Differences In Management Of Patients Research Articles

Clinical impact of using [18F]AlF-NOTA-octreotide PET/CT instead of [68Ga]Ga-DOTA-SSA PET/CT: Secondary endpoint analysis of a multicenter, prospective trial.

[18F]AlF-NOTA-octreotide ([18F]AlF-OC) is a promising alternative for [68Ga]Ga-DOTA-somatostatin analogs (SSAs) in positron emission tomography (PET) imaging of the somatostatin receptor (SSTR). Our aim is to assess changes in TNM staging and differences in patient management between [18F]AlF-OC PET/CT and [68Ga]Ga-DOTA-SSA PET/CT in the work-up of neuroendocrine tumor (NET) patients. Patients who underwent both [18F]AlF-OC and [68Ga]Ga-DOTA-TATE or [68Ga]Ga-DOTA-NOC PET/CT in our multicenter study (Pauwels et al., J Nucl Med.2023;63:632-638) with a NET were included for analysis. TNM staging was determined and compared for both tracers. For each patient, the blinded [68Ga]Ga-DOTA-SSA or [18F]AlF-OC PET/CT images were presented in random order at a multidisciplinary team board. The images were presented together with clinical information and compared with previous SSTR and [18F]FDG PET/CT imaging. After a consensus decision for patient management was recorded, the board was presented with the PET/CT images from the other SSTR tracer and a decision was made for the second tracer. Differences in management were classified as major if it entailed an intermodality change and minor if it led to an intramodality change. Compared with [68Ga]Ga-DOTA-SSA, the use of [18F]AlF-OC led to a change in 16/75 patients: TNM staging changes in 10/75 patients (13.3%; downstaging in 3/10, upstaging in 7/10) and differences in clinical management were seen in 10/75 patients (13.3%), leading to a major difference in 7/10 cases and a minor change in 3/10 cases. All 10 cases with a difference in patient management between both PET tracers were caused by additional lesion detection by [18F]AlF-OC. The use of [18F]AlF-OC did not impact TNM staging or clinical management in the large majority of the patients (86.7%), further validating the potential for routine clinical use of [18F]AlF-OC PET/CT as an alternative for [68Ga]Ga-DOTA-SSA PET/CT. The trial is registered under ClinicalTrials.gov identifier NCT04552847 and EudraCT 2020-000549-15.

Difference in management of patients with prostate cancer and spinal cord compression in teaching vs non-teaching hospitals in the United States.

e17116 Background: Spinal Cord Compression (SCC) secondary to metastatic prostate cancer is a complication that can lead to irreversible loss of neurologic function. Many factors including age, comorbidities, severity of the compression, and neurological deficit can affect the treatment from conservative management to radiation and surgery. We aimed to study the difference in practice patterns and their outcomes in teaching hospitals (TH) vs non-teaching hospitals (NTH) in the United States. Methods: Utilizing the National Inpatient Sample Database (NIS), we conducted a retrospective cohort study on hospitalizations with prostate cancer and SCC between 2016 and 2020 across the US. Patients were divided into two groups of TH and NTH. Demographics, comorbidities, treatment modality, length of hospitalization, costs, and mortality were compared between the two groups. We also studied patients’ characteristics and outcomes in TH and NTH according to their treatment strategy. Results: We identified 11,380 metastatic prostate cancer patients with SCC admitted to the hospitals with a 7-day median length of stay. While 27.4% underwent surgical procedure and 11.5% received inpatient radiation, 61.2% were treated conservatively. The median cost of hospitalization was $21,922 in TH and $15,141 in NTH ( P< 0.001). Although the median age and Charlson Comorbidity Index did not differ between two groups ( P =0.12 & 0.66 respectively), patients in TH were more likely to receive intervention (either radiation or surgery) compared to NTH (Surgery: 28.2% in TH vs 23.0% in NTH; P <0.01 & Radiation: 12.1% in TH vs 8.2% in NTH; P <0.01). Mortality rate was lower in TH than NTH (4.5% vs 7.9%; P < 0.01). In both TH and NTH, patients with private insurance were more likely to undergo surgery (TH: Surgery 25.1% vs Radiation 18.8%; P< 0.05 & NTH: Surgery 27.0% vs 6.9% P< 0.05). Among different races, black patients were more likely to receive radiation than surgery in TH (34.2% vs 26.8%; P <0.05). With no difference in comorbidities between surgery and radiation group in TH ( P =0.16), all-cause mortality was higher for those who received radiation than for surgery (4.4% vs 1.9%; P <0.05) . Conclusions: This study indicated that practice pattern for the management of SCC in prostate cancer is different in teaching and non-teaching hospitals. In addition to more surgery being performed in teaching hospitals, the mortality rate was also lower. There was an association between race and insurance type with different treatment modalities. We also revealed that all-cause mortality was higher with radiation therapy compared to surgery in teaching hospitals.

Macroprolactinemia: a mini-review and update on clinical practice

Hyperprolactinemia is common among infertile patients, with up to 15%-20% of women with oligomenorrhea having hyperprolactinemia. Suppression of the hypothalamic-pituitary-gonadal axis via inhibition of pulsatile gonadotropin releasing hormone because of hyperprolactinemia is a common endocrine etiology of infertility. There are 3 forms of human prolactin (PRL): monomeric PRL, dimeric PRL, and macro-PRL. Also known as big-big PRL, macro-PRL has a molecular weight >150 kDa and normally comprises 5%-10% of circulating PRL. When the predominant form of circulating PRL is macro-PRL, macroprolactinemia is diagnosed. Among patients with hyperprolactinemia, 10%-46% have macroprolactinemia. Patients with macroprolactinemia are at risk of unnecessary pituitary imaging and treatment with dopamine agonists if not correctly diagnosed. Given the high prevalence of macroprolactinemia among patients with elevated PRL levels and the different management of patients with macroprolactinemia vs true monomeric hyperprolactinemia, all patients with persistently elevated PRL levels should be screened for macro-PRL.

Can We Reliably Compare Outcomes of Ream-and-Run and Anatomic Total Shoulder Arthroplasty?: Commentary on an article by James Levins, MD, et al.: "Comparison of Humeral-Head Replacement with Glenoid-Reaming Arthroplasty (Ream and Run) Versus Anatomic Total Shoulder Arthroplasty. A Matched-Cohort Study".

Commentary Ream-and-run arthroplasty represents one of many options for the challenging problem of glenohumeral arthritis in the young active patient. Proponents of this procedure may contend that, despite higher revision rates in the short term compared with anatomic total shoulder arthroplasty (aTSA), ream-and-run arthroplasty may obviate potential longer-term complications related to polyethylene loosening and wear, such as glenoid bone loss and osteolysis leading to reverse baseplate fixation failure and humeral osteolysis and loosening1,2. It may also allow patients to avoid activity restrictions related to concern over polyethylene-related complications and to potentially avoid another surgery in their lifetime. However, these theoretical long-term advantages must be balanced against the fact that patients undergoing ream and run are at higher risk for early revision surgery. Data on ream-and-run arthroplasty outside of the originating institution are sparse, so this study by Levins et al. comparing aTSA and ream and run is useful to consider. Comparing these 2 procedures is no easy task; at baseline, patients choosing to undergo ream-and-run arthroplasty are different in many ways (age, sex, psychosocial factors, and glenoid morphology and retroversion) compared with patients choosing to undergo aTSA3. This usually results in a demographics table full of significant differences4, and therefore, non-comparable patient-reported outcomes and revision rates. Levins et al. attempted to address this in 2 ways. First, they included 2 distinct time periods: an earlier period in which no ream-and-run procedures were performed, and a later period in which both ream and run and aTSA were offered. Such an approach may reduce any surgical decision-making bias that leads to different baseline patient characteristics. Second, they utilized propensity-score matching (PSM). Short of a randomized controlled trial comparing ream and run and aTSA, which would be nearly impossible to undertake, this study provides the most comparable cohorts in the literature since the initial matched-cohort study reported by Dr. Matsen 15 years ago5. This PSM approach used is not perfect, and it is important to understand 2 major limitations of the methodology. First, one must consider the prototypical patient undergoing ream and run: a motivated, resilient male patient with glenoid biconcavity and retroversion who wants to participate in heavy lifting and impact sports. Many of these characteristics are addressed in the PSM algorithm, but notably, activity level and psychosocial attributes like resilience and motivation, thought to be very important in selecting a patient for a ream-and-run procedure, were absent. These characteristics are more difficult to objectively assess, but without taking them into account, the study cannot convince the reader that these cohorts truly comprised similar patients. The second major limitation of the PSM in this study pertains to matching on the basis of duration of follow-up. By doing so, the authors reduce the benefit of including a time period in which ream and run was not offered to patients. While the alternative of not matching on follow-up leads to other issues, such as imbalanced follow-up durations and differences in patient management, this study’s approach of matching length of follow-up increases the probability that the total shoulder cohort contains more patients from the latter time period in which more motivated, resilient, and active patients were likely offered ream-and-run arthroplasty. It should also be noted that the senior author, similar to Dr. Matsen, has substantial experience with the ream-and-run procedure. The technical nuances in addressing glenoid deformity and soft-tissue balancing during the procedure are different from those considered during aTSA. As with any other surgical procedure, higher volume produces better results, and this surgeon’s thoughtful approach to the operative technique and rehabilitation after ream and run likely were adapted over time to optimize patient outcomes. The generalizability of these results may not be assured. Despite these limitations, the authors should be commended for providing us with the largest report on the ream-and-run procedure outside of Dr. Matsen’s cohort. They demonstrate that acceptable results, similar to those of aTSA, can be achieved in this challenging population. Further studies objectively assessing activity level and the psychosocial aspects of patient selection will help us further elucidate who the “optimal” ream-and-run candidate is. Continued follow-up of the cohorts in this study will be essential to determining whether the perceived long-term value of avoiding glenoid polyethylene in the young patient with glenohumeral arthritis is worth it.

Type 1 Diabetes Continuous Glucose Monitoring Use in the Pediatric Emergency Department Affects Laboratory Test Frequency but Not Treatment Timing.

Regular use of continuous glucose monitoring (CGM) in type 1 diabetes management increases the achievement of glycemic targets and reduces health care utilization, specifically emergency department (ED) visits. This retrospective chart review examined the effects of CGM use in patients with type 1 diabetes in a pediatric ED. Use of CGM was associated with several differences in patient management in the ED. This work is a first step toward development of guidelines for the appropriate use of CGM in the pediatric ED. In the future, CGM use in type 1 diabetes may lead to reduced ED-specific health care costs.

Comparative Analysis of Early Outcomes and Complications of PSO Among Neurosurgeons and Orthopedic Surgeons.

Retrospective comparative cohort study using the National Surgical Quality Improvement Program. The aim of this study was to evaluate trends in the annual number of PSOs performed, describe the patient populations associated with each cohort, and compare outcomes between specialties.Summary of Background Data:Pedicle subtraction osteotomies (PSO) are complex and advanced spine deformity surgical procedures performed by neurosurgeons and orthopedic surgeons. Though both sets of surgeons can be equally qualified and credentialed to perform a PSO, it is possible that differences in training and exposure could translate into differences in patient management and outcomes. Patients that underwent lumbar PSO from 2005 to 2014 in the American College of Surgeons-National Surgical Quality Improvement Program registry were identified. Relevant demographic, preoperative comorbidity, and postoperative 30-day complications were queried and analyzed. The data was divided into 2 cohorts consisting of those patients who were treated by neurosurgeons versus orthopedic surgeons. Additional data from the Scoliosis Research Society Morbidity and Mortality database was queried and analyzed for comparison. Demographic and comorbidity factors were similar between the neurosurgery and orthopedic surgery cohorts, except there were higher rates of hypertension among orthopedic surgeon-performed PSOs (65.66% vs. 48.67%, P =0.004). Except for 2012, in every year queried, orthopedic surgeons reported more PSOs than neurosurgeons. In patients who underwent lumbar fusion surgery, there was a higher rate of PSOs if the surgery was performed by an orthopedic surgeon (OR 1.7824, 95% CI: 1.4017-2.2665). The incidence of deep vein thrombosis after PSOs was higher for neurosurgery compared with orthopedic surgery (8.85% vs. 1.20%, P =0.004). However, besides deep vein thrombosis, there were no salient differences in surgical complication rates between neurosurgeon-performed PSOs and orthopedic surgeon-performed PSOs. The number of PSO procedures performed by neurosurgeons and orthopedic surgeons has increased annually. Differences in outcomes between neurosurgeons and orthopedic surgeons suggest an opportunity for wider assessment and alignment of adult spinal deformity surgery exposure and training across specialties.

How to differentiate behavioral variant frontotemporal dementia from primary psychiatric disorders: practical aspects for the clinician.

Due to the early and prominent behavioral changes which characterize behavioral variant frontotemporal dementia (bvFTD), patients are more likely to seek psychiatric help and are often initially diagnosed with a primary psychiatric disorder (PPD). Differentiating these conditions is critical because of the dramatically different outcomes, differences in patient management, family counseling and caregiver education. To propose a practical guide to distinguish between bvFTD and PDD. We conducted a non-systematic review of the published manuscripts in the field, including some previous investigations from our own group and work on which we have collaborated, and summarized the main findings and proposals that may be useful for neurological practice. The reviewed literature suggests that a comprehensive clinical history, brief cognitive and neuropsychological evaluations, detailed neurological examination with special attention to motor alterations related to bvFTD, structural and functional neuroimaging evaluation, genetic investigation in selected cases, and assistance from a multidisciplinary team, including a neurologist and a psychiatrist with expertise in bvFTD, are very helpful in differentiating these conditions. Although the clinician may commonly face great difficulty in differentiating between bvFTD and PPD, the use of appropriate tools in a systematic way and the availability of a well-trained multidisciplinary group can significantly increase diagnostic accuracy.

Usefulness of MRI-based radiomic features for distinguishing Warthin tumor from pleomorphic adenoma: performance assessment using T2-weighted and post-contrast T1-weighted MR images

PurposeDifferentiating Warthin tumor (WT) from pleomorphic adenoma (PA) is of primary importance due to differences in patient management, treatment and outcome. We sought to evaluate the performance of MRI-based radiomic features in discriminating PA from WT in the preoperative setting. MethodsWe retrospectively evaluated 81 parotid gland lesions (48 PA and 33 WT) on T2-weighted (T2w) images and 52 of them on post-contrast fat-suppressed T1-weighted (pcfsT1w) images. All MRI examinations were carried out on a 1.5-Tesla MRI scanner, and images were segmented manually using the software ITK-SNAP (www.itk-snap.org). ResultsThe most discriminative feature on pcfsT1w images was GLCM_InverseVariance, yielding area under the curve (AUC), sensitivity and specificity of 0.9, 86 % and 87 %, respectively. Skewness was the feature extracted from T2w images with the highest specificity (88 %) in discriminating WT from PA. ConclusionRadiomic analysis could be an important tool to improve diagnostic accuracy in differentiating PA from WT.

Abstracts and Case Studies for the College of American Pathologists 2021 (CAP21) Annual Meeting

Abstracts and Case Studies for the College of American Pathologists 2021 (CAP21) Annual Meeting

Enhancing Implementation of Complex Critical Care Interventions through Interprofessional Education.

Background: Many critical care interventions that require teamwork are adopted slowly and variably despite strong evidence supporting their use. We hypothesize that educational interventions that target the entire interprofessional team (rather than professions in isolation) are one effective way to enhance implementation of complex interventions in the intensive care unit (ICU).Objective: As a first step toward testing this hypothesis, we sought to qualitatively solicit opinions about team dynamics, evidence translation, and interprofessional education as well as current knowledge, attitudes, and practices surrounding the use of one example of a team-based practice in the ICU—preventive postextubation noninvasive ventilation (NIV).Methods: We conducted a qualitative evaluation using semistructured interviews and focus groups with nurses, respiratory therapists, and physicians working in four ICUs in four hospitals within an integrated health system. ICUs were selected based on variation in academic versus community status. We iteratively analyzed transcripts using a thematic content analysis approach.Results: From December 2018 to January 2019, we conducted 32 interviews (34 people) and 3 focus groups (20 people). Participants included 31 nurses, 15 respiratory therapists, and 8 physicians. Participants had favorable views of how their teams work together but discussed ways team dynamics (e.g., leader inclusiveness) impact care coordination. Participants viewed interprofessional education favorably and shared suggestions regarding preferred content and delivery (e.g., include both profession-specific and team-oriented content). Though participants reported frequently using NIV as a treatment, they described rarely using NIV as a preventive strategy, and nurses and respiratory therapists described challenges to use such as perceived patient discomfort. There were ICU-specific differences in management of patients at a high risk for respiratory failure after extubation, with some preferring to delay extubation.Conclusion: Participants reported optimism that interprofessional education can be an acceptable and effective way to improve translation of evidence into practice. Participants also detailed patient-specific and ICU-wide barriers to the implementation of preventive postextubation NIV. This information about teamwork in the ICU, suggestions for interprofessional education, and barriers and facilitators to use of a target evidence-based practice can inform the development of novel educational strategies in ways that increase acceptability, appropriateness, and feasibility of the intervention.

Cytomegalovirus Viral Load in Transplanted Patients Using the NeuMoDx™ (Qiagen) Automated System: A 1-Month Experience Feedback

Cytomegalovirus (CMV) reactivations represent a significant morbidity and mortality problem in transplant patients. Reliable and rapid measurement of CMV viral load is a key issue for optimal patient management. We report here the evaluation of NeuMoDx™ (Qiagen) in a routine hospital setting (University Hospitals of Marseille, France) in comparison with our classical reference technique R-GENE. During one month, 719 CMV viral loads from 507 patients were measured in parallel in both techniques. Using the ROC (receiver operating characteristic) curve and our biological experience we suggest that values <52 IU/mL (geometric mean) correspond to negative samples, values >140 IU/mL (Fowlkes–Mallows index) correspond to quantifiable positive results and values ranging from 52 to 140 IU/mL represent non-quantifiable positive results. Follow-up of 15 transplant patients who developed CMV reactivation during the study showed that NeuMoDx™ provided higher viral load measurement during the first two weeks of follow-up for three patients. These important intra-individual variations resulted in a significant median increase considering the whole data set (6.7 points of difference expressed as a percentage of the initial viral load). However, no difference between the two techniques was noticeable after two weeks of treatment. Subsequent to this first study we conclude that NeuMoDx™, used with optimized logistics and an adapted threshold, allows a rapid CMV viral load measurement and that its use does not lead to any difference in patient management compared to the reference technique R-GENE®.

OTHR-06. PACS Lesion Tracking Tool provides real time automatic information on brain tumor metastasis growth curves and RECIST criteria

Abstract Objective Communicating metastatic brain treatment response can be complicated. A widely used method to assess clinical response is called response evaluation criteria in solid tumors or RECIST. In our study, we use a PACS Lesion Tracking Tool (TT) to assess intracranial metastasis using RECIST criteria. We predict that the TT will be superior to the standard radiology reports. Methods Nuance ® mPowerTM was used to identify 30 patients with brain metastasis who received brain MRI from 4/2020–4/2021. Patient’s first brain MRI with metastasis was set as baseline and subsequent 3 brain MRI studies were examined. All lesions were measured on post-gadolinium sequence and defined as target lesions or new lesions. The TT was used to measure lesion size over time with creation of growth curves and RECIST outcomes, which include stable disease, progressive disease, partial response, or complete response. Subsequently, RECIST evaluations were compared with radiologic impressions for discrepancy, and further evaluations were made to see if it made a clinical difference in patient management and/or provide additional useful information. These evaluations were given a rating of agree/yes, equivocal, or disagree/no. They were assessed by 3 neuroradiologists. Results Number of lesions ranged from 1–27. The assessments from 3 neuroradiologists were averaged. Comparing impression versus RECIST evaluation, the results demonstrated the following: 8/30 disagreement, 4/30 equivocal, and 18/30 agreement. Using more stringent criteria, assessing whether the TT would result in either change in patient management or provide additional useful information, the results were the following: 6/30 yes, 4/30 equivocal, and 20/30 no. Discussion In addition to providing real time RECIST criteria evaluations and visually descriptive lesion growth tables, the TT was easy to use. Interpretation of these additional data provided more clarity and was found to be superior to standard radiology report.

Delayed corticosteroid hypersensitivity: a clinical management proposal.

Background. Different clinical pictures are related to corticosteroids (CS) non immediate hypersensitivity and the frequency of these reactions can be underestimated. The classification of CS in 3 groups and the identification of two patient's profiles has been proposed by Baeck to help clinicians in the management of these cases. Methods. Data of 14 patients with clinical history of delayed reactions to various CS and positive skin test and/or oral challenge are retrospectively analyzed. Results. Three different patterns of patients are identified evaluating history, clinical picture and tests results. The first one (6 pts, 43%) is characterized by cutaneous and/or mucosal reaction due to inhaled Budesonide and patch test positive only to topical molecules belonging to the group 1 of CS. The second pattern (4 pts) has clinical history of local and systemic skin reactions to the topic and parenteral administration of the same or other steroid drugs. Patients belonging to the third pattern (4 pts) have a history of systemic reactions to general administration of CS without previous contact reaction. Pattern 2 and 3 show a wide sensitization to molecules belonging to the 3 groups of CS. All the patients show patch test positive to Budesonide. Conclusions. Although the lack of standardization, the allergy workup proves useful to differentiate patients sensitized to one or few molecules from polysensitized and to identify the culprit drugs. Intradermal and challenge test are necessary to complete the diagnostic workup. The results suggest the possibility of a different management of patients. Patients of pattern one can be only patch tested with a limited series of CS belonging to the 3 groups. They don't need an extensive exclusion of steroids use. The pattern 2 and 3 must be submitted instead to a complete allergological individual evaluation to identify alternative tolerated drugs, because of the risk of systemic reactions. The Baeck's classification shows limited usefulness in these cases.

An international, multicenter, real-world analysis of epithelial ovarian cancer treatment and outcomes.

5531 Background: Few major studies have examined and compared the management and outcomes of patients from diagnosis to death between countries. We have established an international collaboration across Europe and South Korea to compare treatment and outcomes in Epithelial Ovarian Cancer (EOC). Methods: Patients diagnosed with EOC between January 2012 and December 2018 (age ≥18), were included for analysis. Data from medical records from five European and a single South Korean treatment centre were extracted, standardised to a common data model and analysed at each centre using a common script developed in R. Time to each progression/recurrence event (defined as time to next treatment) and overall survival have been estimated using Kaplan Meier methodology and outcomes stratified by categories of interest. Changes in the use of anti-cancer therapies over time and the incidence of BRCA mutations and incidence/timing of second breast cancers have also been examined. Results: A total cohort of 2925 patients was identified with a median age at each centre of 53 to 67 years. Advanced disease (FIGO stage III - IV) (range 57% to 84%) and high-grade serous morphology (38% to 70%) were most common at each centre. The timing of surgery (primary, interval debulking or delayed) and the proportion of patients undergoing surgery varied with stage. Patients with stage I disease where most likely to undergo surgery (range 73% to 100%) and stage IV the least (range 39% to 84%). Median overall survival for high grade serous cancers ranged from 1.9 to 4.9 years, and for the whole cohort from 2.1 to 5.5 years. Median time to next treatment at first relapse for the whole cohort ranged from 14 to 22 months. Second breast cancers were noted in 6 to 17% of patients and the majority of these occurred before the diagnosis of EOC at a median time of 96 to 118 months prior to diagnosis of EOC. Additional data on treatment pathways, BRCA status and outcomes by line of therapy for each centre will be presented. Conclusions: Preliminary analysis of results across this network suggests a variation in patient populations between sites and substantial differences in both treatments and outcomes. The establishment of a common data model and the use of a common analytic script between sites across six different countries allows for detailed exploration of the factors influencing differences in patient management and treatment outcomes in ovarian cancer patients.

Cardiovascular Events in Adult Patients With Chronic Hypoparathyroidism Treated With rhPTH(1–84) Compared With a Historical Control Cohort

Abstract Chronic hypoparathyroidism is associated with an increased risk of cardiovascular (CV) complications. This study investigated CV events over a period of up to 5 years in adult patients with chronic hypoparathyroidism treated with recombinant human parathyroid hormone (1–84), rhPTH(1–84), compared with a historical control cohort of patients who did not receive rhPTH(1–84). The rhPTH(1–84)-treated patient cohort was derived from the NCT00732615 (REPLACE), NCT01268098 (RELAY), and NCT01297309 (RACE) clinical trials. A control cohort of adult patients who did not receive rhPTH(1–84) or rhPTH(1–34) was selected from the US Explorys electronic medical record database (Jan 2007−Aug 2019) using selection criteria similar to the enrollment criteria used in the trials. Index date was the day after initiation of treatment for the rhPTH(1–84) cohort and the day after the first calcitriol prescription for the control cohort. The primary outcome was the risk of a composite CV event (defined as any event of cerebrovascular disease, coronary artery disease, heart failure, or peripheral vascular disease) in the rhPTH(1–84) cohort compared with the control cohort through 5 years post-index. Patients with a CV event at baseline were excluded from the analysis. Risk of a CV event was assessed in a Kaplan-Meier analysis and a Cox proportional hazards model adjusted for demographic characteristics, baseline clinical conditions, and baseline serum calcium levels. The analysis included 113 patients in the rhPTH(1–84) cohort and 618 patients in the control cohort. Patients in the rhPTH(1–84) cohort, compared with the control cohort, were younger (mean ± SD age, 47.8±12.0 vs 51.0±16.8 years; P&amp;lt;0.05), a higher proportion were White (94.7% vs 81.9%; P&amp;lt;0.01), and fewer had acute manifestations of hypoparathyroidism before the index date (22.1% vs 69.6%; P&amp;lt;0.001). In a Kaplan-Meier analysis, rhPTH(1–84)-treated patients had a significantly reduced risk of developing a CV event compared with patients in the control cohort (P&amp;lt;0.01); 3.5% of rhPTH(1–84)-treated patients and 16.3% of control cohort patients developed a CV event over the 5-year follow-up period. The adjusted hazard ratio for developing a CV event associated with rhPTH(1–84) treatment vs no rhPTH(1–84) treatment was 0.23 (95% CI, 0.07−0.74; P&amp;lt;0.05). This analysis is limited by differences in patient management under predefined clinical trial protocols for the rhPTH(1–84) cohort vs real-world clinical practice for the control cohort. Over 5 years, patients with chronic hypoparathyroidism treated with rhPTH(1–84) in clinical trials had a significantly reduced risk of CV events compared with a control cohort of patients who did not receive rhPTH(1–84). Further research is needed to better understand the mechanism underlying the association between chronic hypoparathyroidism and risk of developing a CV event.

A Population-based Study Comparing Outcomes for Patients With Metastatic Castrate Resistant Prostate Cancer Treated by Urologists or Medical Oncologists With First Line Abiraterone Acetate or Enzalutamide

ObjectivesTo compare toxicity and all-cause mortality for mCRPC patients receiving first line oral systemic therapy prescribed by medical oncologists and urologists. MethodsPopulation-based retrospective cohort study of chemotherapy-naïve men aged ≥66 years treated for mCRPC with first-line abiraterone or enzalutamide based on administrative health data (Ontario, Canada, 2012-2017). Primary outcomes were hospitalizations/ER visits for any cause or treatment-related toxicity during first-line mCRPC treatment. Secondary outcome was all-cause mortality. We calculated hazard ratios (HRs) comparing outcomes for different medical specialties using multivariable Cox proportional hazards models. ResultsAmong 3405 mCRPC patients, 2407 (70.7%) received abiraterone and 998 (29.3%) received enzalutamide. 1786 (52.5%) patients visited the ER or were hospitalized. Men treated by medical oncologists had an increased risk of hospitalization/ER visits (HR1.16, 95%CI 1.03-1.31; P = .02), toxicity-related visits (HR1.34, 95%CI 1.08-1.69; P = .01), and mortality (HR1.16, 95%CI 1.02-1.33; P = .02) compared to urologists. Limited information was available, beyond PSA adjustment and prior treatment, on patient disease burden. ConclusionWe observed fewer hospital visits overall and for treatment-related toxicity for mCRPC patients who were prescribed first line abiraterone or enzalutamide by urologists compared to medical oncologists. These differences may result from higher prostate cancer disease burden in patients managed by medical oncologists, and/or other unmeasured differences in patient management between specialties.

Diagnostic and investigative approach of consultant neurologists in a real-world clinical setting: A pilot study.

Whilst core curricula in neurology are nationally standardised, in real-world clinical practice, different approaches may be taken by individual consultants. The aims of this study were to investigate differences by assessing: (a) variance in diagnostic and investigative practice, using a case-based analysis of inter-rater agreement; (b) potential importance of any differences in terms of patient care; (c) relationships between clinical experience, diagnostic certainty, diagnostic peer-agreement and investigative approach. The objective was to develop novel individualised metrics to facilitate reflection and appraisal. Three neurologists with 6-23years' experience at consultant level provided diagnosis, certainty (10-point Likert scale), and investigative approach for 200 consecutive general neurology outpatients seen by a newly qualified consultant in 2015. Diagnostic agreement was evaluated by percentage agreement. The potential importance of any diagnostic differences on patient outcome was assigned a score (6-point Likert scale) by the evaluating neurologist. Associations between diagnostic agreement, certainty and investigative approach were assessed using Spearman correlation, logistic and ordinal regression, and reported as individualised metrics for each rater. Diagnostic peer-agreement was 3/3, 2/3 and 1/3 in 55.5%, 31.0% and 13.5% of cases, respectively. In 15.5%, differences in patient management were judged potentially important. Investigation rates were 42%-73%. Mean diagnostic certainty ranged from 6.63/10 (SD 1.98) to 7.72/10 (SD 2.20) between least and most experienced consultants. Greater diagnostic certainty was associated with greater diagnostic peer-agreement (individual-rater regression coefficients 0.33-0.44, P<.01) and lower odds of arranging investigations (individual-rater odds ratios 0.56-0.71, P<.01). It appears that variance in diagnostic and investigative practice between consultant neurologists exists and may result in differing management. Mean diagnostic certainty was associated with greater diagnostic peer-agreement and lower investigation rates. Metrics reflecting concordance with peers, and relationships to diagnostic confidence, could be developed in larger cohorts to inform reflective practice.

Similarities and Differences in the 2019 ISUP and GUPS Recommendations on Prostate Cancer Grading: A Guide for Practicing Pathologists.

Contemporary subspecialization of practice in prostate pathology has seen a transition to complex, nuanced reporting, where a growing number of histopathologic parameters may signal differences in patient management. In this context, the International Society of Urological Pathology (ISUP) and the Genitourinary Pathology Society (GUPS) both published proceedings papers on the grading of prostate cancer in 2019. Overall, the 2 prostate cancer grading manuscripts reached many of the same conclusions and recommendations. Yet, each consensus was conducted somewhat differently, and in a couple of key areas, each reached different conclusions and recommendations. Herein, sourced from the experience and viewpoints of members of both societies, we provide the practicing pathologist a summary of the shared recommendations, and of the discordances. It is anticipated that these 2 documents will inform future iterations of recommendations and guidelines for reporting prostate cancer by organizations such as the College of American Pathologists, the Royal College of Pathologists, and the European Society of Pathology, which will promote best practices for their respective constituents. Our goal is to provide the practicing pathologist a useful catalog of the main points of both, allowing each practitioner to make informed decisions and understand any divergent opinions as may arise between observers for individual cases.

Using a quality of life (QoL)-monitor: preliminary results of a randomized trial in Dutch patients with early breast cancer

PurposeThe diagnosis and treatment of cancer negatively affect patients’ physical, functional and psychological wellbeing. Patients’ needs for care cannot be addressed unless they are recognized by healthcare providers (HCPs). The use of quality of life (QoL) assessments with feedback to HCPs might facilitate the identification and discussion of QoL-topics.Methods113 patients with stage I–IIIB breast cancer treated with chemotherapy were included in this randomized controlled trial. Patients were randomly allocated to receive either usual care, or usual care with an intervention consisting of a QoL-monitor assessing QoL, distress and care needs before every chemotherapy cycle visit. Patients completed questionnaires regarding QoL, illness perceptions, self-efficacy, and satisfaction with communication. From the 2nd visit onwards, patients in the intervention arm and their HCPs received a copy of the QoL overview and results were shown in patients’ medical files. Audio-recordings and patients’ self-reports were used to investigate effects on communication, patient management and patient-wellbeing. A composite score for communication was calculated by summing the number of QoL-topics discussed during each consultation.ResultsUse of the QoL-monitor resulted in a higher communication score (0.7 topics increase per visit, p = 0.04), especially regarding the disease-specific and psychosocial issues (p < 0.01). There were no differences in patient management, QoL, illness perceptions or distress. Patients in the experimental arm (n = 60) had higher scores on satisfaction with communication (p < 0.05).ConclusionsUse of a QoL-monitor during chemotherapy in patients with early breast cancer might result in a more frequent discussion of QoL-topics, associated with high levels of patients’ satisfaction.

Comparative analysis of regional outcomes and adverse events after continuous-flow left ventricular assist device implantation: An IMACS analysis

Regional outcomes after implantation of continuous-flow left ventricular assist devices (LVADs) have not been described. We examined differences in patient selection, survival, and adverse events across 3 geographic regions of the world: the Americas, Asia-Pacific, and Europe. Using data from The International Society for Heart and Lung Transplantation Mechanically Assisted Circulatory Support registry, all adult patients implanted with a continuous-flow LVADs were included in this International Society for Heart and Lung Transplantation Mechanically Assisted Circulatory Support analysis (n = 15,560), of whom, 9,988 (64%) received axial-flow devices and 5,572 (36%) received centrifugal-flow devices. There were significant interregional differences in the rate of implantation of patients aged >70 years (Americas: 14%, Asia-Pacific: 1%, Europe: 5%; p < 0.0001), morbidly obese (Americas: 5%, Asia-Pacific: 1%, Europe: 1%; p < 0.0001), male (Americas: 79%, Asia-Pacific: 77%, Europe: 85%; p < 0.0001), and implanted as destination therapy (Americas: 48%, Asia-Pacific: 4%, Europe: 22%; p < 0.0001). The rates of centrifugal pump usage varied by region (Americas: 30%, Asia-Pacific: 34%, Eu: 74%; p < 0.0001). Survival rates varied by region and the type of pump flow, with survival at 12 and 48 months (axial flow vs centrifugal flow) being 82% vs 82% and 52% vs 53 in Americas; 92% vs 86% and 83% vs 74% in Asia-Pacific; and 80% vs 75% and 69% vs 53% in Europe, respectively (regional survival p < 0.0001). There are marked global differences in LVAD recipient characteristics, device utilization, and post-operative care. These heterogeneities along with differences in patient management and transplantation rates may impact long-term survival. Regional differences in adverse event incidence warrant further investigation.