Discuss Treatment Options Research Articles

RWD79 Relationship between Body Mass Index and Diagnosis of Overweight or Obesity in Veteran’s Administration Population

The overall rate of obesity is rising in the USA as well as among Veterans. It is important that providers appropriately diagnose obesity and discuss treatment options with their patients. We investigate diagnosis of overweight or obesity compared to documented body mass index (BMI) in the veteran’s population.

Will we have a match? Observations from decision making conversations between hematologists and White and Black patients considering allogeneic stem cell transplant.

12133 Background: Allogeneic stem cell transplant (alloSCT) is the only treatment associated with cure for high-risk myelodysplastic syndrome (MDS), but carries substantial risks. One routinely mentioned concern is donor source. While white patients have an 80% chance of finding an unrelated fully matched donor, Black patients have among the lowest chance at 30%. The aim of this secondary analysis, from a telemedicine study assessing how hematologists engage in shared decision making with patients considering alloSCT, is to analyze how hematologists navigate discussions about donor concerns related to the apparent race of the patient. Methods: This is a qualitative analysis of transcribed video-recorded virtual encounters. We recruited US hematologists who perform alloSCT and randomized them to meet with a patient actor of Black or white race. The hematologists conducted a new patient encounter with the actors who were trained to portray the same 67 year old man with newly diagnosed high-risk MDS referred for specialty consultation to discuss treatment options. The patient character had multiple healthy siblings and children. Results: Transcripts from a total of 33 hematologists were available at the time of analysis (61% male, 30% non-white, mean age 46 +/- 11 years). Hematologists spent varying amounts of time discussing the concept of transplant donation. While some used complex language to describe matching and HLA tissue markers, others used simplified terms of finding a donor with “an immune system that’s similar to your own,” to eradicate foreign MDS cells and avoid attack on healthy cells. The majority emphasized searching for a donor among siblings, given the highest likelihood of matching. Conversations with the white actor included reassurance of finding a fully matched donor, whether through family or the international registry. Hematologists frequently disclosed the highest chance of success for people of European ancestry. While hematologists mentioned the registry in conversations with the Black actor, they rarely disclosed the lower chance of finding a fully matched unrelated donor. Instead they reassured that with better technology haploidentical match could be an option through donation from their child, “with as favorable outcomes.” Some gave the Black actor an overestimation of finding a fully matched donor through the registry. Non-white hematologists more frequently acknowledged the concept of race in stem cell donation. Conclusions: Hematologists use multiple strategies to help patients understand the donor process. They reveal to white patients the high likelihood of finding a fully matched donor while appearing to avoid discussing the lower odds for a Black patient.

Timeliness of care for breast cancer patients with a single day multidisciplinary clinic.

e18750 Background: Single-day multidisciplinary cancer clinics began in the 1960s, but have been difficult to institutionalize due to a lack of literature demonstrating the benefits for patients and the high cost of implementation1. Other institutions have shown that patients are seen by specialists sooner, receive treatment earlier, and have reduced stress when care is delivered in this model 1-6. MDA sought to improve breast cancer patient’s access by implementing a single-day multidisciplinary clinic in 2013. Methods: We identified local patients (within 150 miles) who were treated at MD Anderson Cancer Center Main for breast cancer from March 2016 to March 2022. Patients were either seen in the single-day multiteam (MT) model (Table 1) with coordination between surgical oncology, radiation oncology, and medical oncology or by specialists in the traditional model. Time from referral to first completed provider appointment was analyzed. Results: A total of 4,999 patient records were reviewed. 2,288 were seen in MT and 2,711 were seen in the traditional model. Median number of work days from referral to first appointment completion was 8 days vs 14 days respectively (p-value < 0.0001). Conclusions: A single-day MT visit is associated with reduced time from referral to first appointment completion. Further studies are warranted to determine if this shorter interval can improve patient outcomes and experience. Multiteam Protocol Plan Time frame Prior to clinic visit Nurse Patient Access Coordinator obtains pertinent medical information for initial encounter Multiple days prior to visit Clinic Day PA meets with patient to perform H&P, review acquired imaging and pathology, describe multiteam goals, and briefly discuss treatment options 11:00-11:30 PA presents patient cases to surgical oncologist, medical oncologist, and radiation oncologist. Treatment options are discussed. 2:00-2:30 Entire team meets the patient and performs an exam. 2:30 Encounter with medical oncology to discuss systemic treatment options. 2:45 Encounter with surgical oncology to discuss surgical treatment options. If necessary, patient consents for surgery. 3:15 Encounter with radiation oncology to discuss radiation therapy. 3:45 Nurse wraps clinic day with necessary patient teaching and assistance with scheduling any required further work up. 4:15.

RE: A case of treatment-resistant depression in an older adult and a discussion of treatment options.

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The Effect of Language Concordance on Health Care Relationship Trust Score.

Various barriers exist for Limited English Proficient (LEP) patients in the United States healthcare system, including language barriers. To address language access, interpreters have been used as well as physicians who speak the same language (language concordance), with unknown effect. By studying the strength of patient-physician relationships under different communication parameters, such as the use of a variety of language services, we can better understand healthcare interactions and move toward optimizing patient care and health outcomes.This study investigates the importance of language-concordant care in LEP populations to build trusting patient-physician relationships. To determine whether Spanish-speaking patients who receive health care from language-concordant (in this study, Spanish-speaking) physicians have higher total trust scores on the Health Care Relationship (HCR) Trust scale than patients who useprofessional or ad hoc interpreters. This is a prospective survey conducted on Spanish-speaking adult patients coming to family and internal medicine outpatient clinics in the Phoenix, AZ, metro area. Of 214 recruited subjects, 176 completed the survey. Primary outcomes of the study: measured total mean Health Care Relationship (HCR) trust score among three groups (language concordant, professional interpreter, ad hoc interpreter). Secondary outcomes of the study: variance of trust scores among three groups for individual survey items. Results: The group with language concordant providers had a mean trust score of 48.73, significantly higher than the mean for the group with ad hoc interpreters with a mean of 45.53 (p = 0.0090). Patients with a professional interpreter also had a higher mean trust score of 48.27 than the ad hoc interpreters (p = 0.0119). There were several individual questions where the professional language groups had statistically significantly higher HCR trust scoresthan the ad hoc interpreter group in terms of their trust in specific instances, i.e., involving the patient in discussing treatment options, making the patient feel worthy of the doctor's time, and their doctor telling them the whole truth. There were no differences in overall mean scores or individual scores for the two professional language groups (language concordant providers and professional interpreters). The results reinforce the current understanding that professionally acknowledged and trained speakers of a second language in the medical setting allow for the formation of stronger patient-physician relationships, specifically in terms of a patient's trust in their physician. In addition to continuing to increase the availability of high-quality interpreters, the same effort should be placed on increasing the diversity of languages spoken by physicians to foster trusting patient-physician relationship formation.

Monoclonal Antibodies in Pregnancy and Breastfeeding in Patients with Multiple Sclerosis: A Review and an Updated Clinical Guide.

The use of high-efficacy disease-modifying therapies (DMTs) early in the course of multiple sclerosis (MS) has been shown to improve clinical outcomes and is becoming an increasingly popular treatment strategy. As a result, monoclonal antibodies, including natalizumab, alemtuzumab, ocrelizumab, ofatumumab, and ublituximab, are frequently used for the treatment of MS in women of childbearing age. To date, only limited evidence is available on the use of these DMTs in pregnancy. We aim to provide an updated overview of the mechanisms of action, risks of exposure and treatment withdrawal, and pre-conception counseling and management during pregnancy and post-partum of monoclonal antibodies in women with MS. Discussing treatment options and family planning with women of childbearing age is essential before commencing a DMT in order to make the most suitable choice for each individual patient.

Fluoroquinolone-resistant latent tuberculosis infection: A literature review and case series of 5 patients treated with linezolid monotherapy

Latent tuberculosis infection (LTBI) constitutes an important public health problem because of risk of progression to TB disease. Effective treatment of multi-drug resistant (MDR) LTBI would prevent progression to MDR TB disease, which would improve patient and public health outcomes. The majority of MDR LTBI treatment studies have focused on the use of fluoroquinolone-based antibiotic regimens. Options for and experience in the treatment of fluoroquinolone-resistant MDR LTBI are limited in the published literature and not comprehensively addressed in current guidelines. In this review, we share our experience with the treatment of fluoroquinolone-resistant MDR LTBI with linezolid. We discuss treatment options for MDR TB that provide context for predicting effective MDR LTBI treatment, with a focus on the microbiologic and pharmacokinetic properties of linezolid that support its use. We then summarize the evidence for treatment of MDR LTBI. Finally, we present our experiences treating fluoroquinolone-resistant MDR LTBI with linezolid with an emphasis on dosing considerations to optimize efficacy and minimize potential toxicities.

Subchondral insufficiency fracture is a predictive factor of osteoarthritis progression and conversion to arthroplasty in non-surgically treated medial meniscus root tear.

To investigate the radiographic and clinical outcomes of non-surgical treatment for medial meniscus posterior root tear (MMPRT), and prognostic factors for osteoarthritis (OA) progression and clinical failure. A prospectively collected database was retrospectively reviewed for patients who were diagnosed with acute medial meniscus posterior root tear (MMPRT) between 2013 and 2021 and treated non-surgically for more than 2years. Patient demographic characteristics and clinical outcomes including pain numeric rating scale (NRS), International Knee Documentation Committee (IKDC) subjective score, Lysholm score, and Tegner activity scale were evaluated. For radiographic evaluation, knee radiographs were obtained to assess the angle of knee alignment and Kellgren-Lawrence (K-L) grade during the first and annually follow-up visits. Baseline magnetic resonance (MR) images were reviewed for the presence of medial meniscus extrusion, bone marrow edema, subchondral insufficiency fracture of medial femoral condyle, and cartilage lesion. The OA progression group was defined as patients who experienced a worsening of one or more grades in the K-L classification system. Prognostic factors were evaluated for OA progression and conversion to total knee arthroplasty (TKA). Ninety-four patients (90 female and 4 male) with a mean age of 67.0 ± 7.3years (range, 53-83years) were followed for a mean of 46.1 ± 22.1months (range, 24.1-170.5). During the follow-up period, no significant differences in clinical scores were observed, and there were also no significant differences between the groups with and without OA progression. Overall, 12 patients (13%) underwent TKA at a mean of 20.7 ± 16.5months (range, 8-69months) and 34 patients (36%) demonstrated OA progression at a mean time of 24 ± 15months (range, 12-62). The subchondral insufficiency fracture was a prognostic factor for OA progression (p = 0.045 for knee radiograph and p = 0.019 for MR) and conversion to TKA (RR, 4.08 [95% CI 1.23-13.57]; p = 0.022). Non-surgical treatment for acute medial meniscus posterior root tear did not result in any significant change in clinical outcomes from the initial to the final follow-up. The rate of conversion to arthroplasty was 13%, and the rate of osteoarthritis progression was 36%. Furthermore, subchondral insufficiency fracture was found to be a concomitant prognostic factor correlated with OA progression and conversion to arthroplasty. This information can provide insights for physicians when discussing treatment options with patients, particularly regarding the use of non-surgical treatment and may contribute as a source for future studies of medial meniscus posterior root tear. IV.

Hormone therapy for sexual function in perimenopausal and postmenopausal women: a systematic review and meta-analysis update.

Distressing sexual problems are a common complaint of menopausal women. In 2013, a Cochrane review assessed the effect of hormone therapy on sexual function in menopausal women; however, new evidence has since been published, which should be considered. This systematic review and meta-analysis aims to update the evidence synthesis on the effect of hormone therapy, compared with control, on sexual function in perimenopausal and postmenopausal women. Thirteen databases and clinical trial registries (Cochrane Central Register of Controlled Trials, EMBASE, Medical Literature Analysis and Retrieval System Online, PsycINFO, Web of Science, Cumulative Index to Nursing and Allied Health Literature, Literatura Latino-Americana e do Caribe em Ciéncias da Saúde, Database of Abstracts of Reviews of Effects, ClinicalTrials.gov , International Clinical Trials Registry Platform, Iranian Registry of Clinical Trials, Chinese Clinical Trial Registry, ISRCTN) were searched from December 2012 to March 30, 2022. Backward reference searching on all retrieved full texts was also performed. Study quality was assessed using the Cochrane ROB.2 tool. Data were pooled in random-effect model meta-analyses, which included all studies identified in the present search and all studies previously included in the 2013 Cochrane review. Forty-seven randomized controlled trials (35,912 participants) were included in the systematic review, and 34 randomized controlled trials (15,079 participants) were included in the meta-analysis. The meta-analysis revealed that, in comparison to control, estrogen therapy (standardized mean difference [SMD], 0.16; 95% confidence interval [CI], 0.02 to 0.29; I2 = 59%; 2,925 participants, 16 studies), estrogen plus progestogen therapy (SMD, 0.11; 95% CI, -0.07 to 0.29; I2 = 65%; 2,432 participants, 7 studies), tibolone (SMD, 0.15; 95% CI, 0.02 to 0.28; I2 = 0%; 916 participants, 2 studies), and selective estrogen receptor modulators (SMD, 0.18; 95% CI, 0.06 to 0.30; I2 = 0%; 1,058 participants, 4 studies) may result in no effect to small benefit on sexual function composite score. Hormone therapy may slightly improve sexual functioning. This potential small benefit should be considered when discussing treatment options for other menopausal symptoms.

Non‐immune hydrops fetalis: a practical guide for obstetricians

Key content Hydrops fetalis is the accumulation of two or more fetal fluid collections, including pericardial effusion, pleural effusion(s), ascites and skin oedema. In the absence of red cell alloimmunisation, hydrops fetalis is non‐immune and affects approximately 1 in 2000 pregnancies. Non‐immune hydrops fetalis (NIHF) is associated with severe perinatal morbidity/mortality and significant maternal risks, including maternal mirror syndrome. Priorities for clinicians are determining the cause antenatally to optimise management and discuss treatment options, if available. Systematic reviews have indicated that a cause can be identified prenatally in ~60% cases. Recent evidence indicates fetal exome sequencing can provide a diagnosis in 30% of previously unexplained cases. Learning objectives To understand causes of NIHF and its association with perinatal and maternal morbidity and mortality To appreciate the basis for investigations for NIHF, including exome sequencing To understand how care can be effectively shared by referring units and tertiary fetal medicine units

A narrative review of non-infected painful total shoulder arthroplasty: evaluation and treatment.

The prevalence of shoulder arthroplasty has increased significantly over the past two decades outpacing both total hip and total knee arthroplasty. Total shoulder arthroplasty (TSA) has been shown to significantly improve function and pain in most patients, however, complications after shoulder arthroplasty have been reported to be greater than 10% in anatomic shoulder arthroplasty and 10-47% in reverse shoulder arthroplasty leading to a painful shoulder. As the number of performedprimary shoulder arthroplasty increases, the incidence of painful total shoulders and the need for revision shoulder arthroplasty will see a similar trend. Management of post-operative shoulder arthroplasty pain and complications will be even more essential for the orthopedic surgeon in this growing population. Potential sources of pain after shoulder arthroplasty are variable and include infection, implant related complications, hematoma, nerve injury, rotator cuff failure, instability, fracture, among other less prevalent complications. Treatment options for the painful shoulder arthroplasty differ depending on the source of pain, thus early identification of the cause will lead to expedited and appropriate definitive management. The objectives of this narrative review are to highlight the common causes of pain after TSA, provide surgeons an algorithmic approach for working up the painful total shoulder, and discuss treatment options for each source of pain. A database search of PubMed and Google Scholar was conducted including studies relating to painful shoulder arthroplasty evaluation, management, and treatment. This review presents an in-depth evaluation to the non-infected, painful shoulder arthroplasty, providing treatment options for each source with the goal of assisting practicing physicians in the management of painful post-operative shoulder arthroplasty. With increasing numbers of TSA being performed, a thorough understanding of the potential complications and their treatments is essential. A systematic approach to working up the painful TSA can help identify the source of symptoms more readily. Knowledge of the common complications and their specific causes can help surgeons avoid the painful TSA. This knowledge will also help to successfully treat the painful TSA when it is inevitably encountered.

Artificial intelligence annotated clinical-pathologic risk model to predict outcomes of advanced gastric cancer.

Gastric cancer with synchronous distant metastases indicates a dismal prognosis. The success in survival improvement mainly relies on our ability to predict the potential benefit of a therapy. Our objective is to develop an artificial intelligence annotated clinical-pathologic risk model to predict its outcomes. In participants (n=47553) with gastric cancer of the surveillance, epidemiology, and end results program, we selected patients with distant metastases at first diagnosis, complete clinical-pathologic data and follow-up information. Patients were randomly divided into the training and test cohort at 7:3 ratio. 93 patients with advanced gastric cancer from six other cancer centers were collected as the external validation cohort. Multivariable analysis was used to identify the prognosis-related clinical-pathologic features. Then a survival prediction model was established and validated. Importantly, we provided explanations to the prediction with artificial intelligence SHAP (Shapley additive explanations) method. We also provide novel insights into treatment options. Data from a total 2549 patients were included in model development and internal test (median age, 61 years [range, 53-69 years]; 1725 [67.7%] male). Data from an additional 93 patients were collected as the external validation cohort (median age, 59 years [range, 48-66 years]; 51 [54.8%] male). The clinical-pathologic model achieved a consistently high accuracy for predicting prognosis in the training (C-index: 0.705 [range, 0.690-0.720]), test (C-index: 0.737 [range, 0.717-0.757]), and external validation (C-index: 0.694 [range, 0.562-0.826]) cohorts. Shapley values indicated that undergoing surgery, chemotherapy, young, absence of lung metastases and well differentiated were the top 5 contributors to the high likelihood of survival. A combination of surgery and chemotherapy had the greatest benefit. However, aggressive treatment did not equate to a survival benefit. SHAP dependence plots demonstrated insightful nonlinear interactive associations among predictors in survival benefit prediction. For example, patients who were elderly, or poor differentiated, or presence of lung or bone metastases had a worse prognosis if they undergo surgery or chemotherapy, while patients with metastases to liver alone seemed to gain benefit from surgery and chemotherapy. In this large multicenter cohort study, we developed an artificial intelligence annotated clinical-pathologic risk model to predict outcomes of advanced gastric cancer. It could be used to discuss treatment options.

The Efficacy and Tolerability of Continuation and Maintenance Electroconvulsive Therapy for Depression: A Systematic Review of Randomized and Observational Studies.

Electroconvulsive therapy (ECT) is a highly effective treatment for severe and treatment-resistant depression, but relapse rates remain high despite maintenance pharmacotherapy. Continuation or maintenance ECT (C/M-ECT) offers the potential to prevent relapses in the most unwell patients, but there remains disagreement among guidelines regarding its efficacy and tolerability. This review aims to summarize and assess the current evidence for the efficacy and tolerability of continuation and maintenance ECT for depression, including data from randomized and observational studies, which included an appropriate control group. Twenty studies were found meeting inclusion criteria. There was evidence from 14 studies suggesting that relapse rates are reduced in those receiving C/M-ECT. There was evidence from 6 studies suggesting that C/M-ECT had no effect on global cognitive function. Detailed neuropsychological testing was limited, but within studies that assessed specific cognitive domains, there was not consistent evidence for deficits in C/M-ECT compared with the control group. The certainty of evidence across outcomes was low or very low because of inclusion of observational studies, heterogeneity of study design, and patient populations. The findings add further weight to evidence suggesting that C/M-ECT is a viable treatment option to prevent relapse in severe depression and provides clinicians with further evidence for the benefits and risks of C/M-ECT when discussing treatment options with patients. Future research should focus on randomized or well-designed prospective studies with sufficient follow-up to determine longer-term outcomes, while including a standardized, detailed neurocognitive battery to assess potential adverse effects.

Increasing surgical wait time does not increase the risk of node positive prostate cancer: Implications for surgical planning during the COVID-19 pandemic and beyond

PurposeProstate cancer (PCa) is a heterogeneous diagnosis, with a significant latency between diagnosis and risk of cancer specific mortality. During the COVID-19 pandemic, the need to balance the risk of COVID-19 exposure and resource allocation resulted in delays in non-emergent surgeries. We sought to assess if delays in surgical wait time (SWT) result in an increased risk of disease progression in the setting of clinically node positive PCa.Materials and methodsThe National Cancer Database was queried for patients with cT1-3N0-1M0 PCa who underwent radical prostatectomy with lymph node dissection from 2010 to 2016. Patients were grouped based on pathologic node status (pN0 versus pN1). Outcomes including clinical tumor characteristics, hospital readmissions, and survival was correlated with length of SWT prior to radical prostatectomy.ResultsA total of 218 patients with pN0 PCa and 805 patients with pN1 PCa met our inclusion criteria and were included in this study. Hospital length of stay and 30-day readmissions were similar between pN0 and pN1 patients. No significant association was detected between increased SWT and pN1 status among our patient population. Sensitivity multivariable analyses including only patients with Gleason 7-10 and excluding those who received androgen deprivation therapy prior to surgery showed similar findings that SWT was not associated with pN1 disease. With short term follow up, Kaplan-Meier analysis showed no significant difference in overall survival when stratified by SWT at 30-, 60-, 90-, or >90-day intervals.ConclusionWith the impact of the recent pandemic on healthcare and hospital systems, it is important to understand the effect that likely delays in SWT can have on patient outcomes. The findings described in this study suggest that delays in SWT may not result in adverse nodal disease progression among patients diagnosed with pathological node positive PCa. These results will be important to share with patients and their families when discussing treatment options and can result in improved patient outcomes and satisfaction with treatment regimens.

A life course perspective on Mayer-Rokitansky-Küster-Hauser syndrome: women’s experiences and negotiations of living with an underdeveloped uterus and vagina

Purpose Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome is characterized by the absence or underdevelopment of the uterus and upper part of the vagina. It is usually diagnosed during adolescence, and the present study investigates how women experience and negotiate to live with MRKH syndrome long-term. Methods From January to March 2021, eighteen Danish women with MRKH syndrome participated in semi-structured interviews via video conference. The mean time since diagnosis was 11.5 years. A thematic analysis using the life course framework as a theoretical approach was applied. Results The analysis identified the diagnosis as a turning point, that dramatically altered the women’s imagined futures. Not conforming to dominant social norms regarding sexuality and pregnancy meant that the women continuously managed and negotiated the meaning and impact of MRKH syndrome in relation to the five principles of the life course perspective: (1) Lifelong development, (2) Timing, (3) Human agency, (4) Linked lives, and (5) Historical time and place. Conclusion Using the life course framework contributed to a holistic understanding of life with MRKH syndrome by showing how the meaning and consequences of the congenital condition changed over time and in adaptation to gendered and age-related social norms and expectations. IMPLICATIONS FOR REHABILITATION The perceived meaning and impact of living with Mayer-Rokitansky-Küster-Hauser syndrome change over time, and women’s information and support needs thus change accordingly Sensitive, clinical communication is essential when discussing treatment options Online communities may provide support and reduce feelings of loneliness

Surgical treatment of pulmonary bullous diseases.

Sir, We read with interest, the article by Rastin et al. published in the September-October 2022 issue of Lung India on the results of the surgical treatment of pulmonary bleb and bullous disease.[1] We have also been interested in the treatment of bullous diseases.[2-5] After discussion of treatment options, we also performed surgical resection of two young patients with recurrently infected bullae. We paid attention to indications for resection and preoperative infection control but as a result there was no recurrence. One of them had an uneventful 6 years postoperatively, during which time she gave birth to three children. With this background, we ask the authors following the three questions. First, we would like to ask about indications for surgical resection in bulla patients with pneumonia. Especially in young patients, there is a concern that resection might reduce respiratory function. It is also necessary to pay attention to postoperative infection control. Should recurrent episodes of infection or hemoptysis be considered indications? Second, the authors reported multiple bullae in 19 (27.1%) patients and those with pneumonia complications in 24 (34.3%) patients. The authors emphasized the importance of intraoperative complete drainage if the fluid retention within the bulla. Please, let us know if there are any points that should be especially noted as preoperative measures for such patients. Third, it would be beneficial to know whether there were any patients with recurrent development of bullae after surgery. Please, let us know whether there were any patients in particular have recurrences of infected bullae. Declaration of patient consent The authors certify that appropriate patient consent was obtained. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Quality of Life Considerations in Endoscopic Endonasal Management of Anterior Cranial Base Tumors.

Considering quality of life (QOL) is critical when discussing treatment options for patients undergoing endoscopic endonasal skull base surgery (EESBS) for cancers at the base of the skull. Several questionnaires have been developed and validated in the last 20 years to explore QOL in this patient population, including the Anterior Skull Base Questionnaire, Skull Base Inventory, EESBS Questionnaire, and the Sino-Nasal Outcome Test for Neurosurgery. The Sino-Nasal Outcomes Test-22 and Anterior Skull Base Nasal Inventory-12 are other tools that have been used to measure sinonasal QOL in anterior cranial base surgery. In addition to pathology-related perturbations in QOL endoscopic surgical options (transsellar approaches, anterior cranial base surgery, and various reconstructive techniques) all have unique morbidities and QOL implications that should be considered. Finally, we look ahead to new and emerging techniques and tools aimed to help preserve and improve QOL for patients with anterior cranial base malignancies.

Management of Patients with Advanced Prostate Cancer. Part I: Intermediate-/High-risk and Locally Advanced Disease, Biochemical Relapse, and Side Effects of Hormonal Treatment: Report of the Advanced Prostate Cancer Consensus Conference 2022

BackgroundInnovations in imaging and molecular characterisation and the evolution of new therapies have improved outcomes in advanced prostate cancer. Nonetheless, we continue to lack high-level evidence on a variety of clinical topics that greatly impact daily practice. To supplement evidence-based guidelines, the 2022 Advanced Prostate Cancer Consensus Conference (APCCC 2022) surveyed experts about key dilemmas in clinical management. ObjectiveTo present consensus voting results for select questions from APCCC 2022. Design, setting, and participantsBefore the conference, a panel of 117 international prostate cancer experts used a modified Delphi process to develop 198 multiple-choice consensus questions on (1) intermediate- and high-risk and locally advanced prostate cancer, (2) biochemical recurrence after local treatment, (3) side effects from hormonal therapies, (4) metastatic hormone-sensitive prostate cancer, (5) nonmetastatic castration-resistant prostate cancer, (6) metastatic castration-resistant prostate cancer, and (7) oligometastatic and oligoprogressive prostate cancer. Before the conference, these questions were administered via a web-based survey to the 105 physician panel members (“panellists”) who directly engage in prostate cancer treatment decision-making. Herein, we present results for the 82 questions on topics 1–3. Outcome measurements and statistical analysisConsensus was defined as ≥75% agreement, with strong consensus defined as ≥90% agreement. Results and limitationsThe voting results reveal varying degrees of consensus, as is discussed in this article and shown in the detailed results in the Supplementary material. The findings reflect the opinions of an international panel of experts and did not incorporate a formal literature review and meta-analysis. ConclusionsThese voting results by a panel of international experts in advanced prostate cancer can help physicians and patients navigate controversial areas of clinical management for which high-level evidence is scant or conflicting. The findings can also help funders and policymakers prioritise areas for future research. Diagnostic and treatment decisions should always be individualised based on patient and cancer characteristics (disease extent and location, treatment history, comorbidities, and patient preferences) and should incorporate current and emerging clinical evidence, therapeutic guidelines, and logistic and economic factors. Enrolment in clinical trials is always strongly encouraged. Importantly, APCCC 2022 once again identified important gaps (areas of nonconsensus) that merit evaluation in specifically designed trials. Patient summaryThe Advanced Prostate Cancer Consensus Conference (APCCC) provides a forum to discuss and debate current diagnostic and treatment options for patients with advanced prostate cancer. The conference aims to share the knowledge of international experts in prostate cancer with health care providers and patients worldwide. At each APCCC, a panel of physician experts vote in response to multiple-choice questions about their clinical opinions and approaches to managing advanced prostate cancer. This report presents voting results for the subset of questions pertaining to intermediate- and high-risk and locally advanced prostate cancer, biochemical relapse after definitive treatment, advanced (next-generation) imaging, and management of side effects caused by hormonal therapies. The results provide a practical guide to help clinicians and patients discuss treatment options as part of shared multidisciplinary decision-making. The findings may be especially useful when there is little or no high-level evidence to guide treatment decisions.

Long-Term PAE Results: What Do We Know.

Prostatic artery embolization (PAE) is a minimally invasive technique with proven safety and efficacy to treat lower urinary tract symptoms (LUTS) due to benign prostatic obstruction (BPO) or benign prostatic hyperplasia (BPH). In this review, we discuss the required level of evidence to implement and adopt treatment options for patients with LUTS due to BPO/BPH. Focus is given on the long-term (>3 years) data after PAE with reported outcomes including cohort sizes, follow-up times, reintervention rates (repeat PAE and prostatectomy), need for LUTS/BPO medical therapy, and improvements in International Prostate Symptom Score/quality of life score, peak flow rate (Qmax), postvoid residual, prostate volume, and prostate-specific antigen. The durability of treatment effects after PAE and need for prostatic reinterventions need to be taken into consideration when discussing treatment options with patients and referring colleagues from other medical specialties. Developments in medical devices used for PAE have allowed for a continuous drop in unilateral PAE rates over the last 12 years and will probably play a role in optimizing technical and thus clinical outcomes for patients with LUTS due to BPH/BPO.

Lower Extremity Malformations.

Lower Extremity Malformations.