Benefit In Long-term Outcomes Research Articles

Lipid-Lowering Medication and Outcomes After Anatomical and Functional Imaging in Suspected Coronary Artery Disease.

Anatomical and functional imaging identify different phenotypes of coronary artery disease (CAD) that may have implications for lipid-lowering medication (LLM). The aim of this study was to assess the associations between LLM and long-term outcomes after combined anatomical and functional imaging in patients with suspected obstructive CAD. Consecutive patients (n=1,973; 41% men; median age: 63 years) underwent coronary computed tomography angiography (CTA) because of suspected CAD. Patients in whom obstructive CAD was not ruled out by CTA underwent ischemia testing by positron emission tomography. Data on LLM purchases were collected until 2 years, and the combined endpoints of death, myocardial infarction, and unstable angina pectoris were assessed at a median of 6.7 years. After imaging, LLM was used by 24% of patients with no CAD, 51% of patients with nonobstructive CAD, 72% of patients with obstructive CAD on CTA without myocardial ischemia, and 91% of patients with myocardial ischemia. The use of LLM decreased during follow-up, with 77% of patients with myocardial ischemia using LLM for 2 years. The use ofLLM was associated with a lower annual rate of adverse events in patients with myocardial ischemia (6.1% vs 2.8%; P= 0.032) or obstructive CAD without myocardial ischemia (2.9% vs 1.4%; P = 0.004) but not in patients with nonobstructive CAD (1.5% vs 1.4%; P = 0.89) or no CAD (0.3% vs 0.3%; P = 0.68). The CAD phenotype defined by anatomical and functional imaging guides the use of LLM. The presence of myocardial ischemia and anatomical obstructive coronary lesions were associated with a long-term outcome benefit from LLM.

Quantitative myocardial blood flow and long-term outcome benefit from revascularization

Quantitative myocardial blood flow and long-term outcome benefit from revascularization

Vein of Marshall Ethanol Infusion for AF Ablation; A Review.

The outcomes of persistent atrial fibrillation (AF) ablation are modest with various adjunctive strategies beyond pulmonary vein isolation (PVI) yielding largely disappointing results in randomised controlled trials. Linear ablation is a commonly employed adjunct strategy but is limited by difficulty in achieving durable bidirectional block, particularly at the mitral isthmus. Epicardial connections play a role in AF initiation and perpetuation. The ligament of Marshall has been implicated as a source of AF triggers and is known to harbour sympathetic and parasympathetic nerve fibres that contribute to AF perpetuation. Ethanol infusion into the Vein of Marshall, a remnant of the superior vena cava and key component of the ligament of Marshall, may eliminate these AF triggers and can facilitate the ease of obtaining durable mitral isthmus block. While early trials have demonstrated the potential of Vein of Marshall 'ethanolisation' to reduce arrhythmia recurrence after persistent AF ablation, further randomised trials are needed to fully determine the potential long-term outcome benefits afforded by this technique.

Effects of percutaneous coronary intervention on improvement of left ventricular ejection fraction among chronic coronary syndrome patients with left ventricular systolic dysfunction

Abstract Background At present, the therapeutic effects in response to percutaneous coronary intervention (PCI) in chronic coronary syndrome (CCS) patients with left ventricular systolic dysfunction (LVSD) remain unclear. Methods Based on the Cardiorenal ImprovemeNt (CIN) cohort study (NCT04407936), we analyzed data of 468 hemodynamically-stable CCS patients with LVSD accepting guideline-directed medical therapy (GDMT) from January 2007 to December 2018. The primary outcome was the improvement of left ventricular ejection fraction (LVEF) and long-term cardiac death. The association between PCI treatment combined with GDMT (PCI-GDMT) and LVEF improvement was evaluated by using propensity score matching (PSM) and logistics regression analysis. Results Of the 468 patients included in the study, 135 (28.8%) with GDMT alone and 333 (71.2%) cases were treated with PCI-GDMT. Patients undergoing PCI showed remarkably more vessel lesions but have better cardiac function. After fully adjusting for confounders, the LVEF among CCS patients with LVSD accepting PCI-GDMT were less likely to improve compared with GDMT alone [after PSM: risk adjusted odds ratio (aOR) 0.48, 95% confidence interval (CI): 0.25-0.88, P = 0.02]. Also, PCI therapy may did not bring significant long-term outcome benefit [all-cause death: risk adjusted hazard ratio (aHR) 1.00, 95% CI:0.62-1.62, P = 0.99; cardiac death: aHR 0.61, 95% CI:0.31-1.24, P = 0.17]. Conclusions Our cohort suggested that PCI treatment may not favor to the improvement of LVEF and not show significant differences in long-term outcome among hemodynamically-stable CCS patients with LVSD.Central Illustration

Cardiac resynchronization therapy induced QRS narrowing: could it change the prognosis?

Abstract Funding Acknowledgements Type of funding sources: None. Background Cardiac resynchronization therapy (CRT) responders should have symptomatic improvement and benefits in long-term outcomes. CRT is indicated in the treatment of heart failure (HF) patients with systolic dysfunction and prolonged QRS duration. There are conflicting results regarding QRS narrowing on CRT response. Objective We ought to access the impact of QRS narrowing after CRT implantation in clinical outcomes and arrhythmic events. The association between the QRS duration reduction in responders and non-responders was determined. Methods We retrospectively enrolled 110 consecutive patients with CRT. Native QRS duration and QRS duration at least 6 months after procedure were determined by EKG. Baseline clinical characteristics were accessed. Three outcomes were created. Primary outcome: hospitalization or emergency department admissions due to HF decompensation. Secondary outcome: sustained ventricular arrhythmic events. Tertiary MACE outcome (composite of cardiovascular death, hospitalization due to HF or acute coronary syndrome and cerebrovascular events). Results Out of 110 patients included, the mean age was 70.3 ± 10.7 years, 68.2% were male and mean body mass index was 29.1 ± 5.7 kg/m2. Baseline characteristics were similar between genders: 41.1% had atrial fibrillation, 10.3% peripheral arterial disease, 72.9% hypertension, 66.4% dyslipidemia, 44.9% diabetes and 20.7% chronic kidney disease. Ischemic etiology (p 0.001), pulmonary lung obstructive disease (p <0.001; r=0.35) and smoking habits (p <0.001; r=0.5) prevailed in male patients. Responders by clinical and/or echocardiographic criteria were 62.7%. Native QRS mean duration was 162.4 ± 22 ms and mean QRSd after CRT was 141.9 ± 37 ms, with a median QRS narrowing of 20 ± 30 ms. Primary outcome occurred in 28.6%, secondary in 16.4% and MACE occurred in 31.8%. QRS narrowing was an independent predictor of primary and secondary outcomes (U 283; p 0.016 and U 110.5; p 0.043) as well as MACE (U 6.18; p 0.035). ROC curve analysis compared native and post-CRT implantation QRSd and their impact on outcomes. The best cut-off values for hospitalization and MACE were 10 and 13, respectively (AUC 0.69; 95% CI 0.54 – 0.84; p 0.016 and AUC 0.64, 95% CI 0.52 – 0.76; p 0.035). Conclusion Patients with a larger decrease in QRS duration after CRT implantation revealed improved outcomes and it was independent of CRT response. This variable could be of interest in selecting HF patients for CRT.

Secondary Cardiovascular Prevention after Acute Coronary Syndrome: Emerging Risk Factors and Novel Therapeutic Targets.

The control of cardiovascular risk factors, the promotion of a healthy lifestyle, and antithrombotic therapy are the cornerstones of secondary prevention after acute coronary syndrome (ACS). However, many patients have recurrent ischemic events despite the optimal control of traditional modifiable risk factors and the use of tailored pharmacological therapy, including new-generation antiplatelet and lipid-lowering agents. This evidence emphasizes the importance of identifying novel risk factors and targets to optimize secondary preventive strategies. Lipoprotein(a) (Lp(a)) has emerged as an independent predictor of adverse events after ACS. New molecules such as anti-PCSK9 monoclonal antibodies, small interfering RNAs, and antisense oligonucleotides can reduce plasma Lp(a) levels and are associated with a long-term outcome benefit after the index event. The inflammatory stimulus and the inflammasome, pivotal elements in the development and progression of atherosclerosis, have been widely investigated in patients with coronary artery disease. More recently, randomized clinical trials including post-ACS patients treated with colchicine and monoclonal antibodies targeting cytokines yielded promising results in the reduction in major cardiovascular events after an ACS. Gut dysbiosis has also raised great interest for its potential pathophysiological role in cardiovascular disease. This evidence, albeit preliminary and needing confirmation by larger population-based studies, suggests the possibility of targeting the gut microbiome in particularly high-risk populations. The risk of recurrent ischemic events after ACS is related to the complex interaction between intrinsic predisposing factors and environmental triggers. The identification of novel risk factors and targets is fundamental to customizing patient clinical management with a precision medicine perspective.

The role of magnetic sphincter augmentation in the gastroesophageal reflux disease treatment pathway: the gastroenterology perspective.

Magnetic sphincter augmentation (MSA) is a surgical intervention for well-characterized gastroesophageal reflux disease (GERD), where the esophagogastric junction barrier is augmented using a bracelet of magnetized titanium beads. MSA could be an attractive option for patients with documented GERD who wish to avoid long-term pharmacologic therapy or whose symptoms are not adequately managed with lifestyle modifications and pharmacologic therapy. The 'ideal' MSA patient is one with prominent regurgitation, without dysphagia or esophageal motor dysfunction, with objective evidence of GERD on upper endoscopy and/or ambulatory reflux monitoring. Appropriate candidates with significant hiatus hernia may pursue MSA with concomitant hiatus hernia repair. The increasing adoption of MSA in the GERD treatment pathway reflects research that shows benefits in long-term outcomes and healthcare costs compared with other established therapies in appropriate clinical settings.

Association between left ventricular reverse remodeling and long-term outcomes after alcohol septal ablation for hypertrophic obstructive cardiomyopathy.

There is a paucity of data regarding the effect of left ventricular (LV) reverse remodeling (r-LVR) on diastolic function and outcomes after alcohol septal ablation (ASA) in patients with hypertrophic obstructive cardiomyopathy (HOCM). The aim of this study was to identify the impact of r-LVR on the outcome and the predictors of such changes after ASA. Eighty-seven patients (57.5% men) were enrolled and underwent both echocardiography and cardiovascular magnetic resonance (CMR) imaging at baseline and 27 months after the procedure. The study population was divided into two groups by the degree of r-LVR. Compared to the greater r-LVR group, the lesser r-LVR group had a significantly larger LV mass (LVM) and lower diastolic function parameters at baseline. The greater r-LVR group had significantly greater LVM regression and improvement of diastolic function after ASA. Kaplan‒Meier analysis showed significantly worse composite events in the lesser r-LVR group after ASA (P = 0.016). After adjusting for multiple clinical variables, r-LVR was associated with an improved E/e' (β = 0.390, p < 0.001) and reduced events (hazard ratio: 0.795; 95% confidence interval (CI), 0.644-0.983; p = 0.034). Preablation LVM was associated with a decreased probability of r-LVR (β = -0.228, p = 0.021) and diastolic function improvement (β= -0.245, p = 0.006). r-LVR was associated with long-term outcome benefit in patients with HOCM. Preablation LVM prevented LV from favoring reverse remodeling and thus may be a potential parameter for risk stratification and prognosis after ASA treatment.

Outcome of thymectomy in myasthenia gravis patients at Neurological Institute of Thailand

Background &amp; Objective: Myasthenia gravis is the most common neuromuscular junction disorders and is caused by autoantibodies against acetylcholine receptors at the postsynaptic muscle endplate. Although thymectomy is current standard treatment but the benefit in long-term outcomes and in non- thymomatous generalized MG patients with negative AChR antibody are still unclear. The objective is to determine the treatment outcomes of thymectomy in non-thymomatous generalized MG patients with or without AChR antibody and identify features related to remission. Methods: Retrospective chart review of the patients diagnosed with non-thymomatous generalized MG from January 1st, 2014 to December 31th, 2018. Patients were classified into two groups: patients with thymectomy (thymectomy group) and patients with no thymectomy (medication group). Results: Seventy-six patients were included. All baseline clinical features, investigations and treatment response were compared. At 6 and 12 months follow up, most patients in both groups had a good response to treatment. At 24 months follow up, ratio of patients in thymectomy group with complete stable remission is higher than in medication group (25% vs. 7.5%) and all patients in this group had positive acetylcholine receptor antibody. The patients in thymectomy group required lower dosage of prednisone, azathioprine and cholinesterase inhibitors than in medication group. Conclusion: Thymectomy was associated with a high probability of achieving remission, reduced cholinesterase inhibitors and immunosuppressive drugs when compared to medication group. Therefore, thymectomy should be strongly considered for non-thymomatous generalized MG patient with positive AChR antibody; and may be considered in non-thymomatous generalized MG patients with negative AChR antibody.

Evaluating the cost-utility of a direct transfer to angiosuite protocol within 6 h of symptom onset in suspected large vessel occlusion patients

Introduction A direct transfer to angiosuite (DTAS) protocol has shown to be effective and safe by shortening in-hospital workflows and encouraging long-term outcome benefits. To implement DTAS at a new facility, a large organizational effort is necessary. We performed a cost-utility analysis and budget impact analysis (BIA) of the operation of a new angiosuite, primarily dedicated to stroke patients, that allows facilities to approximate the cost implications of utilizing a DTAS pathway. Methods Sixty-one patients who underwent endovascular treatment (EVT) following DTAS were matched for baseline variables to 117 patients who underwent a conventional imaging protocol at a hospital in Catalonia, Spain. An economic model, based on actual data from these patients, was developed to assess the short- and long-term clinical and economic implications of DTAS. In the BIA, the DTAS scenario was gradually implemented for 20% of patients each year until reaching a plateau at 80% of patients in the DTAS pathway. Initial investment and additional organizational costs, €4 million, were taken into consideration to compare the budget impact of the DTAS scenario with no organizational changes over five years. Results DTAS was associated with better patient functional independence rates (mRS 0–2: 50.9% vs. 41.0%) and a quality-adjusted life-years gain of 0.82 per patient. Despite the additional initial investment, DTAS development was associated with an estimated 10.2% reduction (€14.7 million) of the total costs (€144.5 million). Cost savings were mainly due to long-term associated costs related to patient disability (€13.2 million). Limitations The study relies on data obtained from a single-center, and therefore it may be difficult to generalize the findings Conclusions Our economic model predicts that the implementation of a DTAS program is cost-effective compared with no organizational changes. Our model also predicts better clinical outcomes for patients in terms of functional independence and quality-adjusted life years.

A Brief Review of Bolus Osmotherapy Use for Managing Severe Traumatic Brain Injuries in the Pre-Hospital and Emergency Department Settings

Background: Severe traumatic brain injury (TBI) management begins in the pre-hospital setting, but clinicians are left with limited options for stabilisation during retrieval due to time and space constraints, as well as a lack of access to monitoring equipment. Bolus osmotherapy with hypertonic substances is commonly utilised as a temporising measure for life-threatening brain herniation, but much contention persists around its use, largely stemming from a limited evidence base. Method: The authors conducted a brief review of hypertonic substance use in patients with TBI, with a particular focus on studies involving the pre-hospital and emergency department (ED) settings. We aimed to report pragmatic information useful for clinicians involved in the early management of this patient group. Results: We reviewed the literature around the pharmacology of bolus osmotherapy, commercially available agents, potential pitfalls, supporting evidence and guideline recommendations. We further reviewed what the ideal agent is, when it should be administered, dosing and treatment endpoints and/or whether it confers meaningful long-term outcome benefits. Conclusions: There is a limited evidence-based argument in support of the implementation of bolus osmotherapy in the pre-hospital or ED settings for patients who sustain a TBI. However, decades’ worth of positive clinician experiences with osmotherapy for TBI will likely continue to drive its on-going use. Choices regarding osmotherapy will likely continue to be led by local policies, individual patient characteristics and clinician preferences.

Association of Chronic Proton Pump Inhibitor Use in Lung Transplant Recipients with Long-Term Outcomes: A Retrospective Cohort Study

<h3>Purpose</h3> Proton pump inhibitors (PPI) are widely prescribed long-term for lung transplant recipients in the absence of proven PPI-indicated conditions, despite little evidence supporting this practice. Several adverse effects related to chronic PPI use have been reported in observational studies in the general population. We aimed to assess whether chronic PPI use in lung transplant recipients is associated with benefits in long-term outcomes, specifically chronic lung allograft dysfunction (CLAD) and death/retransplant. <h3>Methods</h3> All adult lung transplant recipients transplanted between 1999 and 2018 who survived past 1-year post-transplant and had at least 4 pulmonary function tests were included. Patients were classified as on-PPI if there was a recorded prescription in the electronic medical record for dexlansoprazole, esomeprazole, lansoprazole, omeprazole, pantoprazole, or rabeprazole before 1-year post-transplant that continued after 1-year post-transplant. All other patients were classified as off-PPI. Cox proportional hazards models were used to determine the associations between PPI use and outcomes. <h3>Results</h3> 171 patients were off-PPI and 1394 patients were on-PPI. 780 patients developed CLAD and 808 died/were retransplanted. Compared to the on-PPI group, the off-PPI group was younger, had fewer re-transplants, and more transplants before 2010. In univariable analyses, PPI use was protective against CLAD (HR=0.76[0.62-0.94], p=0.01) and death/retransplant (HR=0.82[0.67-0.99], p=0.04). These associations were no longer significant after adjusting for age, sex, transplant type, transplant number, transplant era, primary disease, and CMV mismatch in multivariable analyses for CLAD (HR=0.87[0.70-1.08], p=0.20) and death/retransplant (HR=0.83[0.68-1.02], p=0.07). <h3>Conclusion</h3> In a retrospective cohort study, chronic PPI use after the first post-transplant year in lung transplant recipients was associated with a non-statistically significant benefit in death/retransplant, independent of potential confounders. As additional unknown confounders may exist, prospective randomized studies are needed to provide higher levels of evidence. Nevertheless, it may be reasonable to re-evaluate the practice of widely prescribing long-term PPIs in lung transplant recipients lacking a clear indication.

Therapeutic drug monitoring in inflammatory bowel disease: The dawn of reactive monitoring.

Inflammatory bowel disease (IBD) is a chronic condition that significantly affects the quality of life of its patients. Biologic drugs have been the mainstay treatment in the management of IBD patients but despite their significant contribution, there remains a proportion of patients that do not respond or lose response to treatment. Therapeutic drug monitoring (TDM) involves measuring levels of serum drug concentrations and anti-drug antibodies. TDM of biologic drugs initially emerged to understand treatment failure in other immune mediated inflammatory diseases. This was then introduced in IBD to rationalize primary non-response or secondary loss of response, given that low serum drug concentrations or the formation of anti-drug antibodies are variably associated with treatment failure. The aim of this narrative review is to provide an overview regarding the current use of TDM in clinical practice and to present the evidence available regarding its use in both proactive and reactive clinical settings in preventing and managing treatment failure. This review also presents the existing evidence regarding the association of various clinical outcomes with specific thresholds of drug concentrations, in everyday practice. A narrative review of published articles and conference abstracts regarding the use of TDM in IBD management, through an electronic search using PubMed and ScienceDirect. TDM has proven to be superior and more cost effective in guiding management of patients with treatment failure compared to empiric dose escalation or change in treatment. Despite a trend towards an association between clinical outcomes and drug concentrations, proactive TDM based strategies have not been shown to achieve clear benefit in long-term outcomes. In the clinical setting, TDM has proven to be useful in managing IBD patients, and its use in the reactive setting, as an additional tool to help manage patients with treatment failure, is being promoted as newer guidelines and consensus groups implement TDM as part of the management plan.

The Application of Fascia Iliaca Compartment Block for Acute Pain Control of Hip Fracture and Surgery.

Over 300,000 patients are hospitalized annually following hip fractures in the USA. Many patients experienced inadequate analgesia. We will review the perioperative effects of the fascia iliaca compartment block (FICB) in hip fracture patients. FICB by injecting local anesthetics beneath the fascia iliaca results in significant pain relief in hip fractures. Neuropathies and vascular injuries are almost unlikely. Single-shot FICB is faster to place, yet providing about 8 h of analgesia when bupivacaine is used. Continuous FICB provides prolonged titratable analgesia, improved patient satisfaction, and leads to faster hospital discharge. FICB reduces opioid consumption, decreases morbidity and mortality, reduces hospital stay, reduces delirium, and improves satisfaction. FICB should form part of a multimodal analgesic regime, in the context of a multidisciplinary approach to the management of hip fracture patients. More clinical investigations are needed to validate the long-term outcome benefits of FICB in hip fracture patients.

Abstract P134: Economic and Clinical Model for Direct Transfer to Angiosuite Protocol Development

Background and purpose: Direct transfer to angiosuite (DTAS) has consistently shown to be effective and safe shortening in-hospital workflows and encouraging long-term outcome benefits. In order to generalize DTAS an organizational and manpower effort is necessary. We aim to perform a cost-effective analysis of the implementation of a new angiosuite primarily dedicated to DTAS of stroke patients that will allow generalization of this pathway Material and methods: Sixty-one patients who underwent endovascular treatment (EVT) following DTAS were matched for baseline variables to 117 patients who underwent conventional imaging protocol before EVT. An economic model based on actual data was developed to assess the short and long term clinical and economic implications. The DTAS development scenario estimates a gradual 20% increase of DTAS rate for 4 years followed by a stable 80% rate of DTAS. Initial investment and additional organizational costs were included: 4M є. A cost-effective study compared the DTAS development scenario (SC1) to a scenario with no organizational changes (SC2) over 10 years. Results: The 10 year model included 1775 EVT patients in each scenario: SC1 60% DTAS Vs SC2 0% DTAS. SC1 would be associated with better functional independence rates (mRS 0-2: 45.8% versus 40.2%; p=0.04) and a quality-adjusted life-years gain of 0.12 per patient. Despite the additional investment, SC1 development was associated with an estimated 15.1% reduction (26.25M є) of total costs (173.749M є). Cost savings was mainly due to long-term associated costs related with patient disability (є 26.4 million). Conclusions: Our economic model predicts that the development of a DTAS program is cost effective.

Clinical and pathological response to neoadjuvant chemotherapy with different chemotherapy regimens predicts the outcome of locally advanced breast cancer.

This retrospective analysis was designed to research whether clinical response partial response (PR)/complete response (CR) and pathological response (PCR) to neoadjuvant chemotherapy can translate into prognosis benefit pathological response in patients with locally advanced breast cancer and whether different chemotherapy regimens will influence the outcomes. One hundred and thirty-five patients with breast cancer patients who received neoadjuvant chemotherapy were included in the retrospective analysis. Patients were followed up strictly. Overall survival (OS) was evaluated by the Kaplan-Meier analysis. The comparison of the clinical and pathological characteristics and recurrence was performed using the carried out by chi-squared and Fisher's exact tests. Univariate and multivariate analyses were performed by the Cox regression analysis. Clinical response was strongly correlated with lymph nodes status (P=0.032). The OS comparison of pathological response between the pCR group and non-pCR groups did not exhibit statistically significant differences (P=0.400). A similar non-significant response result was observed in the comparison of clinical response between the PR/CR and SD/PD groups group (P=0.108). Univariate and multivariate analyses did not support clinical response (P=0.156 P=0.095 respectively) or pathological response (P=0.600 P=0.144 respectively) as the predictors of prognosis. There were no significant differences in either the comparison of the clinical response group it seems no statistically significance (P=0.496) or the comparison of the pathological response group (P=0.460). OS analyses across different neoadjuvant chemotherapy regimens demonstrated no significant differences (P=0.307). In the PR/CR and PD/SD comparison of every single regimen, there were no significant differences. However, for patients with PR/CR patients from the comparison of five regimens, namely, TAC, FAC, AC-T, AT and TCBP demonstrated a significant difference (P=0.022). In the group of patients with luminal A breast cancer, the result of the Fisher's exact test approached significant (P=0.059). Neither PR/CR nor pCR can translate into long-term outcome benefit. PR/CR and PCR are not independent predictors in patients with advanced breast cancer. Patients who received a taxane + anthracycline regimen exhibited a higher recurrence rate than any other regimens, especially those patients with luminal A breast cancer.

Survival Trends in Young Patients With Multiple Myeloma: A Focus on Racial-Ethnic Minorities

IntroductionOutcomes in multiple myeloma (MM) have improved significantly over time. This is true overall for all patients as well as patient subgroups based on age and race/ethnicity. Despite this, disparities are noted in outcomes when looking at racial subgroups. Materials and MethodsWe performed an analysis from the population-based Surveillance, Epidemiology, and End Results (SEER) database to evaluate improvement in relative survival rates (RSRs) for young (≤ 40 years at the time of MM diagnosis) and older (> 40 years at the time of MM diagnosis) over time by race/ethnicity, specifically focusing on Hispanic patients with MM. Expected survival was estimated using the age- and gender-specific death rates from the United States population. RSR was provided as the ratio of the observed to expected survival at individual time points. Five-year and 10-year RSRs were calculated for patients based on treatments modalities available in various time periods. ResultsWe identified a total of 89,451 patients with MM in SEER, of which 1460 patients formed the young patients with MM (≤ 40 years) cohort. Five- and 10-year RSR improved significantly over time for all patients and older patients (> 40 years) by race (all P < .001). Evaluating the younger patients, RSR improved significantly for non-Hispanic whites and non-Hispanic blacks, but not for Hispanics. This was true for the 5-year (P = .08) and 10-year (P = .13) RSRs. ConclusionWe report a lack of significant benefit in long-term outcomes for younger Hispanic patients with MM over time. This could be owing to multifactorial causes that need to be addressed to mitigate outcome disparities.

Rotor mapping: black box or very simple? The FIRM approach.

Catheter ablation has become the most common therapy in patients with atrial fibrillation (AF). However, despite significant advances in technology and operators' experience, ablation outcomes remain suboptimal, especially in patients with persistent AF. Focal impulse and rotor modulation (FIRM) represents anew technology for mapping and ablation of patient-specific AF sources. This approach is based on the concept of localized sources, which can be understood as organized rotational waves or focal impulses driving disorganized AF. Several studies, mainly single-center case series, have shown an incremental benefit in long-term outcome when adding FIRM-guided ablation to conventional pulmonary vein isolation (PVI). Therefore, the results of ongoing multicenter randomized trials are needed to support this data.

Comparison of Mitoxantrone in Combination with Intermediate-dose Cytarabine versus High-dose Cytarabine as Consolidation Therapies for Young Non-APL Acute Myeloid Leukemia Patients with Favorable and Intermediate Cytogenetics

In this study, we compared the efficacy of mitoxantrone in combination with intermediate-dose cytarabine (HAM) with that of high-dose cytarabine alone (HiDAC) as consolidation regimens in non-acute promyelocytic leukemia (APL) acute myeloid leukemia patients with favorable and intermediate cytogenetics. A total of 62 patients from Shenzhen People's Hospital were enrolled in this study. All patients enrolled received standard induction chemotherapy and achieved the first complete remission (CR1). In these patients, 24 received HiDAC and 38 received HAM as consolidation. The median relapse free survival (RFS) and overall survival (OS) were similar between these two consolidation regimens. Even in subgroup analysis according to risk stratification, the combination regimen conferred no benefit in longterm outcome in patients with favorable or intermediate cytogenetics. However, in patients receiving HAM regimen, the lowest neutrophil count was lower, neutropenic period longer, neutropenic fever rate higher, and more platelet transfusion support was required. HAM group also tended to have higher rate of sepsis than HiDAC group. According to our results, we suggest that combination treatment with mitoxantrone and intermediate-dose cytarabine has limited value as compared to HiDAC, even in young non-APL AML patients with favorable and intermediate cytogenetics.

Continuous regional anesthesia: a review of perioperative outcome benefits.

Routine use of regional anesthesia for patients having surgery is supported by general safety and proven effectiveness as a targeted modality in the prevention and treatment of acute pain. Recently, perioperative physicians have become much more interested in improving long-term outcomes after surgery rather than focusing on the well-established short-term benefits of regional anesthesia. This interest has raised important questions regarding the potential influence of regional anesthesia on morbidity and mortality, persistent pain and cancer prognosis. Tissue injury is responsible for the inflammatory reaction and physiologic stress response observed during the perioperative period and can influence a patient's recovery trajectory. Regional anesthesia can modulate the inflammatory response through the direct anti-inflammatory effect of local anesthetics, blocking neural afferents, and blunting sympathetic activation. Moreover, continuous techniques (e.g., epidural and perineural catheters) that provide longer duration and titratable pain relief in the perioperative period may be protective against the development of persistent post-surgical pain by providing effective acute pain management and decreasing exposure to opioids. To maximize the potential for long-term outcome benefits to surgical patients, continuous regional anesthesia techniques are preferred over single injection techniques. Although the data are not yet definitive, some studies have demonstrated better functional recovery after joint replacement and lower rates of cancer recurrence in patients treated with continuous regional anesthesia. Future research studies in regional anesthesia will have to focus on these long-term patient-centered outcomes and may need to incorporate novel study designs and analyses of big data.