorbidity index (10.3 vs. 7.0; p ≤ 0.0001) and a lower preoperative body mass index (22.3 vs. 27.2; p = 0.007). Technical and clinical success was achieved in 100% of patients in both groups (p > 0.99). EUS-GJ was associated with shorter procedure duration (57.5 vs. 146.3 min; p < 0.0001), hospital LOS (4.3 vs. 8.2 days, p = 0.0009), and time to oral intake (1.0 vs. 5.8 days; p < 0.0001) when compared to R-GJ. Adverse events occurred in 5 of the R-GJ patients and none of the EUS-GJ patients (p = 0.003).

Conclusions

EUS-GJ has similar efficacy and superior clinical outcomes compared to R-GJ in the management of malignant GOO. Prospective studies with longer follow-up duration are needed to validate these findings.

False-Positive Rate for Suspected Drug-Related Deaths Following Full Autopsy

ABSTRACT

The sharp increase in drug-related deaths has tempted medical examiner/coroner offices to perform external examinations with comprehensive toxicology testing instead of performing a standard autopsy. Compounding the problem of an increasing workload has been the decrease in available forensic pathologists. Opting for external examinations on suspected drug-related fatalities, however, is antithetical to current best practices. The purpose of this study was to review case files, autopsy reports, and toxicologic results of all deaths that were autopsied at the authors' facility and decide whether significant disease processes or injuries that would supersede the results of toxicologic testing and external examination findings alone were being missed.

Visual Outcomes after Internal Limiting Membrane Peeling vs. Flap in the Closure of Full Thickness Macular Holes

PURPOSE

To examine postoperative outcomes of internal limiting membrane peeling (ILMP) versus flap (ILMF) in the closure of full thickness macular holes (FTMH).

METHODS

Retrospective chart review of patients who underwent pars plana vitrectomy and gas tamponade with ILMP or ILMF to close FTMH at the Atrium Health Wake Forest Baptist from January 2012 to October 2022 with at least 3 months follow up. Main outcome measures were type 1 primary FTMH closure and postoperative best corrected visual acuity (BCVA) in mean logMAR.

RESULTS

130 and 30 eyes underwent ILMP and ILMF respectively. There were no significant differences in baseline characteristics between the groups. 96% of ILMP eyes and 90% of ILMF eyes achieved primary hole closure (p=0.29). Among all eyes with primary hole closure, BCVA at 1 year was not different between the groups but when stratified by lens status, was superior in the ILMP versus ILMF group in pseudophakic eyes: the estimated least-squares mean BCVA (Snellen equivalent) [95% confidence interval] was 0.42 (20/50) [0.34, 0.49] in the ILMP group and 0.71 (20/100) [0.50, 0.92] in the ILMF group.

CONCLUSIONS

ILMP and ILMF techniques yielded similarly high FTMH closure rates. In pseudophakic eyes with primary hole closure, ILMF eyes had worse BCVA at 1 year.

Evaluating residual anti-Xa levels following discontinuation of treatment-dose enoxaparin in patients presenting for elective surgery: a prospective observational trial

INTRODUCTION

Prior studies have demonstrated that patients presenting for elective surgery may have higher-than-expected residual anti-Xa level activity at or beyond 24 hours following their last treatment dose of enoxaparin. Given that 24 hours of abstinence is currently recommended by both European and American societies before the performance of neuraxial or deep anesthetic/analgesic procedures, determining the actual timeframe at which residual anti-Xa level activity reliably falls below 0.2 IU/mL, the lower limit of the target range for thromboprophylaxis, is critical.

METHODS

This was a prospective observational trial. Consenting patients on treatment-dose enoxaparin were randomized to either a 24-hour group (last dose at 07:00 the day prior to surgery) or a 36-hour group (last dose at 19:00 2 days prior to surgery). On arrival for surgery, blood samples were obtained to assess residual anti-Xa level activity and renal function. The primary outcome was residual anti-Xa level activity following the last treatment dose of enoxaparin. Incorporating all patients, linear regression modeling was performed to predict the timepoint at which the level of anti-Xa activity reliably fell below 0.2 IU/mL.

RESULTS

103 patients were analyzed. Time from the last dose at which residual anti-Xa activity fell below 0.2 IU/mL, based on the upper bound of the 95% CI, was 31.5 hours. No correlation overall between age, renal function, or sex was found.

CONCLUSION

Residual levels of anti-Xa activity do not reliably fall below 0.2 IU/mL 24 hours following discontinuation of treatment-dose enoxaparin. Therefore, current time-based guidelines are not conservative enough. Routine anti-Xa testing should be strongly considered, or current time-based guidelines should be reassessed.

TRIAL REGISTRATION NUMBER

NCT03296033.

EUS-guided hepaticogastrostomy versus percutaneous transhepatic biliary drainage after failed ERCP: A propensity score-matched analysis

Background and study aims Percutaneous transhepatic biliary drainage (PTBD) is the traditional second-line option after unsuccessful endoscopic retrograde cholangiopancreatography (ERCP). Endoscopic ultrasound-guided hepaticogastrostomy (EUS-HG) is a viable alternative to PTBD. Our study aimed to compare outcomes of EUS-HG and PTBD for benign and malignant biliary diseases following failed ERCP. Patients and methods This single-center study retrospectively analyzed patients undergoing EUS-HG and PTBD for benign and malignant biliary disorders. A propensity score-matched analysis was performed using age, sex, and Charlson Comorbidity Index. The primary outcome was clinical success, which we defined as a decrease in total bilirubin by ≥ 50% at 2 weeks for malignant disease and resolution of the biliary disorder for benign disease. Results In total, 41 patients underwent EUS-HG and 138 patients underwent PTBD. After propensity score matching in a 1:2 ratio, 32 EUS-HG patients were matched with 64 PTBD. Technical success was achieved in 29 of 32 (91%) for EUS-HG and 63 of 64 (98%) for PTBD ( P =0.11). Clinical success was 100% for EUS-HG and 75% for PTBD ( P =0.0021). EUS-HG was associated with a lower adverse event rate (EUS-HG 13% vs. PTBD 58%, P <0.0001), shorter procedure duration (median 60 vs. 115 minutes, P <0.0001), shorter post-procedure length of stay (median 2 vs. 4 days, P <0.0001), and fewer reinterventions (median 1 vs. 3, P <0.0001). Conclusions Our results suggest that EUS-HG is superior to PTBD in the treatment of benign and malignant biliary disorders after failed ERCP.

Multi-Institutional Report of Re-Irradiation for Recurrent High-Grade Glioma

PURPOSE/OBJECTIVE(S)

Significant heterogeneity exists with regards to prior published reports of re-irradiation (re-RT) in patients with recurrent high grade glioma (HGG). A multi-institutional database of 10 academic centers across the United States was created to analyze prognostic outcomes for re-RT for recurrent HGG, which included WHO Grade III and Grade IV tumors.

MATERIALS/METHODS

Patients with HGG who had initially received standard radiotherapy (RT) and were subsequently treated with a course of re-RT at recurrence were included in the study. Factors assessed to delineate a significant association with overall survival (OS) and toxicity included age, KPS, number of relapses, dose, use of bevacizumab (BEV) or temozolomide (TMZ), time from prior RT, histology, RT target, re-RT target> 5cm and extent of resection, and MGMT methylation status. The Kaplan-Meier Method was used to estimate OS. Cox proportional hazards regression models were used to identify factors associated with OS. Toxicity outcomes were assessed using logistic regression. Significance was assumed if p<0.05. Data management and decision management software were used for all analyses.

RESULTS

Between 2001 and 2022, 280 patients from 10 academic institutions were treated with re-RT for diagnosis of recurrent HGG. 133 patients (71.1%) had a histologic glioblastoma (GBM) at the time of re-RT, with the remainder having Grade 3 gliomas. Median dose delivered at re-RT was 47 Gy BED10 (IQR 47 - 53 Gy BED10), with the most common regimen being 35 Gy in 10 fractions. 83 patients (56%) had GTV greater than 5 cm treated with re-RT. 183 patients (79%) received concurrent systemic therapy, including 95 (41%) who received concurrent TMZ and 86 (45%) who received concurrent BEV. Median OS for the entire cohort was 10 months. Increasing dose at re-RT was associated with improved OS (OR 0.80 95% CI 0.67-0.95, p = 0.10 per 10 Gy BED10), as was dose greater than 47 Gy BED10, which is equivalent to 35 Gy in 10 fractions (OR 0.70, 95% CI 0.54-0.91). Concurrent TMZ was also associated with improved OS (OR 0.68, 95% CI 0.46-0.83, p < 0.01). 32/143 (22%) patients evaluable for toxicity experienced Grade 2 or greater adverse radiation effect (ARE). Use of BEV was associated with decreased toxicity (OR 0.45, 95% CI 0.21-0.98, p = 0.05). Dose at re-RT (OR 1.07 per 10 Gy BED10, p = 0.78), a GTV > 5cm (OR 1.39, p = 0.44), and the use of concurrent TMZ (OR 1.90, p = 0.10) were not associated with Grade 2 or greater ARE.

CONCLUSION

Higher dose of re-RT and use of concurrent TMZ led to improved OS in recurrent HGG patients without an associated increased rate of ARE. Use of BEV decreased the likelihood of Grade 2 or greater ARE in the re-RT setting for these recurrent HGG patients.

Fluid Intake Management in Maintenance Hemodialysis Using a Smartphone-Based Application: A Pilot Study

Rationale & Objective

Increased interdialytic weight gain (IDWG) has been associated with increased morbidity and mortality. We evaluated the usefulness and safety of a mobile application (app) that allows patients receiving maintenance hemodialysis to self-monitor their daily fluid intake.

Study Design

Within group comparison before or during intervention.

Setting & Participants

Patients receiving maintenance hemodialysis with mean IDWG of <4%.

Exposure

Participants were trained to use a smartphone-based app, FiApp that allowed them to record fluid intake and compare with individual targeted daily fluid intake determined by the nephrologist.

Outcomes

The primary study outcome was the association between IDWG and fluid intake recorded in the FiApp. Secondary outcomes included FiApp safety and usage. Patient interviews were performed at weeks 1 and 4 to collect information regarding FiApp usability and recommendations for app improvements.

Analytical Approach

Mean, median, and standard deviation.

Results

Eighteen of 25 patients completed the full 4-week study, provided all app data, and completed 2 patient interviews. The mean 4-week IDWG during app use was similar to the baseline mean 4-week IDWG before app use; however, 61% of the participants had a decrease in IDWG when using the app compared with IDWG at baseline. Of the 18 participants who completed the study, only 1 had a mean 4-week IDWG that was 20% higher than that at baseline. The app was used on ≥80% of the days by 13 (72%) of 18 participants, and was used every day in 7 (39%) of 18 participants. The mean relationship between fluid reported in the app and fluid consumed was 40%.

Limitations

This safety study recruited patients who had IDWG of <4%.

Conclusions

A smartphone-based app can be safely used to help patients receiving maintenance hemodialysis track and control fluid intake. Motivated patients were able to decrease IDWG despite baseline IDWG being <4% of the body weight.

Trial Registration

NCT03759847.

Plain-Language Summary

Patients receiving maintenance hemodialysis struggle to limit fluid intake. Excess fluid intake can lead to adverse cardiovascular events. We developed a smartphone app to help patients receiving dialysis self-monitor their fluid intake. In this safety study in patients receiving dialysis with an interdialytic weight gain of <4% of the body weight, more than half of the patients were able to decrease their interdialytic fluid intake while using the app, and only 1 patient had an increase in interdialytic weight gain of >20% while using the app. Information gleaned from structured patient interviews will be used to refine this app.

Endoscopic Ultrasound-Guided Gallbladder Drainage: Beyond Cholecystitis

Endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) is an alternative to surgery for acute cholecystitis (AC) in poor operative candidates. However, the role of EUS-GBD in non-cholecystitis (NC) indications has not been well studied. We compared the clinical outcomes of EUS-GBD for AC and NC indications. Consecutive patients undergoing EUS-GBD for all indications at a single center were retrospectively analyzed. Fifty-one patients underwent EUS-GBD during the study period. Thirty-nine (76%) patients had AC while 12 (24%) had NC indications. NC indications included malignant biliary obstruction (n = 8), symptomatic cholelithiasis (n = 1), gallstone pancreatitis (n = 1), choledocholithiasis (n = 1), and Mirizzi's syndrome (n = 1). Technical success was noted in 92% (36/39) for AC and 92% (11/12) for NC (p > 0.99). The clinical success rate was 94% and 100%, respectively (p > 0.99). There were four adverse events in the AC group and 3 in the NC group (p = 0.33). Procedure duration (median 43 vs. 45 min, p = 0.37), post-procedure length of stay (median 3 vs. 3 days, p = 0.97), and total gallbladder-related procedures (median 2 vs. 2, p = 0.59) were similar. EUS-GBD for NC indications is similarly safe and effective as EUS-GBD in AC.

Delayed endoscopic necrosectomy improves hospital length of stay and reduces endoscopic interventions in patients with symptomatic walled‐off necrosis

Objectives

Advancements in the endoscopic management of walled‐off necrosis using lumen apposing metal stents have improved outcomes over its surgical and percutaneous alternatives. The ideal procedural technique and timing of direct endoscopic necrosectomy (DEN) have yet to be clarified.

Methods

From November 2015 to June 2021, a retrospective comparative cohort analysis was performed comparing clinical outcomes for patients undergoing immediate DEN (iDEN) versus delayed DEN (dDEN). Subgroups were identified based on the quantification of necrosis. Wilcoxon two‐sample tests were used to compare continuous variables and Fisher's exact test was used to compare categorical variables.

Results

A total of 80 patients underwent DEN for management of walled‐off necrosis (iDEN = 43, dDEN = 37). Technical success was achieved in all patients. Clinical success was seen in 39 (91%) patients in the iDEN group and 34 (92%) in the dDEN group. Amongst iDEN patients, the mean number of necrosectomies was 2.5 (standard deviation [SD] 1.4) in comparison to 1.5 (SD 1.0) for dDEN (p‐value = 0.0011). The median index hospital length of stay was longer with iDEN than dDEN (7.5 days vs. 3.0 days respectively, p‐value = 0.010). Subgroup analysis was performed based on the percentage of necrosis (<25% vs. >25% necrosis). iDEN was associated with more necrosectomies than dDEN regardless of the percentage of necrosis (p = 0.017 and 0.0067, respectively).

Conclusion

Patients undergoing dDEN had a shorter index hospital stay and fewer necrosectomies than iDEN. The large diameter of lumen apposing metal stents permits adequate drainage allowing a less aggressive approach thereby improving clinical outcomes and avoiding unnecessary interventions.

Adaptation of a Personalized Electronic Care Planning Tool for Cancer Follow-up Care: Formative Study

BACKGROUND

Most patients diagnosed with colorectal cancer will survive for at least 5 years; thus, engaging patients to optimize their health will likely improve outcomes. Clinical guidelines recommend patients receive a comprehensive care plan (CP) when transitioning from active treatment to survivorship, which includes support for ongoing symptoms and recommended healthy behaviors. Yet, cancer care providers find this guideline difficult to implement. Future directions for survivorship care planning include enhancing information technology support for developing personalized CPs, using CPs to facilitate self-management, and assessing CPs in clinical settings.

OBJECTIVE

We aimed to develop an electronic tool for colorectal cancer follow-up care (CFC) planning.

METHODS

Incorporating inputs from health care professionals and patient stakeholders is fundamental to the successful integration of any tool into the clinical workflow. Thus, we followed the Integrate, Design, Assess, and Share (IDEAS) framework to adapt an existing application for stroke care planning (COMPASS-CP) to meet the needs of colorectal cancer survivors (COMPASS-CP CFC). Constructs from the Consolidated Framework for Implementation Research (CFIR) guided our approach. We completed this work in 3 phases: (1) gathering qualitative feedback from stakeholders about the follow-up CP generation design and workflow; (2) adapting algorithms and resource data sources needed to generate a follow-up CP; and (3) optimizing the usability of the adapted prototype of COMPASS-CP CFC. We also quantitatively measured usability (target average score ≥70; range 0-100), acceptability, appropriateness, and feasibility.

RESULTS

In the first phase, health care professionals (n=7), and patients and caregivers (n=7) provided qualitative feedback on COMPASS-CP CFC that informed design elements such as selection, interpretation, and clinical usefulness of patient-reported measures. In phase 2, we built a minimal viable product of COMPASS-CP CFC. This tool generated CPs based on the needs identified by patient-completed measures (including validated patient-reported outcomes) and electronic health record data, which were then matched with resources by zip code and preference to support patients' self-management. Elements of the CFIR assessed revealed that most health care professionals believed the tool would serve patients' needs and had advantages. In phase 3, the average System Usability Scale score was above our target score for health care professionals (n=5; mean 71.0, SD 15.2) and patients (n=5; mean 95.5, SD 2.1). Participants also reported high levels of acceptability, appropriateness, and feasibility. Additional CFIR-informed feedback, such as desired format for training, will inform future studies.

CONCLUSIONS

The data collected in this study support the initial usability of COMPASS-CP CFC and will inform the next steps for implementation in clinical care. COMPASS-CP CFC has the potential to streamline the implementation of personalized CFC planning to enable systematic access to resources that will support self-management. Future research is needed to test the impact of COMPASS-CP CFC on patient health outcomes.

Endoscopic management of hemorrhagic pancreatic fluid collections: A propensity-matched analysis

Objectives

Hemorrhagic pancreatic fluid collections (hPFC) are a complication of pancreatitis with an unknown influence on prognosis. Advancements in endoscopic management of PFC have improved results over their surgical and percutaneous alternatives. We performed a propensity-matched analysis comparing clinical outcomes in hemorrhagic and non-hemorrhagic PFC (nhPFC).

Methods

From November 2015 to November 2021, a retrospective comparative cohort analysis was performed comparing clinical outcomes for patients with hPFC and nhPFC managed with lumen-apposing metal stents. Propensity score matching was used to balance the two subgroups. Wilcoxon two-sample tests were used to compare continuous variables and Fisher's exact test was used to compare categorical variables. Kaplan-Meier method was used to estimate overall survival.

Results

Fifteen patients with hPFC were matched with 30 nhPFC patients. Technical and clinical success was similar in both groups. The median length of hospitalization was 6 days in the hPFC group and 3 days in the nhPFC group (p = 0.23); however, more hPFC patients required intensive care unit admission post-procedure (33.3% vs. 16.7%, p = 0.26). Patients with hPFC were more likely to be readmitted to the hospital within 30 days (33.3% vs. 6.7%, p = 0.032). Mortality at 3 months (13% vs 3%, p = 0.25) and 6 months (27% vs. 7%, p = 0.09) was higher in the hPFC cohort. The 1-year survival estimate was 73.3% (standard error = 11.4) in the hPFC group and 88.9% (6.1) in the nhPFC group (p = 0.16).

Conclusions

Patients with hPFC are more likely to be readmitted to the hospital within 30 days and have worse clinical outcomes.

New Razor Technology Improves Appearance and Quality of Life in Men With Pseudofolliculitis Barbae

Pseudofolliculitis barbae (PFB) consists of ingrown hairs leading to papules, pustules, and discomfort. This prospective, 12-week clinical study aimed to assess the appearance of males with razor bumps and shaving irritation when using a new razor technology with 2 blades separated by a bridge feature (SkinGuard [Procter & Gamble]). The impact on participants' shave-related itching, burning, and stinging severity, as well as quality of life (QOL), also was assessed. In men with PFB, shaving with the test razor at least 5 times per week over a 12-week period improved the appearance and QOL of males with razor bumps and shaving irritation compared with baseline.

Trends in the Diversity of Pediatric Faculty: 2000 to 2020

OBJECTIVE

Academic medicine diversity is important for addressing health disparities and training the next generation. A recent study highlighted the lack of diversity among pediatric trainees over time. However, trends in US pediatric faculty diversity have not been clearly illuminated. The aim of this study is to evaluate pediatric faculty diversity trends and compare racial/ethnic representation between pediatric faculty and the US population.

METHODS

Repeat cross-sectional study of the Association of American Medical Colleges Faculty Roster of pediatric faculty from 2000 to 2020. Trends in sex, race, ethnicity, and rank were compared with the Cochran-Armitage test. Data on faculty race/ethnicity were compared with the general and child population by using US Census Bureau data.

RESULTS

Trends in underrepresented in medicine (URiM) faculty representation significantly increased at all ranks: professor (+3.5%, P < .0001), associate professor (+3.0%, P = .0001), and assistant professor (+2.5%, P = .0001). URiM male representation remained unchanged (P = .14), whereas significantly increased trends occurred in URiM female representation (+3.4%, P < .0001). African American/Black males significantly decreased representation at associate (-0.4%, P = .04) and assistant professor levels (-0.6%, P < .0001), and American Indian/Alaska Native males significantly decreased representation at the assistant professor rank (-0.1%, P < .0001). The percentage of URiM pediatric faculty representation was considerably lower compared with 2020 US overall and longitudinal child population representation.

CONCLUSION

The stagnation of URiM male representation and lack of faculty diversity reflective of the US population may have a critical impact on the ability to recruit/retain a diverse pediatric workforce and promote equitable care.

Long-term transmural drainage of pancreatic fluid collections with double pigtail stents following lumen-apposing metal stent placement improves recurrence-free survival in disconnected pancreatic duct syndrome

OBJECTIVES

Disconnected pancreatic duct syndrome (DPDS) is the most common cause of pancreatic fluid collection (PFC) recurrence. While long-term transmural drainage with plastic stents is the preferred endoscopic approach, there is a paucity of literature on patients undergoing initial drainage with lumen-apposing metal stents (LAMS). We describe our experience managing patients with DPDS.

METHODS

A retrospective review of a prospectively maintained database (November 2015-September 2020) was performed looking at clinical outcomes and overall survival for patients undergoing endoscopic management of PFCs using LAMS. The primary outcome was to assess recurrence-free survival in PFC patients with DPDS managed with or without double pigtail stents (DPS) replacement after LAMS removal.

RESULTS

Of 96 patients with PFCs, 48 with DPDS were included in the study. The median follow-up was 20.1 months. LAMS replacement with DPS was successful in 21/48 (43.8%) patients. Recurrence was seen in 1/21 (5%) patients with DPS replacement and 10/27 (37%) without DPS replacement. In multivariable models, a longer duration of LAMS placement was negatively associated with successful DPS replacement (odds ratio 1.33, 95% confidence interval [CI] 1.11, 1.59, P = 0.0019) and successful LAMS replacement with DPS in patients with DPDS improved recurrence-free survival (hazard ratio 0.09, 95% CI 0.01, 0.83, P = 0.033).

CONCLUSION

In patients with PFCs and DPDS, early replacement of LAMS with DPS improves the likelihood of successful long-term transmural drainage and decreases recurrences.

810 Impact of immune-related adverse event development on overall survival in hospitalized lung cancer patients

Background

Immune-related adverse events (irAEs) are a unique characteristic of immune checkpoint inhibitors (ICIs) and can confer survival benefits. For example, melanoma patients who develop vitiligo as an irAE tend to have improved overall survival (OS), hypothesized to be due to molecular mimicry between similar antigens.1 2 Further analysis of the impact of irAEs on OS among real-world lung cancer patients is needed; this study addresses this need in a hospitalized population.3–5

Methods

This single-center retrospective cohort study collected data on a subset of lung cancer patients who received > 1 dose of an ICI (nivolumab or pembrolizumab) between 6/1/18 and 2/1/20 (n=210) and who were subsequently hospitalized and received > 1 dose of systemic corticosteroids for any indication (n=97). Patients were stratified according to whether or not they developed irAEs at any point. Clinical factors for data collection included: comorbidities, irAE development (organ and grade), cancer stage, ICI cycles, biomarkers, progression, and survival. OS analysis was calculated from the first dose of ICI to date of death or last known follow-up. To assess significance, the log-rank approximation of the chi-square test was used.

Results

Kaplan-Meier survival analysis revealed that patients who developed irAEs (n=28, median OS 14.9 months) did not have an association with increased median OS when compared to patients without irAEs (n=69, 8.7 months, p 0.072) (table 1). The subgroup of patients who developed either colitis or pneumonitis had an increased median OS (n=15, 41.3 months, p 0.049) compared to patients without irAEs . Patients who only experienced grade ≥ 3 irAEs (n = 20, median OS 17.0 months, p 0.095) did not show any OS difference compared to patients without irAEs. Patients who developed ≥2 irAEs of any grade (n = 7, median OS 17.0 months, p 0.22) did not show any OS difference as compared to patients without irAEs.

Conclusions

Initial analysis shows that while generalized irAEs in this hospitalized lung cancer population were not significantly associated with OS change, patients who developed pneumonitis and colitis were associated with treatment response and increased OS. Patients could be developing an interaction between pneumonitis and lung cancer analogous to the interaction between vitiligo and melanoma via molecular mimicry, resulting in improved OS. Thus, certain organ-related irAEs may indicate an immune response to ICIs depending on the malignancy being treated, correlating with improved prognosis.

References

Bertrand A, Kostine M, Barnetche T, Truchetet M-E, Schaeverbeke T. Immune related adverse events associated with anti-CTLA-4 antibodies: systematic review and meta-analysis. BMC Med 2015;13:211.

Teulings H-E, Limpens J, Jansen SN, et al. Vitiligo-like depigmentation in patients with stage III-IV melanoma receiving immunotherapy and its association with survival: a systematic review and meta-analysis. J Clin Oncol 2015;33(7):773–81.

Owen DH, Wei L, Villalona-Calero MA, et al. Impact of immune-related adverse events (irAE) on overall survival (OS) in patients treated with immunotherapy for non-small cell lung cancer (NSCLC). J Clin Orthod 2017;35(15_suppl):9080–9080.

Haratani K, Hayashi H, Chiba Y, et al. Association of immune-related adverse events with nivolumab efficacy in non–small-cell lung cancer. JAMA Oncol 2018;4(3):374–8.

Owen DH, Wei L, Bertino EM, et al. Incidence, risk factors, and effect on survival of immune-related adverse events in patients with non–small-cell lung cancer. Clin Lung Cancer 2018;19(6):e893–900.

Ethics Approval

The study protocol was approved by Wake Forest Baptist Medical Center's institutional review board.

Abstract 810 Table 1

Results of irAE impact on median OS analysis

Bladder-to-bladder metastasis: gallbladder cancer metastasising to the urinary bladder

We report a 48-year-old fit and healthy woman who was incidentally diagnosed to have adenocarcinoma of gallbladder after laparoscopic cholecystectomy. Subsequent imaging showed no evidence of regional or distant spread. She was scheduled for elective laparotomy and resection of gallbladder bed, but during laparotomy frozen section analysis of an incidentally discovered peritoneal deposit confirmed metastasis, so the procedure was abandoned. Thereafter, she received cisplatin and gemcitabine chemotherapy. However, surveillance computed tomography incidentally noted a urinary bladder mass which had not been present before. Transurethral resection of the bladder lesion revealed moderately differentiated adenocarcinoma of urinary bladder. The appearance and immunoprofile of the lesion confirmed metastasis from the primary gallbladder cancer, which has not been documented in the literature to the best of our knowledge. Her disease progressed and she is being challenged with gemcitabine and carboplatin as second-line palliative chemotherapy. She is still alive two years after the initial diagnosis.

Diabetic Retinopathy Screening in Patients with Diabetes Using a Handheld Fundus Camera: The Experience from the South-Eastern Region in Hungary

PURPOSE

Diabetic retinopathy (DR) is the leading cause of vision loss among active adults in industrialized countries. We aimed to investigate the prevalence of diabetes mellitus (DM), DR and its different grades, in patients with DM in the Csongrád County, South-Eastern region, Hungary. Furthermore, we aimed to detect the risk factors for developing DR and the diabetology/ophthalmology screening patterns and frequencies, as well as the effect of socioeconomic status- (SES-) related factors on the health and behavior of DM patients.

METHODS

A cross-sectional study was conducted on adults (>18 years) involving handheld fundus camera screening (Smartscope Pro Optomed, Finland) and image assessment using the Spectra DR software (Health Intelligence, England). Self-completed questionnaires on self-perceived health status (SPHS) and health behavior, as well as visual acuity, HbA1c level, type of DM, and attendance at healthcare services were also recorded.

RESULTS

787 participants with fundus camera images and full self-administered questionnaires were included in the study; 46.2% of the images were unassessable. T1D and T2D were present in 13.5% and 86.5% of the participants, respectively. Among the T1D and T2D patients, 25.0% and 33.5% had DR, respectively. The SES showed significant proportion differences in the T1D group. Lower education was associated with a lower DR rate compared to non-DR (7.7% vs. 40.5%), while bad/very bad perceived financial status was associated with significantly higher DR proportion compared to non-DR (63.6% vs. 22.2%). Neither the SPHS nor the health behavior showed a significant relationship with the disease for both DM groups. Mild nonproliferative retinopathy without maculopathy (R1M0) was detected in 6% and 23% of the T1D and T2D patients having DR, respectively; R1 with maculopathy (R1M1) was present in 82% and 66% of the T1D and T2D groups, respectively. Both moderate nonproliferative retinopathy with maculopathy (R2M1) and active proliferative retinopathy with maculopathy (R3M1) were detected in 6% and 7% of the T1D and T2D patients having DR, respectively. The level of HbA1c affected the attendance at the diabetology screening (HbA1c > 7% associated with >50% of all quarter-yearly attendance in DM patients, and with 10% of the diabetology screening nonattendance).

CONCLUSION

The prevalence of DM and DR in the studied population in Hungary followed the country trend, with a slightly higher sight-threatening DR than the previously reported national average. SES appears to affect the DR rate, in particular, for T1D. Although DR screening using handheld cameras seems to be simple and dynamic, much training and experience, as well as overcoming the issue of decreased optic clarity is needed to achieve a proper level of image assessability, and in particular, for use in future telemedicine or artificial intelligence screening programs.

Digital Image Analysis of the Angle and Optic Nerve: A Simple, Fast, and Low-Cost Method for Glaucoma Assessment

PURPOSE

To devise a simple, fast, and low-cost method for glaucoma assessment using digital image analysis of the angle and optic nerve in human subjects.

METHODS

Images from glaucoma and fundus assessment were used in this study, including color fundus photographs, standard optic nerve optical coherence tomography (OCT), and digital slit-lamp images of the angle/gonioscopy. Digital image conversion and analysis of the angle using ImageJ (NIH, USA) and adaptive histogram equalization contrast-limited AHE (CLAHE) to prevent noise amplification were implemented. Angle and optic nerve images were analyzed separately in the red, green, and blue (RGB) channels followed by 3D volumetric analysis of the degrees of angle depth and cup volume of the optic nerve. Horizontal tomogram reconstitution and nerve fiber detection methods were developed and compared to standard OCT images.

RESULTS

Digital slit-lamp angle images showed similar accuracy as standard anterior OCT measurements. Comparative analysis of RGB channels produced volumetric cup and horizontal tomogram, which closely resembled the 3D OCT appearance and B-scan of the cup, respectively. RGB channel splitting and image subtraction produced a map closely resembling that of the retinal nerve fiber layer (RNFL) thickness map on OCT.

CONCLUSIONS

While OCT imaging is rapidly progressing in the area of optic disc and chamber angle assessment, rising healthcare costs and lack of availability of the technology open a demand for alternative and cost-minimizing forms of image analysis in glaucoma. Volumetric, geometric, and segmentational data obtained through digital image analysis correspond well to those obtained by OCT imaging.

Ilioinguinal/Iliohypogastric versus quadratus lumborum nerve blockade for elective open inguinal herniorrhaphy: a prospective, randomized, double-blinded, equivalency trial

BACKGROUND

Open inguinal herniorrhaphy (OIH) is a commonly performed surgical procedure with expected postoperative pain. Historically, an option for regional analgesia has been an ilioinguinal and iliohypogastric nerve block (IINB). More recently, the transmuscular quadratus lumborum block (QLB) has been used as an analgesic technique for a variety of abdominal and truncal surgical procedures. Given our own institutional experiences with the performance of QLB combined with the body of literature supporting the proximal blockade of the ilioinguinal and iliohypogastric nerves via this approach, we compared the analgesia provided by an IINB to a QLB. We hypothesized that the two blocks would provide equivalent analgesia, as defined by a difference of less than±2 points on the pain scale (0-10 numeric rating scale (NRS)), for patients undergoing OIH.

METHODS

Sixty patients scheduled for elective outpatient OIH under general anesthesia were randomized to preoperatively receive either an IINB or a transmuscular QLB with 0.25% bupivacaine/epinephrine/clonidine for postoperative analgesia. The primary endpoint was movement NRS pain scores at 8 hours. Secondary outcomes included resting NRS pain scores at 8 and 24 hours, movement NRS pain scores at 24 hours, incidence of opioid related side effects (nausea, vomiting, pruritus), time-to-first oral opioid analgesic, and total opioid consumption at 24 hours.

RESULTS

Fifty-nine patients were analyzed per an intention-to-treat approach (one patient was excluded because the surgical procedure was canceled). Movement pain scores at 8 hours were equivalent (IINB 5.10±3.02 vs QLB 5.03±3.01 (mean NRS±SD); two one-sided test mean difference (90% CI), 0.07 (-1.24 to 1.38), p ≤0.01). There were no differences between groups for any of the secondary endpoints.

CONCLUSION

An IINB and a transmuscular QLB are equivalent with regards to their ability to provide postoperative analgesia after OIH.

Hepatic arterial infusion chemotherapy for colorectal liver metastases revisited

BACKGROUND

Recent reports indicate improved survival in patients undergoing surgical treatment for colorectal liver metastases (CRLM) with hepatic arterial infusion (HAI) pump chemotherapy compared to surgery alone.

METHODS

Patients who underwent resection and/or ablation of CRLM between 1996 and 2016 were included from a single-institution prospectively maintained database. Proportional hazards regression analysis was performed to determine predictors of overall survival (OS) and 3:1 propensity score analysis (PSA).

RESULTS

Of 349 patients included, 36 had HAI pumps placed (HAI group) and 313 did not (no-HAI group). There was no difference in primary tumor grade (p = 0.24), ECOG status (p = 0.44), tumor number (p = 0.1), tumor size (p = 0.56), margin status (p = 0.76) between the two groups. Median overall survival was 44.7months vs 37.1months for the HAI versus no-HAI group (p = 0.01). Cox proportional hazards regression analysis demonstrated positive margin status (HR:2.47,p < 0.0001), HAI therapy (HR:0.56,p = 0.02), preoperative chemotherapy (HR:0.69,p = 0.02) and tumor diameter (HR:1.07,p = 0.005) as predictors of OS. In 3:1 PSA, 32 HAI subjects were matched with 87 non-HAI subjects balancing all covariates. Median OS was 42.4 months versus 35.6 months for the HAI versus no-HAI group (p = 0.03).

CONCLUSION

Surgical treatment of CRLM combined with HAI chemotherapy is associated with improved OS compared to surgery alone. Further study of this treatment approach is indicated.

Prognostic Awareness, Disease and Palliative Understanding Among Caregivers of Patients With Dementia

BACKGROUND

Persons with dementia (PwD) often have significant cognitive deficits and functional limitations, requiring substantial caregiver assistance. Given the high symptom burden and terminal nature of dementia, good prognostic awareness and integration of palliative care (PC) is needed.

OBJECTIVE

To evaluate prognostic awareness, disease, and PC understanding among caregivers of PwD and to assess for improvements in routine care.

DESIGN

A cross-sectional study of 2 cohorts at a single-academic medical center. Surveys were mailed to 200 caregivers of PwD in 2012 (cohort 1). Surveys were sent to new subset of caregivers of PwD (n = 80) in 2018 (cohort 2) to assess trends over time.

RESULTS

A total of 154 of caregivers completed the survey (response rate 55%). Compared to 2012, a higher proportion of caregivers in 2018 reported having conversations about prognosis with PwD's physicians (25% in 2012 vs 45% in 2018; P = .027). However, a large percentage (43% in 2012 and 40% in 2018) of caregivers reported no understanding of the PwD's prognosis. Despite most stating dementia was not curable, only 39% in 2012 and 52% in 2018 (P = .015) understood that dementia was a terminal disease. In addition, only 32% in 2012 and 40% in 2018 (P = .39) felt that they were knowledgeable about PC.

CONCLUSIONS

Prognostic discussions between caregivers of PwD and the PwD's physicians may be occurring more often; however, a high percentage of caregivers report a poor understanding about the terminal nature of dementia and the role of PC.

Optimal Timing of Systemic Therapy in Resectable Colorectal Liver Metastases

Perioperative chemotherapy has been shown to improve disease-free survival compared with surgery alone for resectable colorectal liver metastases (CLM). We examined our experience with systemic chemotherapy in this clinical setting. A prospectively collected liver surgery database identified 210 patients treated for resectable CLM from 1996 to 2010. Results were correlated to four treatment groups: posthepatectomy adjuvant only, prehepatectomy preoperative only, peri-operative (preoperative and adjuvant), and surgery only. Seventy-nine (37.6%) patients received posthepatectomy adjuvant only treatment, 33 (15.7%) received prehepatectomy preoperative only treatment, 46 (21.9%) received perioperative (preoperative and adjuvant) treatment, whereas 52 (24.8%) received surgery alone. Preoperative and adjuvant systemic chemotherapy regimens were as follows: 23 (29.1%) and 18 (14.4%) received a 5-fluorouracil monotherapy regimen, 19 (24.1%) and 31 (24.8%) received an irinotecan-based regimen, and 28 (35.4%) and 37 (29.6%) received an oxaliplatin-based regimen. Nine (11.4%) and 12 (9.6%) received some other unknown combination. Treatment groups showed no difference in gender, mean tumor size, number of tumors, margin status, or postoperative complications with the only difference being a higher incidence of metachronous tumors in the preoperative only and perioperative groups (P = 0.01). Median follow-up and overall survival were 25 and 41 months, respectively. The adjuvant, preoperative, perioperative, and surgery only groups had a median survival time of 48, 35, 39, and 29 months, respectively (log-rank P = 0.04). Independent predictors of overall survival on multivariate analysis included treatment algorithm used and postoperative complication status. Adjuvant only systemic therapy was associated with an improved survival in resectable CLM. Prospective randomized trials are needed to confirm these findings.

Barriers and enablers to the use of venous leg ulcer clinical practice guidelines in Australian primary care: A qualitative study using the theoretical domains framework

BACKGROUND

Venous leg ulcers represent the most common chronic wound problem managed in Australian primary care. Despite the prevalence of the condition, there is an evidence-practice gap in both diagnosis and management of venous leg ulcers.

OBJECTIVE

We used the Theoretical Domains Framework to identify barriers and enablers perceived by primary care practitioners in implementing venous leg ulcer guidelines in clinical practice.

DESIGN

We collected data to explore the experiences of practice nurses and general practitioners related to their use of clinical practice guidelines in management of venous leg ulcers.

SETTING(S)

We recruited participants from primary care settings located in metropolitan and rural areas across Victoria, Australia.

PARTICIPANTS

We recruited general practitioners (15) and practice nurses (20).

METHODS

We conducted 35 semi-structured face-to-face and telephone interviews. Content analysis of health practitioners' statements was performed and barriers to implementing clinical practice guidelines were mapped across the Theoretical Domains Framework theoretical domains.

RESULTS

Six main domains from the Theoretical Domains Framework (Environmental context and resources, Knowledge, Skills, Social influences, Social/Professional Role and Identity and Belief about Capabilities) best explained these barriers and enablers. Many participants were not aware of venous leg ulcer clinical practice guidelines. Those that were aware, stated that finding and accessing guidelines was challenging and most participants relied on other sources of information. Venous leg ulcer management was greatly influenced by professional experience and suggestions from colleagues. Other barriers included busy clinical practice, absence of handheld Doppler ultrasonography, insufficient skills and a lack of confidence related to the use of technology to rule out arterial involvement prior to compression application, a particular skill related to venous leg ulcer management that will impact on healing outcomes.

CONCLUSIONS

We identified a number of barriers and the lack of enablers that influence the uptake of venous leg ulcer clinical practice guidelines in primary care. This paper adds a theoretically sound, systematic approach for understanding and addressing the behaviour change required to improve translation of venous leg ulcer clinical practice guidelines in clinical practice. Tweetable abstract: The need to optimise venous leg ulcer clinical practice guidelines (CPG) has never been greater as the current estimate of health cost is AUD3billion and increasing due to rising epidemics of diabetes and obesity. We found most primary care health practitioners are unaware of CPG and this will impact on health and healing outcomes in Australian primary care.

Barriers and predictors of medication use for childhood ADHD: findings from a UK population-representative cohort

PURPOSE

Little is known about sociodemographic and clinical factors that predict and act as barriers to ADHD medication independently of symptom severity. We examined the proportion of children using medication for ADHD, age of initiation of medication, and predictors of medication use in a population-representative cohort.

METHODS

Data from the Millennium Cohort Study on child ADHD, medication use for ADHD at age 14 (in 2014-2015) and child, parent and sociodemographic variables were collated. Logistic regression models were used to identify factors that predict medication use for ADHD (the main outcome measure), adjusting for symptom severity at age seven.

RESULTS

The weighted prevalence of ADHD was 3.97% (N = 11,708). 45.57% of children with ADHD (N = 305) were taking medication. The median age at initiation was 9 years (range 3-14). Male gender (AOR 3.66, 95% CI 1.75, 7.66) and conduct problems at age seven (AOR 1.24 95% CI 1.04, 1.47) and 14 predicted medication use at age 14 after adjusting for symptom severity.

CONCLUSIONS

Our study is the first to assess predictors of medication whist adjusting for ADHD symptom severity. Girls with ADHD were less likely to be prescribed medication, even when they displayed similar ADHD symptom levels to boys. Conduct problems also predicted medication independently of ADHD symptoms. ADHD may be more often medicated in boys because clinicians may think a prototypical ADHD child is male, and perhaps conduct problems make boys more disruptive in the classroom, leading to boys being more often treated.

Health-Related Quality of Life After Cytoreductive Surgery/HIPEC for Mucinous Appendiceal Cancer: Results of a Multicenter Randomized Trial Comparing Oxaliplatin and Mitomycin

BACKGROUND

This study evaluated health-related quality of life (HRQOL) using patient-reported outcomes in subjects with mucinous appendiceal neoplasms who underwent cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) as part of a randomized trial comparing mitomycin with oxaliplatin.

METHODS

In this prospective multicenter study, 121 mucinous appendiceal cancer patients, with evidence of peritoneal dissemination who underwent CRS, were randomized to receive mitomycin (divided 40 mg) or oxaliplatin (200 mg/m²) for HIPEC. The Functional Assessment of Cancer Therapy Neurotoxicity (FACT-G/NTX) questionnaire was utilized to assess HRQOL. The Trial Outcome Index (TOI) is a summary index responsive to changes in physical/functional outcomes. Repeated measures mixed models with an unstructured variance matrix were applied to assess changes in HRQOL longitudinally.

RESULTS

Baseline questionnaire compliance was 95.9%. Baseline physical well-being (PWB) was independently associated with overall survival (hazard ratio 0.79, 95% confidence interval 0.66-0.96; p = 0.017). The TOI was significantly lower in the mitomycin group compared with the oxaliplatin arm at 12 weeks (p = 0.044; score difference 6.35) and 24 weeks after surgery (p = 0.049; score difference 5.61). At 12 weeks after surgery, declines from baseline were significant in the TOI (p = 0.004; score decline 8.99), PWB (p < 0.001; score decline 2.83), and FWB (p < 0.001; score decline 3.42) in the mitomycin group but not the oxaliplatin group.

CONCLUSIONS

Compared with mitomycin, HIPEC perfusion with oxaliplatin results in significantly better physical and functional outcomes. With similar survival outcomes and complication rates, oxaliplatin should be considered as the chemoperfusion agent of choice in mucinous appendiceal cancer patients undergoing CRS/HIPEC.

Risk factors associated with excessive negative energy balance in commercial United Kingdom dairy herds

This study assessed risk factors associated with excessive negative energy balance (eNEB) in UK dairy cows between April 2006 and March 2015. Blood samples were analysed for β-hydroxybutyrate (BHB), non-esterified fatty acids (NEFA) and glucose. Following removal of all potential duplicate cows, a final dataset of 69,161 unique individual cows was obtained including biochemical results, individual cow and feed data. Generalised linear mixed-effect models and multivariable classification tree-based models showed that individual cow risk factors for eNEB included: (1) days relative to predicted calving date (dry cows); (2) days in milk (lactating cows); (3) body condition score (BCS; lactating cows ≥ BCS 4; OR 2.1); (4) milk yield (around 40 L per day); (5) parity (first lactation heifers; odds ratio [OR] 0.46 compared to older cows during lactation); and (6) chronic inflammatory conditions as assessed by globulin concentrations ≥ 50 g/L (OR 0.79 for cows with evidence of chronic inflammation). There was a higher prevalence during April to October (OR 1.19), and the lowest prevalence was in November. Feeding grass silage and wholecrop (silage made from cereal crops) to dry cows was associated with a reduced prevalence of eNEB, whereas access to grazed grass was associated with a higher prevalence in both the dry period (OR 1.32) and lactation (OR 1.33). Knowledge of the risk factors associated with eNEB in commercial dairy herds assists in both the implementation of herd monitoring programs and reduction of eNEB in dairy herds, with associated reductions in the risk of periparturient diseases and improved dairy cow performance.

Clinical and molecular markers in retinal detachment-From hyperreflective points to stem cells and inflammation

PURPOSE

Retinal detachment (RD) is one of the most frequently diagnosed ophthalmologic conditions requiring prompt surgical intervention. Combination of proper surgical technique and new diagnostic markers, both clinical and molecular, can help improve the diagnosis and prognosis of RD treatment.

METHODS

12 patients with rhegmatogenous RD (rRD) were included into the study after obtaining patient consent and Regional Ethical Approval (average age: 58.1 ± 17.4 years). OCT was performed before and after 23G vitrectomy for RD. Pure subretinal fluid (SRF) was collected during surgery and analyzed by protein array profiling on a panel of 105 inflammatory cytokines (Human XL Cytokine Array), while the effect of SRF upon human macrophages-driven phagocytosis of apoptotic retinal pigment epithelial (RPE) cells ex vivo was quantified by flow cytometry. Immunohistochemistry (IHC) of retinectomized tissue due to PVR caused by RD was performed to determine presence of markers for microglial cells (CD34), macrophages and activated microglia (CD68), regulator of the immune response to infection (NFkB), progenitor and stem cell marker (Sox2), pluripotency marker (Oct4) and intermediate filament markers (GFAP and Nestin).

RESULTS

OCT of fresh RD patients contained pre-operatively hyper reflective points (HRPs) at the detached neuroretina border and proximal to the RPE layer-their size and number decreased following successful reattachment surgery. IHC of the retinectomized tissue from detached retina due to severe PVR showed presence of cell conglomerates at the detached neuroretina border which were positive for CD68, NFkB, Sox2 and GFAP, less positive for CD47 and Nestin and negative for Oct4 and CD34. The SRF contained at least 37 cytokines with higher, and 4 cytokine with lower concentration compared to that in vitreous from non-RD pathology; when used as conditional medium to human macrophages ex vivo, the SRF doubled their capacity for engulfing dying RPEs.

CONCLUSIONS

Fresh RD can be hallmarked by presence of HRPs at the detached neuroretina border on OCT; the HRPs decrease in size and number after successful reattachment surgery, and likely resemble the macrophage conglomerates seen by IHC. The neuroretina in RD contains progenitor/stem-like cells and signs of inflammatory reaction, while the SRF contains inflammatory cytokines and other factors which increase the ability of professional phagocytes to engulf dying RPE, or for that matter, other dying cells in the retina.

Connecting Refugees to Medical Homes Through Multi-Sector Collaboration

As increasing numbers of refugees have resettled globally, an interdisciplinary group of stakeholders in Forsyth, North Carolina, recognized obstacles preventing coordinated medical care, which inspired the development of our Refugee Health Collaborative. This study assessed the Collaborative's impact on access to coordinated care within patient-centered medical homes (PCMH). A Collaborative-developed novel algorithm guided the process by which refugees establish care in PCMHs. All refugees who established medical care in the two primary health systems in our county (n = 285) were included. Logistic non-linear mixed models were used to estimate the differences between three time frames: pre-algorithm, algorithm implementation and refinement, and ongoing algorithm implementation. After algorithm implementation, there has been a significant decrease in the time required to establish care in PCMHs, increased provider acknowledgment of refugee status, and decreased emergency department (ED) visits. Multi-disciplinary, organized collaboration can facilitate enhanced access to care for refugee families at the population level.

Effect of Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy on Quality of Life in Patients with Peritoneal Mesothelioma

INTRODUCTION

Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (HIPEC) is an accepted treatment for peritoneal mesothelioma. In this study, we evaluated QOL after HIPEC for peritoneal mesothelioma.

METHODS

This was a prospective study performed after HIPEC for peritoneal mesothelioma between 2002 and 2015. Patients completed QOL surveys, including the Short Form-36 (SF-36), Functional Assessment of Cancer Therapy + Colon (FACT-C), Brief Pain Inventory (BPI), and Center for Epidemiologic Studies Depression Scale (CES-D) preoperatively and at 3, 6, 12, and 24 months postoperatively.

RESULTS

Overall, 46 patients underwent HIPEC for peritoneal mesothelioma and completed QOL surveys. Mean age was 52.8 ± 13.8 years and 52% were male. Good preoperative functional status was 70%. Median survival was 3.4 years, and 1, 3, and 5-year survivals were 77.4, 55.2, and 36.5%, respectively. CES-D score decreased at 3 months postoperatively, but increased at 24 months (p = 0.014); SF-36 physical functioning scale decreased at 3 months but returned to baseline at 12 months (p = 0.0045); and the general health scale decreased at 3 months, then improved by 6 months (p = 0.0034). Emotional well-being (p = 0.0051), role limitations due to emotional problems (p = 0.0006), social functioning (p = 0.0022), BPI (p = 0.025), least pain (p = 0.045), and worst pain (p < 0.0001) improved. FACT-C physical well-being decreased at 3 months but returned to baseline at 6 months (p = 0.020), and total FACT-C score improved at 6 months (p = 0.052).

CONCLUSION

QOL returned to baseline or improved from baseline between 3 months and 1 year following surgery. Despite the risks associated with this operation, patients may tolerate HIPEC well and have good overall QOL postoperatively.

Prevalence of excessive negative energy balance in commercial United Kingdom dairy herds

The objectives of this study were to determine the individual animal and herd level prevalence of excessive negative energy balance (eNEB) in commercial UK dairy herds. Between April 2006 and March 2015, blood samples from 84,369 individual cows from 1748 different UK farms were received by a commercial laboratory service specializing in dairy cow nutritional monitoring. Following removal of all potential duplicate cows, the final dataset comprised 69,161 unique individual cows. The prevalence of eNEB was determined using plasma thresholds of β-hydroxybutyrate (BHB), non-esterified fatty acids (NEFA) and glucose. Overall prevalence of subclinical ketosis (SCK) in the first 20 days of lactation was 28.5%, 17.3% and 11.7% using BHB thresholds of 1.0, 1.2 and 1.4 mmol/L respectively. Prevalence of NEFA values ≥0.5 mmol/L in the last 10 days prior to calving was 26.0%, and 40.3% of cows had NEFA values ≥0.7 mmol/L in the first 20 days in milk (DIM). Combining BHB, NEFA and glucose showed that 52.0% of cows had one or more of the three biochemical measures of energy balance outside the respective threshold value in the last 10 days pre-calving, and 75.2% of cows showed a similar biochemical pattern in the first 20 DIM. The median herd prevalence of elevated BHB and/or NEFA was 37.5% in late pregnancy and 59.8% in the first 20 DIM, with substantial herd variation. Using multiple measures for the assessment of energy balance, this study has shown that eNEB affects substantial numbers of UK dairy cows.

Critical care usage after major gastrointestinal and liver surgery: a prospective, multicentre observational study

BACKGROUND

Patient selection for critical care admission must balance patient safety with optimal resource allocation. This study aimed to determine the relationship between critical care admission, and postoperative mortality after abdominal surgery.

METHODS

This prespecified secondary analysis of a multicentre, prospective, observational study included consecutive patients enrolled in the DISCOVER study from UK and Republic of Ireland undergoing major gastrointestinal and liver surgery between October and December 2014. The primary outcome was 30-day mortality. Multivariate logistic regression was used to explore associations between critical care admission (planned and unplanned) and mortality, and inter-centre variation in critical care admission after emergency laparotomy.

RESULTS

Of 4529 patients included, 37.8% (n=1713) underwent planned critical care admissions from theatre. Some 3.1% (n=86/2816) admitted to ward-level care subsequently underwent unplanned critical care admission. Overall 30-day mortality was 2.9% (n=133/4519), and the risk-adjusted association between 30-day mortality and critical care admission was higher in unplanned [odds ratio (OR): 8.65, 95% confidence interval (CI): 3.51-19.97) than planned admissions (OR: 2.32, 95% CI: 1.43-3.85). Some 26.7% of patients (n=1210/4529) underwent emergency laparotomies. After adjustment, 49.3% (95% CI: 46.8-51.9%, P<0.001) were predicted to have planned critical care admissions, with 7% (n=10/145) of centres outside the 95% CI.

CONCLUSIONS

After risk adjustment, no 30-day survival benefit was identified for either planned or unplanned postoperative admissions to critical care within this cohort. This likely represents appropriate admission of the highest-risk patients. Planned admissions in selected, intermediate-risk patients may present a strategy to mitigate the risk of unplanned admission. Substantial inter-centre variation exists in planned critical care admissions after emergency laparotomies.

A Single-Center Retrospective Study of Acute Kidney Injury Incidence in Patients With Advanced Malignancies Treated With Antimitochondrial Targeted Drug

Introduction

Mitochondrial dysfunction plays an important role in the pathophysiology of kidney disease. Inhibitors of mitochondrial metabolism are being developed for the treatment of solid organ and hematologic malignancies. We describe the incidence and clinical features of acute kidney injury (AKI) in patients treated with the antimitochondrial drug CPI-613.

Methods

We identified 33 patients with relapsed or refractory malignancy, previously enrolled in 3 open-label phase II studies, who received single-agent CPI-613 chemotherapy. AKI was defined by the Kidney Disease Improving Global Outcomes serum creatinine criteria. Participants were followed for a median (25th–75th percentile) of 120.0 (74.0–301.0) days. Risk factors for AKI were assessed by proportional hazards regression using univariate and multivariate analyses.

Results

Participants had baseline mean (SD) age of 63.8 (11.6) years and serum creatinine 0.9 (0.3) mg/dl. AKI developed in 9 (27%) patients; chart review failed to identify a potential cause of AKI other than CPI-613 administration in 5 (15%) patients, of whom 1 had AKI stage 1, 1 had AKI stage 2, and 3 experienced AKI stage 3. Time from initiation of CPI-613 treatment to AKI was 51.0 (16.0–58.0) days. Age, per 5-year increase, was associated with higher risk of AKI (adjusted hazard ratio 2.01, 95% confidence interval 1.06–3.79, P = 0.03). Follow-up serum creatinine was available in 4 participants 174.8 (139.6) days after the episode of AKI; 3 patients had complete recovery in kidney function and 1 had partial recovery.

Conclusion

AKI is a possible complication during treatment with mitochondria-targeted chemotherapy.

Factors associated with multiple barriers to access to primary care: an international analysis

Background

Disparities in access to primary care (PC) have been demonstrated within and between health systems. However, few studies have assessed the factors associated with multiple barriers to access occurring along the care-seeking process in different healthcare systems.

Methods

In this secondary analysis of the 2016 Commonwealth Fund International Health Policy Survey of Adults, access was represented through participant responses to questions relating to access barriers either before or after reaching the PC practice in 11 countries (Australia, Canada, France, Germany, Norway, the Netherlands, New Zealand, Sweden, Switzerland, the United Kingdom, and United States). The number of respondents in each country ranged from 1000 to 7000 and the response rates ranged from 11% to 47%. We used multivariable logistic regression models within each of eleven countries to identify disparities in response to the access barriers by age, sex, immigrant status, income and the presence of chronic conditions.

Results

Overall, one in five adults (21%) experienced multiple barriers before reaching PC practices. After reaching care, an average of 16% of adults had two or more barriers. There was a sixfold difference between nations in the experience of these barriers to access. Vulnerable groups experiencing multiple barriers were relatively consistent across countries. People with lower income were more likely to experience multiple barriers, particularly before reaching primary care practices. Respondents with mental health problems and those born outside the country displayed substantial vulnerability in terms of barriers after reaching care.

Conclusion

A greater understanding of the multiple barriers to access to PC across the stages of the care-seeking process may help to inform planning and performance monitoring of disparities in access. Variation across countries may reveal organisational and system drivers of access, and inform efforts to improve access to PC for vulnerable groups. The cumulative nature of these barriers remains to be assessed.

Electronic supplementary material

The online version of this article (10.1186/s12939-018-0740-1) contains supplementary material, which is available to authorized users.

A Multicenter Randomized Trial to Evaluate Hematologic Toxicities after Hyperthermic Intraperitoneal Chemotherapy with Oxaliplatin or Mitomycin in Patients with Appendiceal Tumors

BACKGROUND

Appendiceal cancer is a rare disease that has proven difficult to study in prospective trials. Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (HIPEC) is an established therapy for peritoneal dissemination from appendiceal cancer. The optimal chemotherapeutic agent to use in the HIPEC is not clear. Mitomycin has long been used, however, our previous phase I experience and European retrospective studies suggest oxaliplatin as an alternative. Therefore, we initiated a multicenter randomized trial to compare mitomycin with oxaliplatin HIPEC for appendiceal cancer.

STUDY DESIGN

Patients with mucinous appendiceal neoplasms with evidence of peritoneal dissemination underwent cytoreductive surgery and HIPEC using a closed technique for 120 minutes. Patients were randomized intraoperatively to HIPEC using mitomycin (40 mg) or oxaliplatin (200 mg/M²). Follow-up included daily blood counts and toxicity assessments.

RESULTS

One hundred and twenty-one analytic patients were accrued to the trial during 6 years at 3 sites. The patients were 57% female, with a mean age of 55.3 years (range 22 to 82 years). The disease was low grade in 77% and high grade in 23%. There were no significant differences in hemoglobin or platelet counts. The WBC was significantly lower in the mitomycin group between postoperative days 5 and 10. Overall and disease-free survival rates at 3 years were similar at 83.7% and 66.8% for mitomycin and 86.9% and 64.8% for oxaliplatin.

CONCLUSIONS

This represents the first completed prospective randomized trial for cancer of the appendix, and shows that multicenter trials for this disease are feasible. Both mitomycin and oxaliplatin are associated with minor hematologic toxicity. However, mitomycin has slightly higher hematologic toxicity and lower quality of life than oxaliplatin in HIPEC. Consequently, oxaliplatin might be preferred in patients with leukopenia and mitomycin preferred in patients with thrombocytopenia due to earlier chemotherapy.

PCI is Not Predictive of Survival After Complete CRS/HIPEC in Peritoneal Dissemination from High-Grade Appendiceal Primaries

BACKGROUND

Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) is a treatment option in patients with carcinomatosis from high-grade appendiceal (HGA) primaries. It is unknown if there is a Peritoneal Carcinomatosis Index (PCI) upper limit above which a complete CRS/HIPEC does not assure long-term survival.

METHODS

Retrospective analysis from three centers was performed. The PCI was used to grade volume of of disease. Survival in relation to PCI was studied on patients with complete cytoreduction.

RESULTS

Overall, 521 HGA patients underwent CRS/HIPEC from 1993 to 2015, with complete CRS being achieved in 50% (260/622). Mean PCI was 14.8 (standard deviation 8.7, range 0-36). Median survival for the complete CRS cohort was 6.1 years, while 5- and 10-year survival was 51.7% (standard error [SE] 4.6) and 36.1% (SE 6.3), respectively. Arbitrary cut-off PCI limits with 5-point splits (p = 0.63) were not predictive of a detrimental effect on survival as long as a complete CRS was achieved. A linear effect of the PCI on survival (p = 0.62) was not observed, and single-point PCI cohort splits within a PCI range of < 5 to > 10 were not predictive of survival for complete CRS patients. The PCI correlated with the ability to achieve a complete CRS, with a mean PCI of 14.7 (8.7) for completeness of cytoreduction (CC)0, 22.3 (7.8) for CC1 and 26.1 (9.5) for CC2/3 resections (p = 0.0001, hazard ratio 1.12, 95% confidence interval 1.09), with an HR of 1.15 for each 1-unit increase in the PCI score. Only 21% of the cohort achieved a complete CRS with a PCI ≥ 21.

CONCLUSIONS

The PCI correlates with the ability to achieve a complete CRS in carcinomatosis from HGA. PCI is not associated with survival as long as a complete CRS can be achieved.

Is Cytoreductive Surgery with Hyperthermic Intraperitoneal Chemotherapy Justified for Biphasic Variants of Peritoneal Mesothelioma? Outcomes from the Peritoneal Surface Oncology Group International Registry

BACKGROUND

Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) has dramatically improved the survival of patients with epithelioid peritoneal mesothelioma. It is unknown if CRS/HIPEC is indicated for the more aggressive biphasic mesothelioma variant.

METHODS

A retrospective analysis of the Peritoneal Surface Oncology Group International (PSOGI) registry including data from 33 centers was performed. Survival was reviewed based on mesothelioma type, completion of cytoreduction, and volume of disease.

RESULTS

Overall, 484 of 1165 (41.5%) CRS/HIPEC procedures with complete CC0 and CC1 cytoreductions were analyzed; 450 (93%) procedures were performed for epithelioid mesotheliomas, while 34 (7%) were performed for biphasic mesotheliomas. For patients with CC0 resection, 5-year survival was 64.5 and 50.2% (median 7.8 and 6.8 years; p = 0.015) for epithelioid and biphasic mesotheliomas, respectively, while inclusion of CC1 resections in the analysis resulted in inferior 5-year survival of 62.9% and 41.6% (median 7.8 and 2.8 years; p = 0.0012), respectively. Incomplete CC2 resections for biphasic primaries resulted in a median survival of 4.3 months. Univariate analysis of the biphasic cohort indicated Peritoneal Cancer Index (PCI; p = 0.015), CC status of resection (p < 0.0001), and Ki67 (p = 0.04) as predictors of survival. Systemic chemotherapy before (p = 0.55) or after (p = 0.7) CRS/HIPEC did not influence survival. In multivariate analysis, only PCI (p = 0.03) and CC (p = 0.04) remained significant.

CONCLUSIONS

Long-term survival is achievable in patients with low-volume biphasic mesothelioma after complete macroscopic cytoreduction. Biphasic peritoneal mesotheliomas should not be considered as an absolute contraindication for CRS/HIPEC if there is low-volume disease and if complete cytoreduction can be achieved.

Problems Experienced by Ovarian Cancer Survivors During Treatment

OBJECTIVE

To identify problems at different treatment points (early treatment, mid-treatment, early posttreatment, and late posttreatment) among women with ovarian cancer.

DESIGN

Longitudinal and cross-sectional study design.

SETTING

An academic and community clinical cancer center in the Southeastern United States.

PARTICIPANTS

Sixty-eight women with Stage I to IV ovarian cancer.

METHODS

Variables assessed included reported problems (physical, psychosocial, pain, marital, medical interaction), social support, optimism, and responses to open-ended questions. Analysis involved mixed models for longitudinal repeated measures and unpaired t tests and content analysis to describe responses to open-ended questions.

RESULTS

Physical and psychosocial problems were greatest during early treatment and decreased throughout the treatment trajectory. Women with greater levels of social support and optimism at baseline had fewer problems over time. Women who did not have trouble paying for basics had fewer problems related to pain and psychological problems.

CONCLUSION

Problems across all domains must be addressed throughout the treatment trajectory, even after chemotherapy has ended. Nurses are well positioned to refer women appropriately to social workers and clinical navigators across all domains of care and should consider systematic assessment of patient-reported problems as a routine form of practice.

Gaps and barriers in health-care provision for co-morbid diabetes and chronic kidney disease: a cross-sectional study

BACKGROUND

Patients with diabetes and chronic kidney disease (CKD) are a complex subset of the growing number of patients with diabetes, due to multi-morbidity. Gaps between recommended and received care for diabetes and chronic kidney disease (CKD) are evident despite promulgation of guidelines. Here, we document gaps in tertiary health-care, and the commonest patient-reported barriers to health-care, before exploring the association between these gaps and barriers.

METHODS

This cross-sectional study recruited patients with diabetes and CKD (eGFR < 60 mL/min/1.73 m2) across 4 large hospitals. For each patient, questionnaires were completed examining clinical data, recommended care, and patient-reported barriers limiting health-care. Descriptive statistics, subgroup analyses by CKD stage and hospital, and analyses examining the relationship between health-care gaps and barriers were performed.

RESULTS

308 patients, of mean age 66.9 (SD 11.0) years, and mostly male (69.5%) and having type 2 diabetes (88.0%), participated. 49.1% had stage 3, 24.7% stage 4 and 26.3% stage 5 CKD. Gaps between recommended versus received care were evident: 31.9% of patients had an HbA1c ≥ 8%, and 39.3% had a measured blood pressure ≥ 140/90 mmHg. The commonest barriers were poor continuity of care (49.3%), inadequate understanding/education about CKD (43.5%), and feeling unwell (42.6%). However, barriers associated with a failure to receive items of recommended care were inadequate support from family and friends, conflicting advice from and poor communication amongst specialists, the effect of co-morbidities on self-management and feeling unmotivated (all p < 0.05).

CONCLUSIONS

Barriers to health-care varied across CKD stages and hospitals. Barriers associated with a deviation from recommended care were different for different items of care, suggesting that specific interventions targeting each item of care are required.

DR HAGIS-a fundus image database for the automatic extraction of retinal surface vessels from diabetic patients

A database of retinal fundus images, the DR HAGIS database, is presented. This database consists of 39 high-resolution color fundus images obtained from a diabetic retinopathy screening program in the UK. The NHS screening program uses service providers that employ different fundus and digital cameras. This results in a range of different image sizes and resolutions. Furthermore, patients enrolled in such programs often display other comorbidities in addition to diabetes. Therefore, in an effort to replicate the normal range of images examined by grading experts during screening, the DR HAGIS database consists of images of varying image sizes and resolutions and four comorbidity subgroups: collectively defined as the diabetic retinopathy, hypertension, age-related macular degeneration, and Glaucoma image set (DR HAGIS). For each image, the vasculature has been manually segmented to provide a realistic set of images on which to test automatic vessel extraction algorithms. Modified versions of two previously published vessel extraction algorithms were applied to this database to provide some baseline measurements. A method based purely on the intensity of images pixels resulted in a mean segmentation accuracy of 95.83% ([Formula: see text]), whereas an algorithm based on Gabor filters generated an accuracy of 95.71% ([Formula: see text]).