Search

While renal cell carcinoma (RCC) is often linked to smoking, obesity, and hypertension, hereditary forms also account for about 3% of RCC cases. Notably, NCCN guidelines identify 7 major hereditary syndromes associated with an increased RCC risk. Inherited mutations in DNA repair genes, such as ATM, BRCA, and TP53, significantly increase the risk of various cancers. Biallelic pathogenic mutations in ATM cause Ataxia-Telangiectasia (A-T) syndrome, while heterozygous germline pathogenic ATM mutations, present in about 1% of the population, also elevate cancer risk. RCC has not traditionally been associated with germline pathogenic ATM mutations, only limited retrospective analyses have identified such mutations. This case report presents a 68-year-old woman with a germline pathogenic ATM mutation (c.8786+1 G>A) who developed high-risk clear cell RCC followed by an acquired somatic VHL mutation in RCC and a 3-cm serous cystadenoma, illustrating the double-hit phenomenon. Her brother, who shares the same germline pathogenic mutation, was diagnosed with pancreatic cancer and prostate cancer. This case highlights the potential use for enhanced screening protocols for RCC in patients who have germline pathogenic ATM mutations and the importance of research in targeted treatments for tumors driven by dual genetic mechanisms. Increased awareness and vigilant screening for RCC are crucial in managing hereditary cancer syndromes effectively.

Background. In the United States, universal screening for human T-lymphotropic virus (HTLV) in deceased organ donors was discontinued in 2009. Since then, the transplant guideline suggests considering targeted screening. However, the outcomes of this change in HTLV screening have not been evaluated. Methods. Using the Organ Procurement and Transplantation Network database between 2010 and 2022, we analyzed the HTLV antibody screening frequency and seroprevalence in potential deceased organ donors and their correlations with HTLV infection risks, including race and high-risk behaviors for blood-borne pathogen infection. Although targeted screening has not been established for HTLV, we hypothesized that screening rates should correlate with the proportions of donors with infection risk if screening is targeted. We also evaluated the organ utilization of HTLV-seropositive donors. Results. Of 130 284 potential organ donors, 22 032 (16.9%) were tested for HTLV antibody. The proportion of donors tested for HTLV varied between Organ Procurement Organizations (median [interquartile range], 3.8% [1.0%–23.2%]; range, 0.2%–99.4%) and was not correlated to HTLV infection risks. There were 48 seropositive donors (0.22%), and at least 1 organ from 42 of these donors (87.5%) was transplanted. The number of organs recovered and transplanted per donor was significantly lower in HTLV-seropositive than in HTLV-negative donors (recovered, 2 [2–3] versus 3 [3–5], P

Purpose: Patients with primary sinonasal and cutaneous head and neck (H&N) malignancies often receive meaningful radiation dose to their hippocampi, but this not a classic avoidance structure in radiation planning. We aimed to characterize the feasibility and tradeoffs of hippocampal-sparing radiation therapy (HSRT) for patients with primary sinonasal and cutaneous H&N malignancies. Methods and Materials: We retrospectively selected patients who were treated definitively for primary sinonasal or cutaneous malignancies of the H&N at an academic medical center. All received (chemo)radiation alone or adjuvantly and substantial radiation dose to 1 or both hippocampi. We created new HSRT plans for each patient with intensity modulated radiation therapy using the original target and organ-at-risk (OAR) volumes. Hippocampi were contoured based on Radiation Therapy Oncology Group guidelines and reviewed by a neuroradiologist. Absolute and relative differences in radiation dose to the hippocampi, planning target volumes (PTVs), and OARs were recorded and compared. Results: There were 18 sinonasal and 12 cutaneous H&N primary tumors (30 patients in total). Median prescription dose was 6600 cGy (range, 5000-7440 cGy), and 14 of the 30 patients received 120 cGy/fraction twice daily, 13 of the 30 patients received 200 cGy/fraction once daily, whereas others received 180-275 cGy/fraction once daily. The relative decrease in ipsilateral hippocampal Dmax and D100% using HSRT was 44% (median, 2009 cGy from 3586 cGy) and 65% (median 434 cGy from 1257 cGy), respectively. There were no statistically significant or clinically meaningful differences in PTV V100%, PTV D1%, or radiation dose to other OARs between HSRT and non-HSRT plans. Conclusions: HSRT is feasible and results in meaningful dose reduction to the hippocampi without reducing PTV coverage or increasing dose to other OARs. We suggest target hippocampal constraints of Dmax < 1600 cGy and D100% < 500 cGy when feasible (without compromising PTV coverage or impacting other critical OARs). The clinical significance of HSRT in patients with primary H&N tumors should be investigated prospectively.

Objective:. To determine the extent to which within-hospital temporal clustering of postoperative complications is observed in the American College of Surgeons, National Surgical Quality Improvement Program (ACS-NSQIP). Background:. ACS-NSQIP relies on periodic and on-demand reports for quality benchmarking. However, if rapid increases in postoperative complication rates (clusters) are common, other reporting methods might be valuable additions to the program. This article focuses on estimating the incidence of within-hospital temporal clusters. Methods:. ACS-NSQIP data from 1,547,440 patients, in 425 hospitals, over a 2-year period was examined. Hospital-specific Cox proportional hazards regression was used to estimate the incidence of mortality, morbidity, and surgical site infection (SSI) over a 30-day postoperative period, with risk adjustment for patient and procedure and with additional adjustments for linear trend, day-of-week, and season. Clusters were identified using scan statistics, and cluster counts were compared, using unpaired and paired t tests, for different levels of adjustment and when randomization of cases across time eliminated all temporal influences. Results:. Temporal clusters were rarely observed. When clustering was adjusted only for patient and procedure risk, an annual average of 0.31, 0.85, and 0.51 clusters were observed per hospital for mortality, morbidity, and SSI, respectively. The number of clusters dropped after adjustment for linear trend, day-of-week, and season (0.31–0.24; P = 0.012; 0.85–0.80; P = 0.034; and 0.51–0.36; P < 0.001; using paired t tests) for mortality, morbidity, and SSI, respectively. There was 1 significant difference in the number of clusters when comparing data with all adjustments and after data were randomized (0.24 and 0.25 for mortality; P = 0.853; 0.80 and 0.82 for morbidity; P = 0.529; and 0.36 and 0.46 [randomized data had more clusters] for SSI; P = 0.001; using paired t tests) for mortality, morbidity, and SSI, respectively. Conclusions:. Temporal clusters of postoperative complications were rarely observed in ACS-NSQIP data. The described methodology may be useful in assessing clustering in other surgical arenas.

Objective: To develop a deep learning algorithm for the analysis of patch testing. Patients and Methods: A retrospective case series between January 1, 2010, and December 31, 2020, was constructed to develop a deep learning model for the classification of patch test results from photographs. The performance of human expert readers reviewing the same photographs blinded to the original clinical physical examination findings was measured to benchmark model performance. Results: Model performance on the independent test set (n=5070 test site locations from 37 patients) achieved an area under the receiver operating characteristic curve of 0.89 (95% CI, 0.86-0.91) and an F1 score of 37.1. The optimal cutoff had a sensitivity of 70.1% (136/194; 95% CI, 63.1%-76.5%) and a specificity of 91.7% (4472/4876; 95% CI, 90.9%-92.5%). Conclusion: We demonstrated proof-of-concept utility for detecting allergic contact dermatitis using an automated deep learning approach.

Background:. Studies have shown that chronic marijuana use is associated with increased vascular inflammation, endothelial damage, myocardial infarctions, strokes, arteritis, and cardiomyopathies; however, cannabis’s effect on wound healing in immediate direct-to-implant (DTI) breast reconstruction is unknown. With the increasing prevalence of marijuana use, it is imperative to understand its effects on surgical outcomes. Methods:. We performed a retrospective cohort study of consecutive patients in a quaternary-care breast cancer center undergoing immediate DTI reconstruction. Patient demographics, operative details, and surgical complications were extracted through chart review. Active cannabis use was defined as use within 12 weeks of operation. Univariate and multivariable analyses were performed. Results:. In total, 243 consecutive patients underwent immediate DTI reconstruction, and 12 reported active cannabis use. There were no significant differences in patient demographics, cancer treatment, or operative details. Active marijuana users demonstrated higher rates of cellulitis treated with IV antibiotics (P = 0.004), explantation for infection (P = 0.004), emergency department visits (P = 0.028), readmission (P = 0.037), takeback to the operating room in 90 days (P < 0.001), and overall major complications (P < 0.001). Multivariable analysis demonstrated that active marijuana users were more likely to experience cellulitis treated with IV antibiotics [odds ratio (OR) = 3.55, P = 0.024], takeback to the OR within 90 days of operation (OR = 4.75, P = 0.001), and major complications (OR = 2.26, P = 0.048). Conclusions:. The consumption of cannabis in the perioperative setting is associated with increased rates of complications in patients undergoing immediate DTI reconstruction; however, an analysis with a larger patient population is needed to conclude that abstinence from its use should be highly encouraged.

Primary central nervous system (CNS) ALK-negative anaplastic large cell lymphoma (ALCL) is a rare and enigmatic disease, with limited data available in the literature. This case report adds to the existing body of knowledge by describing a unique case of a 68-year-old, immunocompetent male who presented with a single ring-enhancing lesion, which upon further analysis proved to be an ALK-negative ALCL that was primary to the CNS. A comprehensive review of the existing literature is provided, highlighting the genetic characteristics and diverse neuroimaging findings of this disease entity. This report adds valuable information to the understanding of this rare disorder, and highlights the need for further research in the field of primary CNS ALK-negative ALCL.

Background: Little is known about de novo human luekocyte antigen (HLA) antibody development with Impella 5.5 temporary mechanical circulatory assist support and downstream effects following heart transplantation in the new heart allocation system. Methods: Thirteen Impella and 17 control patients without device support were prospectively enrolled between December 2020 and June 2022. HLA antibodies with calculated panel reactive antibodies (cPRA) were assessed pre and postdevice implantation and within 1-year postheart transplantation. Results: Baseline prevalence of HLA antibodies and median cPRA were similar between groups. Patients in the study arm were on Impella support for a median of 7 days. No significant differences in HLA antibodies were observed postdevice or postheart transplant. One patient in the Impella arm developed rejection and required treatment. One Impella patient died due to infection and 1 control patient died due to primary graft dysfunction. Conclusions: Short-term use of Impella 5.5 in the new heart allocation system does not appear to increase risk of de novo HLA antibody development. Further studies are needed to validate these preliminary findings.

BACKGROUND: Endomyocardial biopsy (EMBx) is considered the gold standard for rejection monitoring after heart transplantation; however, it is invasive and histologic interpretation has limitations. Sensitive blood biomarkers, including donor-derived cell-free DNA (dd-cfDNA), have emerged to decrease EMBx frequency. METHODS: We retrospectively reviewed data on 237 patients who underwent heart transplantation at our institution. Of these, 125 patients underwent monitoring using dd-cfDNA, combined with a fewer number of EMBx, and 112 patients underwent monitoring using EMBx only. We compared rates of rejection, graft dysfunction, and survival at 1 year. RESULTS: Median age at time of transplant was 59.8 years, and 77.6% were men. In the dd-cfDNA group, there were significantly fewer episodes of EMBx defined acute cellular rejection (ACR) (2.5% vs 18.8%, p

Background: Inadequate pain control after lung transplantation increases perioperative complications. Standard opioid-based regimens are associated with adverse effects and epidural catheters that reduce opioid use are limited by contraindications and technical challenges. We report the use of intercostal nerve cryoablation to enhance perioperative pain control as part of an opioid-sparing protocol for lung transplant recipients (LTR). Methods: We conducted a retrospective cohort study of LTRs from January 1, 2016 to December 31, 2021, before (precryo) and after (postcryo) initiation of an opioid-sparing protocol utilizing intraoperative intercostal nerve cryoablation. The precryo cohort included consecutive patients treated with opioids and selective use of epidural catheters. The postcryo cohort received intercostal nerve cryoablation at levels 3 to 7, scheduled acetaminophen, gabapentin, and tramadol. Additional opioids or epidural catheters were used for breakthrough pain. Results: In total, 49 precryo and 40 postcryo patients were analyzed. Baseline demographics were similar aside from a shift to performing more bilateral lung transplants in the postcryo cohort (57% vs 95%, p

Background: Environmental and social factors, including lack of access to asthma care, contribute to persistent inequities in asthma outcomes among children from historically marginalized ethnoracial groups. Telemedicine, which expanded rapidly during the coronavirus disease 2019 (COVID-19) pandemic, may be an approach to augment access to pediatric asthma care. Objectives: We sought to describe characteristics of pediatric (0-17 years) telemedicine users with asthma and characterize use trends throughout the COVID-19 pandemic. Methods: We conducted a retrospective analysis using electronic health record data of pediatric patients with asthma seen at University of California, Los Angeles, Medical Center between March 2019 to March 2022 describing telemedicine user characteristics, trends of asthma-related telemedicine use, and associations between user characteristics and having a telemedicine visit. Results: Among 6,777 patients with asthma, the percentage of asthma-related telemedicine visits peaked early in the pandemic, comprising 74.3% of visits, before decreasing to 13.6% in 2022. Compared to White patients, Black patients had lower odds of an asthma telemedicine visit (odds ratio [OR], 0.49; 95% confidence interval [CI], 0.26, 0.94). Those with public insurance (OR, 1.7; 95% CI, 1.19, 2.43), severe persistent asthma (OR, 3.03; 95% CI, 1.70, 5.42), or comorbidities (OR, 1.59; 95% CI, 1.08, 2.33) had higher odds. Time to first emergency department visit and hospitalization comparing those with at least one telemedicine visit to those with none were similar. Conclusions: More pediatric asthma patients are using telemedicine since the COVID-19 pandemic, particularly those with medical complexity and comorbidities, and outcomes appear similar. However, Black patients at our institution have lower odds of using telemedicine.

Purpose: Retroperitoneal sarcomas (RPS) have varied treatment practices with regard to the use of radiation therapy (RT). Preoperative RT ∼50 Gy is commonly used, but the Surgery With or Without Radiation Therapy in Untreated Nonmetastatic Retroperitoneal Sarcoma (STRASS-1) randomized trial demonstrated no improvement in abdominal recurrence-free survival with preoperative RT. Dose escalation has been proposed to improve the efficacy of preoperative RT. We analyzed RPS treated with preoperative intensity modulated proton therapy (IMPT) to an escalated dose of 63 Gy at a single institution. Methods and Materials: Patients who received preoperative RT with IMPT with RPS between January 2015 and October 2021 were reviewed. IMPT 63 Gy in 28 fractions to the clinical target volume high-risk and 50.4 Gy in 28 fractions to clinical target volume low-risk was used. Patient baseline characteristics, RT dose parameters, toxicities, margin status, and recurrence patterns were recorded. Local control was computed by Fine-Gray analysis and overall survival by Kaplan-Meier analysis. Results: Sixteen patients met the study criteria (n = 16): 12 primary and 4 isolated local recurrences. Median age was 62 years (IQR, 43.5-66 years) and 62.5% were male; 10 were liposarcoma. The median maximum tumor diameter was 19.9 cm (IQR, 12-24 cm). With a median follow-up of 18 months (IQR, 11.5-37 months), the estimated 3-year freedom from local failure rate was 68.2% (95% CI, 41.7%-94.7%); 3-year overall survival (OS) rate was 68.8% (95% CI, 41.9%-95.8%). No Radiation Therapy Oncology Group grade ≥3 acute or late toxicities were noted. Conclusions: In our RPS cohort, preoperative dose-escalated RT to 63 Gy demonstrated comparable local control without G3 acute toxicities. Given the high local recurrence rates of RPS, this approach warrants further study to validate these results and identify patients most likely to benefit from therapy.

Background: Patients with chronic lymphocytic leukemia (CLL) are immunocompromised and have both a higher incidence of and more aggressive skin cancers, often requiring treatment with Mohs micrographic surgery. Objective: Characterize operative expectations for Mohs surgery in patients with CLL. Methods: Multicenter retrospective cohort study. Results: One hundred fifty-nine tumors from 99 patients with CLL were matched 1:4 with controls. Cases had higher odds for requiring at least 3 stages during Mohs surgery compared to controls (odds ratio = 1.91; 95% CI [1.21-3.02]; P = .01). The mean number of Mohs stages in cases was 1.97 (±0.92) compared with 1.67 (±0.87) in controls (P = .0001). A regression analysis showed that cases had larger postoperative tumor areas (cm2) versus controls (mean = 5.57 vs 4.47; estimate difference Δβ = 1.10 cm2; 95% CI [0.18-2.03]; P = .02). In logistic regression, cases were twice as likely to receive a flap repair compared to controls (odds ratio = 2.45; 95% CI [1.58-3.8]). Limitations: Retrospective cohort study and lack of histologic subtyping of tumors. Conclusion: Patients with CLL require more Mohs stages to attain clear surgical margins, have larger postoperative defect areas, and require more advanced repair techniques compared to a control population without CLL. These findings are essential for preoperative planning and patient counseling and further support the use of Mohs surgery in patients with CLL.

Objective:. To compare the performance of the ACS NSQIP “universal” risk calculator (N-RC) to operation-specific RCs. Background:. Resources have been directed toward building operation-specific RCs because of an implicit belief that they would provide more accurate risk estimates than the N-RC. However, operation-specific calculators may not provide sufficient improvements in accuracy to justify the costs in development, maintenance, and access. Methods:. For the N-RC, a cohort of 5,020,713 NSQIP patient records were randomly divided into 80% for machine learning algorithm training and 20% for validation. Operation-specific risk calculators (OS-RC) and OS-RCs with operation-specific predictors (OSP-RC) were independently developed for each of 6 operative groups (colectomy, whipple pancreatectomy, thyroidectomy, abdominal aortic aneurysm (open), hysterectomy/myomectomy, and total knee arthroplasty) and 14 outcomes using the same 80%/20% rule applied to the appropriate subsets of the 5M records. Predictive accuracy was evaluated using the area under the receiver operating characteristic curve (AUROC), the area under the precision-recall curve (AUPRC), and Hosmer-Lemeshow (H-L) P values, for 13 binary outcomes, and mean squared error for the length of stay outcome. Results:. The N-RC was found to have greater AUROC (P = 0.002) and greater AUPRC (P < 0.001) compared to the OS-RC. No other statistically significant differences in accuracy, across the 3 risk calculator types, were found. There was an inverse relationship between the operation group sample size and magnitude of the difference in AUROC (r = −0.278; P = 0.014) and in AUPRC (r = −0.425; P < 0.001) between N-RC and OS-RC. The smaller the sample size, the greater the superiority of the N-RC. Conclusions:. While operation-specific RCs might be assumed to have advantages over a universal RC, their reliance on smaller datasets may reduce their ability to accurately estimate predictor effects. In the present study, this tradeoff between operation specificity and accuracy, in estimating the effects of predictor variables, favors the N-R, though the clinical impact is likely to be negligible.

Background. Therapeutic donors (TDs) are individuals who undergo organ removal for medical treatment with no replacement organ, and the organ is then transplanted into another person. Transplant centers in the United States have started using TDs for kidney transplantation (KT). TD-KT recipient outcomes may be inferior to those of non-TD-living-donor (non-TD-LD)-KT or deceased-donor (DD)-KT because of the conditions that led to nephrectomy; however, these outcomes have not been sufficiently evaluated. Methods. This was a retrospective cohort study using Organ Procurement and Transplantation Network data. Via optimal matching methods, we created 1:4 fivesomes with highly similar characteristics for TD-KT and non-TD-LD-KT recipients and then separately for TD-KT and DD-KT recipients. We compared a 6-mo estimated glomerular filtration rate (eGFR) between groups (primary endpoint) and a composite of death, graft loss, or eGFR 0.05). However, the 6-mo composite outcome occurred more frequently with TD-KT than with non-TD-LD-KT and DD-KT (18%, 2% [P < 0.001], and 8% [P = 0.053], respectively). Conclusions. Early graft function was no different between well-matched groups, but TD-KT demonstrated a higher risk of otherwise poor 6-mo outcomes compared with non-TD-LD-KT and DD-KT. Our results support selective utilization of TD kidneys; however, additional studies are needed with more detailed TD kidney information to understand how to best utilize these kidneys.

Patients with anomalous aortic arch undergoing transcatheter aortic valve implantation may require modifications to the deployment protocols of cerebral protection device systems. We share the first reported case, to our knowledge, of a cerebral protection device via the left radial artery and using a distal basket alone in a patient with truncus bicaroticus and arteria lusoria. (Level of Difficulty: Intermediate.)

Background: Anastomotic leak (AL) after minimally invasive esophagectomy (MIE) is a well-described source of morbidity for patients undergoing surgical treatment of esophageal neoplasm. With improved early recognition and endoscopic management techniques, the long-term impact remains unclear. Methods: A retrospective review was conducted of patients who underwent MIE for esophageal neoplasm between January 2015 and June 2021 at a single institution. Cohorts were stratified by development of AL and subsequent management. Baseline demographics, perioperative data, and post-operative outcomes were examined. Results: During this period, 172 MIEs were performed, with 35 of 172 (20.3%) complicated by an AL. Perioperative factors independently associated with AL were post-operative blood transfusion (leak rate 52.9% versus 16.8%; p = 0.0017), incompleteness of anastomotic rings (75.0% vs 19.1%; p = 0.027), and receiving neoadjuvant therapy (18.5% vs 30.8%; p < 0.0001). Inferior short-term outcomes associated with AL included number of esophageal dilations in the first post-operative year (1.40 vs 0.46, p = 0.0397), discharge disposition to a location other than home (22.9% vs 8.8%, p = 0.012), length of hospital stay (17.7 days vs 9.6 days; p = 0.002), and time until jejunostomy tube removal (134 days vs 79 days; p = 0.0023). There was no significant difference in overall survival between patients with or without an AL at 1 year (79% vs 83%) or 5 years (50% vs 47%) (overall log rank p = 0.758). Conclusions: In this large single-center series of MIEs, AL was associated with inferior short-term outcomes including hospital length of stay, discharge disposition other than to home, and need for additional endoscopic procedures, without an accompanying impact on 1-year or 5-year survival. Key message: In this large, single-center series of minimally invasive esophagectomies, anastomotic leak was associated with worse short-term outcomes including hospital length of stay, discharge disposition other than to home, and need for additional endoscopic procedures, but was not associated with worse long-term survival. The significant association between neoadjuvant therapy and decreased leak rates is difficult to interpret, given the potential for confounding factors, thus careful attention to modifiable pre- and peri-operative patient factors associated with anastomotic leak is warranted.

Background: Early self-detection of atrial fibrillation (AF) can help delay and/or prevent significant associated complications, including embolic stroke and heart failure. We developed a facial video technology, videoplethysmography (VPG), to detect AF based on the analysis of facial pulsatile signals. Objective: The purpose of this study was to evaluate the accuracy of a video-based technology to detect AF on a smartphone and to test the performance of the technology in AF patients across the whole spectrum of skin complexion and under various recording conditions. Methods: The performance of video-based monitoring depends on a set of factors such as the angle and the distance between the camera and the patient’s face, the strength of illumination, and the patient’s skin tone. We conducted a clinical study involving 60 subjects with a confirmed diagnosis of AF. A continuous electrocardiogram was used as the gold standard for cardiac rhythm annotation. The VPG technology was fine-tuned on a smartphone for the first 15 subjects. Validation recordings were then done using 7053 measurements collected from the remaining 45 subjects. Results: The VPG technology detected the presence of AF using the video camera from a common smartphone with sensitivity and specificity ≥90%. The ambient level of illumination needs to be ≥100 lux for the technology to deliver consistent performance across all skin tones. Conclusion: We demonstrated that facial video-based detection of AF provides accurate outpatient cardiac monitoring including high pulse rate accuracy and medical-grade performance for AF detection.

Introduction Radiation therapy for head and neck squamous cell carcinoma is constrained by radiotoxicity to normal tissue. We demonstrate 100 nm theranostic nanoparticles for image-guided radiation therapy planning and enhancement in rat head and neck squamous cell carcinoma models. Methods PEG conjugated theranostic nanoparticles comprising of Au nanorods coated with Gadolinium oxide layers were tested for radiation therapy enhancement in 2D cultures of OSC-19-GFP-luc cells, and orthotopic tongue xenografts in male immunocompromised Salt sensitive or SS rats via both intratumoral and intravenous delivery. The radiation therapy enhancement mechanism was investigated. Results Theranostic nanoparticles demonstrated both X-ray/magnetic resonance contrast in a dose-dependent manner. Magnetic resonance images depicted optimal tumor-to-background uptake at 4 h post injection. Theranostic nanoparticle + Radiation treated rats experienced reduced tumor growth compared to controls, and reduction in lung metastasis. Conclusions Theranostic nanoparticles enable preprocedure radiotherapy planning, as well as enhance radiation treatment efficacy for head and neck tumors.

Little is known about the development of human leukocyte antigen antibodies with use of the temporary transvalvular pump 5.5 mechanical circulatory support device. This case reports a patient who developed de novo antibodies prior to his heart transplantation and remains free of any episodes of rejection post transplantation to date. (Level of Difficulty: Advanced.)

Background:. Patient values may be obscured when decisions are made under the circumstances of constrained time and limited counseling. The objective of this study was to determine if a multidisciplinary review aimed at ensuring goal-concordant treatment and perioperative risk assessment in high-risk orthopaedic trauma patients would increase the quality and frequency of goals-of-care documentation without increasing the rate of adverse events. Methods:. We prospectively analyzed a longitudinal cohort of adult patients treated for traumatic orthopaedic injuries that were neither life- nor limb-threatening between January 1, 2020, and July 1, 2021. A rapid multidisciplinary review termed a “surgical pause” (SP) was available to those who were ≥80 years old, were nonambulatory or had minimal ambulation at baseline, and/or resided in a skilled nursing facility, as well as upon clinician request. Metrics analyzed include the proportion and quality of goals-of-care documentation, rate of return to the hospital, complications, length of stay, and mortality. Statistical analysis utilized the Kruskal-Wallis rank and Wilcoxon rank-sum tests for continuous variables and the likelihood-ratio chi-square test for categorical variables. Results:. A total of 133 patients were either eligible for the SP or referred by a clinician. Compared with SP-eligible patients who did not undergo an SP, patients who underwent an SP more frequently had goals-of-care notes identified (92.4% versus 75.0%, p = 0.014) and recorded in the appropriate location (71.2% versus 27.5%, p < 0.001), and the notes were more often of high quality (77.3% versus 45.0%, p < 0.001). Mortality rates were nominally higher among SP patients, but these differences were not significant (10.6% versus 5.0%, 5.1% versus 0.0%, and 14.3% versus 7.9% for in-hospital, 30-day, and 90-day mortality, respectively; p > 0.08 for all). Conclusions:. The pilot program indicated that an SP is a feasible and effective means of increasing the quality and frequency of goals-of-care documentation in high-risk operative candidates whose traumatic orthopaedic injuries are neither life- nor limb-threatening. This multidisciplinary program aims for goal-concordant treatment plans that minimize modifiable perioperative risks. Level of Evidence:. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Renal artery aneurysm (RAA) and renal arteriovenous fistula are rare vascular pathologies with reported incidences of 0.3% to 1.0% and 0.04% in the general population, respectively. We describe a 61-year-old Caucasian man who presented to the hospital with symptoms of right flank pain. Imaging demonstrated a right RAA with concurrent hilar RAA and renal arteriovenous fistula. He ultimately underwent an open right nephrectomy, ligation of the fistula, and bovine patch repair of the aortic defect.

Objective:. Assess associations of social determinants of health (SDoH) using area deprivation index (ADI), race/ethnicity and insurance type with textbook outcomes (TO). Background:. Individual- and contextual-level SDoH affect health outcomes, but only one SDoH level is usually included. Methods:. Three healthcare system cohort study using National Surgical Quality Improvement Program (2013–2019) linked with ADI risk-adjusted for frailty, case status, and operative stress examining TO/TO components (unplanned reoperations, complications, mortality, emergency department/observation stays, and readmissions). Results:. Cohort (34,251 cases) mean age 58.3 [SD = 16.0], 54.8% females, 14.1% Hispanics, 11.6% Non-Hispanic Blacks, 21.6% with ADI >85, and 81.8% TO. Racial and ethnic minorities, non-private insurance, and ADI >85 patients had increased odds of urgent/emergent surgeries (adjusted odds ratios [aORs] range: 1.17–2.83, all P < 0.001). Non-Hispanic Black patients, ADI >85 and non-Private insurances had lower TO odds (aORs range: 0.55–0.93, all P < 0.04), but ADI >85 lost significance after including case status. Urgent/emergent versus elective had lower TO odds (aOR = 0.51, P < 0.001). ADI >85 patients had higher complication and mortality odds. Estimated reduction in TO probability was 9.9% (95% confidence interval [CI] = 7.2%–12.6%) for urgent/emergent cases, 7.0% (95% CI = 4.6%–9.3%) for Medicaid, and 1.6% (95% CI = 0.2%–3.0%) for non-Hispanic Black patients. TO probability difference for lowest-risk (White-Private-ADI 85-urgent/emergent) was 29.8% for very frail patients. Conclusion:. Multilevel SDoH had independent effects on TO, predominately affecting outcomes through increased rates/odds of urgent/emergent surgeries driving complications and worse outcomes. Lowest-risk versus highest-risk scenarios demonstrated the magnitude of intersecting SDoH variables. Combination of insurance type and ADI should be used to identify high-risk patients to redesign care pathways to improve outcomes. Risk adjustment including contextual neighborhood deprivation and patient-level SDoH could reduce unintended consequences of value-based programs.

Objective: Functional popliteal artery entrapment syndrome (fPAES) is a rare form of nonatherosclerotic claudication most often seen in young athletic patients. Diagnosis remains challenging, with various imaging modalities showing equivocal or subtle findings that may be missed. We sought to critically examine and quantitate the utility of intravascular ultrasound (IVUS) imaging, a common diagnostic tool for vascular compression syndromes, in diagnosis and characterization of fPAES. Methods: Patients presenting to a single tertiary care center between 2019 and 2022 with symptoms of PAES but without an anatomic etiology or equivocal workup were selected. Angiogram and IVUS with maneuvers were performed on affected extremities at rest, active plantarflexion/dorsiflexion, and plantarflexion/dorsiflexion against resistance. IVUS examination was recorded using a pull-back technique from the tibial vessels to the superficial femoral artery. The degree, length, and anatomic location of compression using the two imaging modalities were compared. Results: Angiogram and IVUS with maneuvers were performed on 17 lower extremities (9 left, 8 right) in 15 patients (88% female; mean age, 21.2 years). Evidence of arterial compression on angiography was noted in 88.2% (n = 15) of limbs (66.7% complete contrast cessation and 20% popliteal artery tapering); 13.3% (n = 2) only demonstrated sluggish flow as possible evidence of compression. Arterial compression was seen on IVUS imaging in 15 of 17 limbs, and all completely compressed around the IVUS catheter. The IVUS-measured mean length of compression was 10.5 cm ± 4.2 (median, 11 cm; range, 4-23 cm). Compression involved only the popliteal vessels in 86.7% (n = 13); one patient had both popliteal and tibioperoneal trunk compression, whereas another had tibioperoneal trunk and peroneal artery compression. Popliteal vein compression was 100%. The contrast cessation point on angiography and the proximal point of compression on IVUS imaging differed in 80% of cases (P < .05). The distal extent of compression was unable to be determined by angiogram findings but was clearly delineated by IVUS imaging in all cases. Conclusions: IVUS imaging is a more sensitive diagnostic and descriptive imaging modality compared with angiogram in patients with possible fPAES. IVUS and angiogram findings are greatly discordant; moreover, IVUS imaging can provide detailed information such as the precise extent and anatomic location of the arterial compression, which may be useful in aiding surgical planning. IVUS imaging should be considered the gold standard for diagnosing and characterizing fPAES before intervention planning.

The interplay between Adverse Childhood Experiences (ACEs) and resilience on health in children is not well understood. Parents completed 3 questionnaires: ACEs, Child and Youth Resilience Measure (CYRM), and the Pediatric Symptom Checklist-17(PSC-17). BMI and blood pressure were measured. 19.8% of children had 4 or more ACEs, resilience ranged from 25 to 51, 14.3% had a positive PSC-17 score, 25.6% were obese, 3.1% had systolic hypertension, and 1.2% had diastolic hypertension. Higher ACEs (ACE OR: 1.398, 95% CI = 1.044-1.893, P = .026) and lower resilience (Resilience OR: 0.740, 95% CI 0.668-0.812; P = 1.13 × 10 −9 ) were predictive of increased reports of behavioral health symptoms, but not obesity or hypertension. The personal resilience subscale was a predictor of positive PSC-17 score (OR 0.646, 95% CI = 0.546-0.749, P = 3.18 × 10 −8 ); relationship subscale was not. Cultivating resilience, especially personal aspects, may provide an effective intervention for behavioral health symptoms in children.

Aortic aneurysms (AA) are a common complication in patients with large-vessel vasculitis, such as chronic phase Takayasu arteritis, that often require surgical management to prevent a lethal rupture. Historically, mainstay of treatment for AA in the setting of arteritis was traditional open repair. However, in this case study an alternative surgical approach was devised to successfully treat an extent III thoracoabdominal AA in a patient with a diagnosis of Takayasu arteritis and a complex surgical history that made her high risk for an open surgical intervention. This case study summarizes a hybrid surgical approach that successfully excluded a thoracoabdominal AA and revascularized the superior mesenteric artery and left renal artery, by directly accessing the infrarenal aorta and using a bifurcated abdominal aortic endograft as a two-vessel branched device.

While new offerings of virtual urgent care services from peer hospitals faltered after initial provincial pilot funding lapsed, our 3 regional academic health sciences centers decided to partner to enhance patient access, achieve efficiencies, and support long-term sustainability. Utilizing the Development Model for Integrated Care framework, we progressed through the 4 phases to ensure joint success and high-quality care: (1) initiative and design phase—individual parallel projects but with strong collaborations and broad stakeholder engagement; (2) experimental and execution phase—continuous quality improvement approach for governance, policies, and processes; (3) expansion and monitoring phase—weekly leadership touchpoints on key performance indicators; and (4) consolidation and transformation phase—sustainability through ongoing funding.

Purpose: Local tumor progression is a cause of significant morbidity and mortality in patients with pancreatic ductal adenocarcinoma (PDAC) with surgically unresectable disease. Novel and effective approaches to accomplish durable local control are urgently needed. We tested whether CPI-613 (devimistat), a first-in-class investigational small molecule inhibitor of mitochondrial metabolism, was capable of altering cancer cell energy metabolism and sensitizing PDAC cells to radiation therapy (RT). Methods and Materials: The effect of a combined treatment of RT with CPI-613 on the viability of, clonogenic potential of, and cell death induction in PDAC cells (MiaPaCa-2 and Panc-1) was determined using a trypan blue dye exclusion assay, a colony formation assay, and a 7–amino-actinomycin D assay, respectively. The synergistic effects of CPI-613-RT and chemotherapeutic agents (gemcitabine or 5-fluorouracil) were measured in MiaPaCa-2 cells using a 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide and spheroid formation assay. Changes in energy metabolism were determined by profiling metabolites treated with either RT, CPI-613, or both using liquid chromatography-mass spectrometry. Results: This study demonstrates that a combination of single-fraction RT (2 and 10 Gy) with CPI-613 significantly inhibits PDAC cell growth compared with RT alone. Molecular analysis revealed inhibition of α-ketoglutarate dehydrogenase at the protein level. In addition, we demonstrate enhanced cell death of PDAC cells when treated with RT-CPI-613 combination. Targeted metabolomic analysis on PDAC cells post–CPI-613-RT treatment revealed alterations in key mitochondrial metabolites, with broader target engagement by the combination treatment, indicating the sensitization of CPI-613–treated PDAC cells to RT. Furthermore, a combination treatment of CPI-613 with either gemcitabine or 5-fluorouracil in the presence of 2 Gy RT synergistically inhibits PDAC cell proliferation. Conclusions: Our results support a novel combination of CPI-613-RT that warrants further preclinical and early-phase clinical investigations. A phase 1 trial designed to identify the maximum tolerated dose of CPI-613 in combination with chemo-RT in patients with PDAC was recently initiated (NCT05325281).

Purpose: Nearly all patients with pancreatic ductal adenocarcinoma (PDAC) eventually die of progressive cancer after exhausting treatment options. Although distant metastases (DMs) are a common cause of death, autopsy studies have shown that locoregional progression may be directly responsible for up to one-third of PDAC-related deaths. Ablative stereotactic magnetic resonance-guided adaptive radiation therapy (A-SMART) is a novel treatment strategy that appears to improve locoregional control compared with nonablative radiation therapy, potentially leading to improved overall survival. Methods and Materials: A single-institution retrospective analysis was performed of patients with nonmetastatic inoperable PDAC treated between 2018 to 2020 using the MRIdian Linac with induction chemotherapy, followed by 5-fraction A-SMART. We identified causes of death that occurred after A-SMART. Results: A total of 62 patients were evaluated, of whom 42 (67.7%) had died. The median follow-up time was 18.6 months from diagnosis and 11.0 months from A-SMART. Patients had locally advanced (72.6%), borderline resectable (22.6%), or resectable but medically inoperable PDAC (4.8%). All patients received induction chemotherapy, typically leucovorin calcium (folinic acid), fluorouracil, irinotecan hydrochloride, and oxaliplatin (69.4%) or gemcitabine/nab-paclitaxel (24.2%). The median prescribed dose was 50 Gy (range, 40-50), corresponding to a median biologically effective dose of 100 Gy10. Post-SMART therapy included surgery (22.6%), irreversible electroporation (9.7%), and/or chemotherapy (51.6%). Death was attributed to locoregional progression, DMs, cancer-related cachexia/malnutrition, surgery/irreversible electroporation complications, other reasons not due to cancer progression, or unknown causes in 7.1%, 45.2%, 11.9%, 9.5%, 11.9%, and 14.3% of patients, respectively. Intra-abdominal metastases of the liver and peritoneum were responsible for 84.2% of deaths from DMs. Conclusions: To our knowledge, this is the first contemporary evaluation of causes of death in patients with PDAC receiving dose-escalated radiation therapy. We demonstrated that the predominant cause of PDAC-related death was from liver and peritoneal metastases; therefore novel treatment strategies are indicated to address occult micrometastatic disease at these sites.

Background:. The subjective degenerative spondylolisthesis instability classification (S-DSIC) system attempts to define preoperative instability associated with degenerative lumbar spondylolisthesis (DLS). The system guides surgical decision-making based on numerous indicators of instability that surgeons subjectively assess and incorporate. A more objective classification is warranted in order to decrease variation among surgeons. In this study, our objectives included (1) proposing an objective version of the DSIC system (O-DSIC) based on the best available clinical and biomechanical data and (2) comparing subjective surgeon perceptions (S-DSIC) with an objective measure (O-DSIC) of instability related to DLS. Methods:. In this multicenter cohort study, we prospectively enrolled 408 consecutive adult patients who received surgery for symptomatic DLS. Surgeons prospectively categorized preoperative instability using the existing S-DSIC system. Subsequently, an O-DSIC system was created. Variables selected for inclusion were assigned point values based on previously determined evidence quality. DSIC types were derived by point summation: 0 to 2 points was considered stable, Type I); 3 points, potentially unstable, Type II; and 4 to 5 points, unstable, Type III. Surgeons’ subjective perceptions of instability (S-DSIC) were retrospectively compared with O-DSIC types. Results:. The O-DSIC system includes 5 variables: presence of facet effusion, disc height preservation (≥6.5 mm), translation (≥4 mm), a kyphotic or neutral disc angle in flexion, and low back pain (≥5 of 10 intensity). Type I (n = 176, 57.0%) and Type II (n = 164, 53.0%) were the most common DSIC types according to the O-DSIC and S-DSIC systems, respectively. Surgeons categorized higher degrees of instability with the S-DSIC than the O-DSIC system in 130 patients (42%) (p < 0.001). The assignment of DSIC types was not influenced by demographic variables with either system. Conclusions:. The O-DSIC system facilitates objective assessment of preoperative instability related to DLS. Surgeons assigned higher degrees of instability with the S-DSIC than the O-DSIC system in 42% of cases. Level of Evidence:. Diagnostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Category: Trauma; Ankle Introduction/Purpose: There has been significant scrutiny of physicians' opioid prescribing patterns for both operative and non- operative patients. Orthopaedic surgeons are the third highest group of opioid prescribers among physicians in the United States. The wide scope of orthopaedic procedures lends to the variability and difficulty in setting forth prescribing guidelines. Recent orthopedic literature has highlighted that orthopaedic surgeons are prescribing excess narcotic medication than is needed in common orthopaedic procedures. Ankle fractures make up about 9% of all fractures, which correlates to about 400,000 per year. The purpose of this study was to assess the amount of post-operative pain medication being prescribed and how much of that medication was being consumed in patients who underwent an open reduction internal fixation (ORIF) of an ankle fracture. Methods: We identified all patients that underwent a unilateral ORIF of a closed ankle fracture. We prospectively collected data on patients at the time of surgery. Patients were identified and enrolled in the study prior to their surgical procedure, where they were instructed to bring their pain medication bottle with them to their first post-operative visit. Patients were asked about the quantity of opioids consumed. At the twelve-week post-op, the American Orthopedic Foot and Ankle Score (AOFAS) was completed by the patient. We recorded the number, dosage, and formulation of opioid medication prescribed up to 90 days after surgery using the Pennsylvania Drug Monitoring Program (PDMP) website. Using opioid equianalgesic charts, we converted dosages of opioid to a morphine milligram equivalent (MEq) to standardize prescription amounts across all patients. Descriptive statistics were calculated and reported. Categorical data were compared using chi-square tests and quantitative data were compared using independent sample t-tests. Results: 75 patients were included in our study, 45 of which were female. The mean age of the patient was 46.7 years old with a range from 17-77 years old. On average, 400MEq were prescribed to the patient after surgery. Patients consumed an average of 258 MEq within the 2 weeks following surgery, which accounted for about 65% of the initial prescription. Thirty (13.3%) patients consumed their entire first prescription. Patients who consumed the full opioid prescription were 8.7 times more likely (95% CI 2.6, 29.3, X2(1)=14.1, p

Purpose: Randomized data show a survival benefit of stereotactic ablative body radiation therapy in selected patients with oligometastases (OM). Stereotactic magnetic resonance guided adaptive radiation therapy (SMART) may facilitate the delivery of ablative dose for OM lesions, especially those adjacent to historically dose-limiting organs at risk, where conventional approaches preclude ablative dosing. Methods and Materials: The RSSearch Registry was queried for OM patients (1-5 metastatic lesions) treated with SMART. Freedom from local progression (FFLP), freedom from distant progression (FFDP), progression-free survival (PFS), and overall survival (LS) were estimated using the Kaplan-Meier method. FFLP was evaluated using RECIST 1.1 criteria. Toxicity was evaluated using Common Terminology Criteria for Adverse Events version 4 criteria. Results: Ninety-six patients with 108 OM lesions were treated on a 0.35 T MR Linac at 2 institutions between 2018 and 2020. SMART was delivered to mostly abdominal or pelvic lymph nodes (48.1%), lung (18.5%), liver and intrahepatic bile ducts (16.7%), and adrenal gland (11.1%). The median prescribed radiation therapy dose was 48.5 Gy (range, 30-60 Gy) in 5 fractions (range, 3-15). The median biologically effective dose corrected using an alpha/beta value of 10 was 100 Gy10 (range, 48-180). No acute or late grade 3+ toxicities were observed with median 10 months (range, 3-25) follow-up. Estimated 1-year FFLP, FFDP, PFS, and OS were 92.3%, 41.1%, 39.3%, and 89.6%, respectively. Median FFDP and PFS were 8.9 months (95% confidence interval, 5.2-12.6 months) and 7.6 months (95% confidence interval, 4.5-10.6 months), respectively. Conclusions: To our knowledge, this represents the largest analysis of SMART using ablative dosing for non-bone OM. A median prescribed biologically effective dose of 100 Gy10 resulted in excellent early FFLP and no significant toxicity, likely facilitated by continuous intrafraction MR visualization, breath hold delivery, and online adaptive replanning. Additional prospective evaluation of dose-escalated SMART for OM is warranted.

OBJECTIVES:. Delayed identification of hemodynamic deterioration remains a persistent issue for in-hospital patient care. Clinicians continue to rely on vital signs associated with tachycardia and hypotension to identify hemodynamically unstable patients. A novel, noninvasive technology, the Analytic for Hemodynamic Instability (AHI), uses only the continuous electrocardiogram (ECG) signal from a typical hospital multiparameter telemetry monitor to monitor hemodynamics. The intent of this study was to determine if AHI is able to predict hemodynamic instability without the need for continuous direct measurement of blood pressure. DESIGN:. Retrospective cohort study. SETTING:. Single quaternary care academic health system in Michigan. PATIENTS:. Hospitalized adult patients between November 2019 and February 2020 undergoing continuous ECG and intra-arterial blood pressure monitoring in an intensive care setting. INTERVENTIONS:. None. MEASUREMENTS AND MAIN RESULTS:. One million two hundred fifty-two thousand seven hundred forty-two 5-minute windows of the analytic output were analyzed from 597 consecutive adult patients. AHI outputs were compared with vital sign indications of hemodynamic instability (heart rate > 100 beats/min, systolic blood pressure < 90 mm Hg, and shock index of > 1) in the same window. The observed sensitivity and specificity of AHI were 96.9% and 79.0%, respectively, with an area under the curve (AUC) of 0.90 for heart rate and systolic blood pressure. For the shock index analysis, AHI’s sensitivity was 72.0% and specificity was 80.3% with an AUC of 0.81. CONCLUSIONS:. The AHI-derived hemodynamic status appropriately detected the various gold standard indications of hemodynamic instability (hypotension, tachycardia and hypotension, and shock index > 1). AHI may provide continuous dynamic hemodynamic monitoring capabilities in patients who traditionally have intermittent static vital sign measurements.

Purpose: Compared with computed tomography, magnetic resonance (MR) image guidance offers significant advantages for radiation therapy (RT) that may be particularly beneficial for reirradiation (reRT). However, clinical outcomes of MR-guided reRT are not well described in the published literature. Methods and Materials: We performed a single-institution retrospective safety and efficacy analysis of reRT patients treated on the MRIdian Linac to targets within the abdomen or pelvis using continuous intrafraction MR-based motion management with automatic beam triggering. Fiducial markers were not used. Results: We evaluated 11 patients who received prior RT to a median of 50 Gy (range, 30-58.8 Gy) in 25 fractions (range, 5-28 fractions). The median interval to reRT was 26.8 months. The most frequently retreated sites were nodal metastases (36.4%) and pancreatic cancer (27.3%). The median reRT dose was 40 Gy (range, 25-54 Gy) in 6 fractions (range, 5-36 fractions); ultrahypofractionation (63.6%) was more common than hyperfractionation (36.4%). Daily on-table adaptive replanning was used for 3 patients (27.3%). With a median of 14 months’ follow-up from reRT completion (range, 6-32 months), the median and 1-year freedom from local progression were 29 months and 88.9%, respectively, and the median and 1-year overall survival were 17.5 months and 70.0%, respectively. One patient (9.1%) experienced acute grade 2 toxic effects; there were no acute or late treatment-related toxic effects of grade 3 or greater. Conclusions: Magnetic resonance–guided reRT appeared to be feasible and may facilitate safe dose escalation. Additional follow-up is needed to better assess long-term efficacy and late toxic effects. Prospective evaluation of this novel treatment strategy is warranted.

Purpose: Magnetic resonance-guided online adaptive radiation therapy (MRgOART) requires accurate and efficient segmentation. However, the performance of current autosegmentation tools is generally poor for magnetic resonance imaging (MRI) owing to day-to-day variations in image intensity and patient anatomy. In this study, we propose a patient-specific autosegmentation strategy using multiple-input deformable image registration (DIR; PASSMID) to improve segmentation accuracy and efficiency for MRgOART. Methods and materials: Longitudinal MRI scans acquired on a 1.5T MRI-Linac for 10 patients with abdominal cancer were used. The proposed PASSMID includes 2 steps: applying a patient-specific image processing pipeline to longitudinal MRI scans, and populating all contours from previous sessions/fractions to a new fractional MRI using multiple DIRs and combining the resulted contours using simultaneous truth and performance level estimation (STAPLE) to obtain the final consensus segmentation. Five contour propagation strategies were compared: planning computed tomography to fractional MRI scans through rigid body registration (RDR), pretreatment MRI to fractional MRI scans through RDR and DIR, and the proposed multi-input DIR/STAPLE without preprocessing, and the PASSMID. Dice similarity coefficient (DSC) and mean distance to agreement (MDA) with ground truth contours were calculated slice by slice to quantify the contour accuracy. A quantitative index, defined as the ratio of acceptable slices, was introduced using a criterion of DSC > 0.8 and MDA < 2 mm. Results: The proposed PASSMID performed well with an average 2-dimensional DSC/MDA of 0.94/1.78 mm, 0.93/1.04 mm, 0.93/1.06 mm, 0.93/1.14 mm, 0.92/0.83 mm, 0.84/1.53 mm, 0.86/2.39 mm, 0.81/2.49 mm, 0.72/5.48 mm, and 0.70/5.03 mm for the liver, left kidney, right kidney, spleen, aorta, pancreas, stomach, duodenum, small bowel, and colon, respectively. Starting from the third fractions, the contour accuracy was significantly improved with PASSMID compared with the single-DIR strategy (P < .05). The mean ratio of acceptable slices were 13.9%, 17.5%, 60.8%, 70.6%, and 71.8% for the 5 strategies, respectively. Conclusions: The proposed PASSMID solution, by combining image processing, multi-input DIRs, and STAPLE, can significantly improve the accuracy of autosegmentation for intrapatient MRI scans, reducing the time required for further contour editing, thereby facilitating the routine practice of MRgOART.

Purpose: Pediatric patients with cancer benefit significantly from psychosocial support during and after treatment, but to date, limited data exist regarding the patterns of psychosocial support provided to patients in radiation oncology departments. The purpose of this study was to assess the supportive care services provided at proton therapy institutions in the United States with a specific focus on education, parental involvement, and coping techniques. Materials and Methods: Physicians, nurses, and child life specialists at 29 operational proton therapy facilities in the United States were sent an online questionnaire regarding pediatric treatment support. The survey consisted of 10 questions exploring strategies employed to educate and support pediatric patients before and during radiotherapy. Results: Staff members from 23 of 29 operational proton centers (79%) in the United States completed the survey. Three centers (10%) declined to participate, and three (10%) did not complete the questionnaire. Respondents permitted parental presence for body positioning on the first day of treatment and every day of treatment if needed at 95.6% (22 of 23) and 73.9% (17 of 23) of the centers, respectively. Primary education methods included a facility tour (91.3%; 21 of 23) and psychological preparation (78.3%; 17 of 23). Physicians (82.6%; 19 of 23), nurses (73.9%; 17 of 23), and child life specialists (69.6%; 16 of 23) most commonly provided education to pediatric patients and their families. Only 21.7% (5 of 23) of the facilities reported documentation of a psychosocial support policy. Common coping techniques included music (87.0%; 20 of 23), parental presence for positioning (73.9%; 17 of 23), listening to audio recordings (73.9%; 17 of 23), aromatherapy on or near the patient (73.9%; 17 of 23), and use of a stress ball (65.2%; 15 of 23). Conclusion: Proton therapy institutions frequently offered psychologic preparation before treatment and employed various coping strategies. Based on this survey, we propose several recommendations to raise awareness and improve the experience of pediatric patients at radiation oncology centers.

Purpose: Transarterial chemoembolization (TACE) in combination with stereotactic body radiation therapy (SBRT) is a promising therapy for patients with hepatocellular carcinoma (HCC). A radiopaque drug-eluting embolic bead used during TACE, called LC Bead LUMI (Boston Scientific), was developed to allow improved visualization during TACE. The purpose of this case series is to assess the visibility of LUMI after TACE and discuss its potential use as an alignment tool for SBRT. Methods: Fourteen patients with HCC (median age 69) received TACE using LUMI immediately followed by SBRT to 50 Gy in 5 fractions (13 patients) or 40 Gy in 5 fractions (1). Computed tomography (CT) simulation and cone beam CT (CBCT) images taken before each fraction were compared with immediate post-TACE imaging. Success of the LUMI bead opacification was graded from excellent to poor visualization. Patients were followed to assess target lesion response, disease control, survival, and the long-term visibility of LUMI beads. Results: CBCT immediately after TACE with LUMI displayed excellent tumor visibility for 6 of 13 patients (46.2%), moderate tumor visibility for 4 patients (30.8%), and poor tumor visibility for 3 patients (23.1%). When comparing CBCTs used for SBRT image verification to post-TACE CBCT, 53.8% remained unchanged and 46.2% deteriorated from excellent to moderate or moderate to poor, but none deteriorated from excellent to poor visualization. Median follow-up was 13 months (range 2-35). On average, LUMI beads were visible on noncontrast CT up to 20 months after SBRT. Conclusions: LC Bead LUMI has the ability to provide liver tumor demarcation on noncontrast and cone beam CT weeks to months following TACE. It can serve as an alignment tool and could improve the therapeutic ratio in liver SBRT by allowing for tumor margin reduction with a potential decrease in the risk of toxicity when treating HCC in facilities without magnetic resonance imaging-linear accelerator.

Purpose: Postoperative radiation therapy (RT) is commonly used for World Health Organization grade II-III intracranial ependymoma. Clinicians generally aim to begin RT ≤5 weeks after surgery, but postoperative recovery and need for second look surgery can delay the initiation of adjuvant therapy. On ACNS 0831, patients were required to enroll ≤8 weeks after initial surgery and begin adjuvant therapy within 3 weeks after enrollment. The purpose of this study was to determine the optimal timing of RT after surgery. Methods and Materials: The National Cancer Database was queried for patients (aged 1-39 years) with localized World Health Organization grade II-III intracranial ependymoma treated with surgery and postoperative RT. Overall survival (OS) curves were plotted based on RT timing (≤5 weeks, 5-8 weeks, and >8 weeks after surgery) and were compared by log-rank test. Factors associated with OS were identified by multivariate analysis. After 2009, complete data were available on whether patients underwent gross total resection or subtotal resection. Planned subset analysis was performed to examine the effect of RT timing on OS in patients with known extent of resection. Results: In the final analytical data set of 1043 patients, no difference in 3-year OS was observed in patients who initiated RT ≤5 weeks, 5 to 8 weeks, and >8 weeks after surgery (89.8% vs 89.1% vs 88.4%; P = .796). On multivariate analysis, grade III tumors (hazard ratio, 2.752; 95% confidence interval, 1.969-3.846, P < .001) and subtotal resection (hazard ratio, 2.253; 95% confidence interval, 1.405-3.611, P < .001) were significantly associated with reduced OS. Timing of RT, total RT dose, age, and other factors were not significant. These findings were affirmed in the subset of patients treated between 2010 and 2016, when extent of resection was routinely recorded. Conclusions: Delayed postoperative RT was not associated with inferior survival in patients with intracranial ependymoma. Delayed RT initiation may be acceptable in patients who require longer postoperative recovery or referral to an appropriate RT center, but should be minimized whenever practical.

Background:. While perinatal risk factors are widely used to help identify those at risk for developmental dysplasia of the hip (DDH) within the first 6 to 8 weeks of life, limited data exist about their association with radiographic evidence of dysplasia in childhood. The purpose of this study was to determine which perinatal risk factors are associated with acetabular dysplasia in children who are ≥2 years of age. Methods:. Pelvic radiographs were made in 1,053 children (mean age, 4.4 years [range, 2 to 7 years]) who had been assessed prospectively as having at least 1 of 9 widely accepted perinatal risk factors for DDH. Two radiologists who were blinded to patient risk factors, history, and age determined the acetabular index (AI). The primary outcome was defined as an AI >2 standard deviations from the Tönnis reference values (“severe” dysplasia). The secondary outcome was an AI of >20° at >2 years of age. The association between risk factors and outcomes was assessed using logistic regression. The effect of treatment in infancy was adjusted for in 37 hips. Results:. Twenty-seven participants (3%) showed “severe” hip dysplasia; 3 of these had received treatment for DDH in infancy. Girls were more likely to experience this outcome (odds ratio [OR] = 2.59; 95% confidence interval [CI] = 1.04 to 6.46; p = 0.04); no other examined risk factors were significant. The secondary outcome appeared in 146 participants (14%), 12 of whom had received treatment in infancy. We observed the following predictors for this outcome: female sex (OR = 1.77; 95% CI = 1.21 to 2.59; p = 0.003), breech presentation (OR = 1.74; 95% CI = 1.08 to 2.79; p = 0.02), and being a firstborn child, which had a protective effect (OR = 0.67; 95% CI = 0.46 to 0.96; p = 0.03). Conclusions:. We identified a substantial number of cases that will require at least radiographic surveillance for mild and severe hip dysplasia; 92% had no prior diagnosis of DDH. Those who had been born breech were affected by this outcome even if ultrasonography of the hip had been normal at 6 to 8 weeks, suggesting a benefit from additional radiographic testing. Level of Evidence:. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Background:. From a public health perspective, nasal surgery accounts for many unused opioids. Patients undergoing septorhinoplasty require few opioids, and efforts to eliminate this need may benefit both patients and the public. Methods:. A multimodal analgesic protocol consisting of 15 components encompassing all phases of care was implemented for 42 patients. Results:. Median age and BMI were 34 years and 23, respectively. Most were women (79%), White (79%), primary surgeries (62%), and self-pay (52%). Comorbid conditions were present in 74% of the patients, with anxiety (33%) and depression (21%) being the most common. Septoplasties (67%) and osteotomies (45%) were common. The median operative time was 70 minutes. No patients required opioids in recovery, and median time in recovery was 63 minutes. Ten (24%) patients required an opioid prescription after discharge. In those patients, median time to requirement was 27 hours (range 3–81), and median total requirement was 20 mg morphine equivalents (range 7.5–85). Protocol compliance inversely correlated to opioid use (P = 0.007). Compliance with local and regional anesthetic (20% versus 63%, P = 0.030) as well as ketorolac (70% versus 100%, P = 0.011) was lower in patients who required opioids. Patients who required opioids were less likely to be administered a beta blocker (0% versus 34%, P = 0.041). Pain scores were higher in opioid users on postoperative days 1–5 (P < 0.05). No complications occurred in those requiring opioids, and satisfaction rates were equivalent between groups. Conclusion:. This protocol allowed us to safely omit opioid prescriptions in 76% of patients following septorhinoplasty, without adverse effects on outcomes or patient satisfaction.