Excellent 5-year Outcomes Research Articles

SP6.8 - Predicting Determinants of Successful Transplantation Using Supra-Marginal (DRI-Donor Risk Index >1.5) Deceased Donor Kidneys

Abstract Objective To develop machine-learning-models with national registry data to predict factors associated with favourable outcomes using supra-marginal ( DRI -Donor Risk Index >1,5) deceased donor kidneys Design A retrospective cohort study using UK Transplant Registry data from 2000-2019 Setting National registry administered by NHS Blood and Transplant in the United Kingdom. Participants Adult recipients (n = 6254) of first kidney-alone transplants from very supra-marginal deceased-donors (DRI≥1.5) Main Outcome Measures Death-censored graft failure and patient mortality Predictors Comprehensive recipient, donor, and transplant characteristics. Statistical Analysis Bayesian neural networks, gradient boosting machines, random forest, and SMOTE-balanced bagging classifiers tuned using Bayesian optimisation Cox regression, competing risk analysis, and calibration plots Results Overall 5-year graft survival was 81%. The random-forest-model had excellent predictive performance for graft failure (AUC 0.88, 95% CI 0.87-0.89; RMSE 0.29). recipient age > 75-years (SHR 1.02, 95% CI 1.01-1.03), recipient-BMI >30 (SHR 1.04, 95% CI 1.02-1.07), HLA mismatches >4 (SHR 1.09, 95% CI 1.01-1.17), donor-creatinine >120mmol/L (SHR 1.002, 95% CI 1.001-1.003), and rejection- within 3-months (SHR 1.56, 95% CI 1.32-1.85) were key determinants of poor survival. Prolonged cold-ischemia-time >14hrs (SHR 1.01, 95% CI 1.007-1.015) was detrimental Conclusions Supra-marginal deceased-donor-kidneys can achieve excellent 5-year outcomes with careful recipient selection. Machine-learning accurately predicted factors associated with success. Adjusted predictors of graft failureVariableSHR95% CIp-valueRecipient-age > 75 years1.021.01-1.03<0.001Recipient-BMI >301.041.02-1.070.002HLA-mismatches >41.091.01-1.170.03Creatinine at offer >120 mmol/L/ 1.4 mg/dl1.0021.001-1.003<0.001Rejection at 3 month1.561.32-1.85<0.001Cold-ischemia-time >14 hrs1.011.007-1.015<0.001SHR: subdistribution hazard ratio;

High survivorship and excellent 5-year outcomes in patients older than 40years undergoing arthroscopy for femoroacetabular impingement.

To assess 5-year clinical outcome, in adults > 40years of age, following hip arthroscopy for femoroacetabular impingement compared to a younger, matched, control group. All primary arthroscopies for FAI between 2009 and 2016 were considered (n = 1762). Hips presenting with Tönnis > 1, lateral centre edge angle < 25°, or prior hip surgery were excluded. Younger (< 40years) and older hips (> 40years) were matched for gender, Tönnis grade, capsular repair and radiological parameters. Survival (avoidance of total hip replacement {THR}) was compared between the groups. Patient reported outcome measures (PROMs) were also completed at baseline and 5years to assess changes in functional capacity. Additionally, hip range of motion (ROM) was assessed at baseline and review. The minimal clinically important difference (MCID) was determined and compared between groups. Ninety-seven older hips were matched to 97 younger controls (78% male in both groups). The average age of the older group at the time of surgery was 48.0 ± 5.7years, compared to 26.7 ± 6.0. Six (6.2%) of the older hips and 1 (1%) of younger hips converted to THR (p = 0.043, effect size = 0.74, large). There were statistically significant improvements in all PROMs. At follow-up, there were no differences in PROMs between groups; significant improvements in hip ROM were also observed with no difference in ROM between groups at either time point. Similar achievement of MCIDs was observed in both groups. Older patients experience a high survivorship rate at 5years, although this may be lower than younger patients. Where THR is avoided, large clinically significant improvements in pain and function are observed. Level IV.

Combined 70- and 80-gene signatures identify tumors with genomically luminal biology responsive to neoadjuvant endocrine therapy and are prognostic of 5-year outcome in early-stage breast cancer

BackgroundAs more patients with early-stage breast cancer receive neoadjuvant endocrine therapy (NET), there is a need for reliable biomarkers that can identify patients with HR+ HER2- tumors who are likely to benefit from NET. NBRST (NCT01479101) compared the prognostic value of the 70-gene risk classification and 80-gene molecular subtyping signatures with conventional pathological classification methods in response to neoadjuvant therapy. We evaluated the association of these signatures with clinical response and 5-year outcome of patients treated with NET. Methods1091 patients with early-stage breast cancer scheduled to receive neoadjuvant therapy were prospectively enrolled into NBRST, and a sub-analysis of 67 patients treated with NET was performed. Patients received standard of care genomic testing using the 70-gene and 80-gene signatures and were treated with NET, per physician's discretion. The primary endpoint was pathologic partial response (pPR) and secondary endpoints were distant metastasis-free survival (DMFS) and overall survival (OS). Clinical benefit was defined as having a pPR or stable disease (SD) with NET. ResultsOverall, 94.4% of patients with genomically (g) Luminal A-Type (50.0% pPR and 44.4% SD) and 95.0% with Luminal B-Type tumors (55.0% pPR and 40.0% SD) exhibited clinical benefit. At 5 years, patients with gLuminal B tumors had significantly worse DMFS (75.6%, 95% CI 50.8–89.1) than patients with gLuminal A (91.1%; 95% CI 74.8–97.1; p = 0.047), with a similar trend for OS, albeit not significant (81.0%, 95% CI 56.9–92.4 and 91.1%, 95% CI 74.8–97.1, respectively; p = 0.13). ConclusionsGenomic assays offer a broader understanding of the underlying tumor biology, which adds precision to pathology as a preoperative risk classifier. Patients with 70-gene signature Low Risk, gLuminal A tumors treated with endocrine therapy alone have excellent 5-year outcomes. Most patients with genomically-defined Luminal A- and B-Type tumors respond well to NET, suggesting these patients may be safely treated with NET, while those with gLuminal B tumors will also require post-operative chemotherapy or CDK4/6 inhibitors to improve long-term outcomes. Overall, these findings demonstrate that genomic classification, defined by the combined 70- and 80-gene signatures, is associated with tumor response and prognostic of long-term outcomes.

Abstract 10484: Carotid Plaque Score Adds Discriminatory Benefit to the Stress Echo for Major Adverse Cardiovascular Events in Low-Intermediate Risk Cardiac Patients

Introduction: Carotid plaque is recommended for cardiac risk stratification for intermediate risk patients but has not been integrated into cardiology community clinics to help refine testing and reduce risk for major adverse cardiovascular events (MACE). The purpose was to determine the clinical usefulness of carotid plaque score (PS) to guide management of low-intermediate risk patients. Methods: Patients 40-75 years who received a carotid ultrasound were followed up to 10 years for MACE (cardiovascular death, myocardial infarction, stroke). Low-intermediate risk participants (n = 9,114) with no known cardiovascular disease were included. Administrative data holdings housed at IC/ES were used for event follow-up. Kaplan-Meier curves and Cox proportional hazard ratios determined relative risk. Combining plaque score (Rotterdam method, plaque presence within carotid segments, PS 0 to 6) with stress echo (SE) was assessed in a subset of participants (n = 624). Results: The optimum threshold for PS = 2 for 1-year MACE (AUC = 0.738). The population rate of MACE over 10 years was 4%. In participants referred for SE, PS of &lt;2 was associated with an excellent 5-year outcome irrespective of the SE result (PS&lt;2 = 0.9% MACE, normal SE = 1.6% MACE). A PS of ≥2 and an abnormal SE was associated with increased risk (MACE = 11%). The hazard ratio for MACE increased with PS from 1.08 to 9.86 (PS = 1 and 6; reference PS=0). Combining SE with PS (either test positive) increased the sensitivity of the SE from 36% to 71%, with an excellent specificity (SE alone = 94% vs SE+PS = 87%). Conclusions: In low-intermediate risk patients, if a PS is &lt;2, cardiac testing for atherosclerotic risk is not required for up to 5 years. However, patients with a PS of ≥2 should undergo a stress echo. Combining SE with PS adds discriminatory benefit in identifying risk for MACE. This simple stratification parameter can be easily integrated in community cardiology clinics to prioritize patients requiring further testing.

T020: Interim PET-guided treatment of early-stage nodular lymphocyte-predominant Hodgkin lymphoma: a subgroup analysis of the GHSG HD16 and HD17 studies

Background: The optimal treatment for patients with early-stage nodular-lymphocyte predominant Hodgkin lymphoma (NLPHL) other than stage IA is undefined. Patients and Methods: We investigated characteristics and outcomes of patients with early-stage NLPHL (favorable: 85 patients; unfavorable: 15 patients) who had treatment within the randomized GHSG HD16 and HD17 studies. Results were compared to those from patients with classical Hodgkin lymphoma (cHL) (favorable: 495 patients; unfavorable: 764 patients) treated within the same studies. Chemotherapy consisted of 2 cycles of ABVD (HD16) or 2 cycles of escalated BEACOPP plus 2 cycles of ABVD („2 + 2“) (HD17). In the experimental study arms, consolidation radiotherapy (RT) was applied on the basis of the result of interim positron emission tomography (PET-2). In the standard arms, consolidation RT was mandatory. Progression-free survival (PFS) and overall survival (OS) were analyzed using the Kaplan-Meier method. Results: In the HD16 and HD17 studies, 62/85 (73%) and 13/15 (87%) NLPHL patients were male as compared to 254/495 (51%) and 337/764 (44%) cHL patients. The median age of patients with NLPHL was 37 years in the HD16 study (cHL: 36 years) and 42 years in the HD17 study (cHL: 31 years). The majority of NLPHL patients included in the HD16 and HD17 studies presented with a typical histopathological growth pattern (HD16: 66%; HD17: 70%) The 5-year PFS for all NLPHL patients was 90.3% (cHL: 90.8%) in the HD16 study and 92.9% (cHL: 95.7%) in the HD17 study. In the HD16 study, the 5-year PFS for the subgroup of PET-2-positive NLPHL patients was 89.3% (cHL: 91.6%); PET-2-negative NLPHL patients had a 5-year PFS of 91.0% (cHL: 90.4%). For PET-2-negative NLPHL patients assigned to the chemotherapy only arm, the 5-year PFS was 83.0% (cHL: 88.2%) whereas PET-2-negative NLPHL patients treated with chemotherapy plus RT had a 5-year PFS of 100% (cHL: 92.3%) (p=0.05). Subgroup analyses according to the PET-2 result were not conducted for NLPHL patients treated within the HD17 study due to the small number of individuals with NLPHL histology included in this trial. The 5-year OS for NLPHL patients treated within the HD16 and HD17 studies was 100% (cHL: 98.6% in HD16; 99.2% in HD17). Conclusion: Contemporary HL-directed treatment results in excellent 5-year outcomes for patients with newly diagnosed early-stage NLPHL and should thus be considered as valid approach for this patient group.

Reimplantation should be the gold standard to treat the regurgitant bicuspid aortic valve.

Mokashi and associates1 have recently shared the Cleveland Clinic's intermediate-term experience with reimplantation of tricuspid aortic valves (TAV) and bicuspid aortic valves (BAV). In a propensity score–matched analysis, the authors demonstrated excellent 5-year outcomes with 100% survival in the BAV and 98% survival in the TAV group. Freedom from reoperation in the BAV and TAV cohort was 94% and 98%, respectively. Although both procedures were done with equal safety and short-term outcomes, the authors were concerned due to greater transvalvular gradients and less ventricular reverse remodeling in the BAV cohort, as well as less freedom from reoperations in the BAV cohort at 8 years (77%).

Reply: Reimplantation should be the gold standard to treat the regurgitant bicuspid aortic valve.

Reply: Reimplantation should be the gold standard to treat the regurgitant bicuspid aortic valve.

Hip Arthroscopy for Femoroacetabular Impingement Syndrome Shows Good Outcomes and Low Revision Rates, With Young Age and Low Postoperative Pain Score Predicting Excellent 5-Year Outcomes

To evaluate the clinical outcomes of hip arthroscopy for femoroacetabular impingement syndrome (FAIS) and their predictors at a minimum 5 years' follow-up. We retrospectively analyzed patients with FAIS after first-time unilateral hip arthroscopy between January 2010 and July 2016. Patient-reported outcomes (PROs) included the validated modified Harries Hip Score (mHHS) and Visual Analog Scale for Pain (Pain VAS). We included patients with Tönnis grade 0 or 1 and reported PROs, and excluded patients with previous hip diseases or bilateral symptoms. Bivariate and multivariate analyses were used for data analysis. We included 159 patients with a mean follow-up of 6.4 years, aged 36.18 ± 8.61 years, 41.5% female, and a mean body mass index of 23.61 ± 3.45. The mean postoperative mHHS was 88.82 ± 11.60, and the mean Pain VAS was 1.93 ± 1.89, significantly better than before surgery (P < .001). Postoperative alpha angle (P= .003) and lateral center edge angle (P < .001) were significantly decreased. Most patients (83.7%) achieved clinically important improvement based on patient-acceptable symptom state and minimal clinically important difference (MCID). The overall revision surgery rate was 2.5%. There were no conversions to total hip arthroplasty. Bivariate analysis indicated that age (P < .001), preoperative mHHS (P= .002), and postoperative Pain VAS (P <.001) correlated with postoperative mHHS at a minimum 5 years' follow-up. Multivariate regression analysis of MCID showed that age (P <.001), preoperative PROs (P < .01 for both), and postoperative Pain VAS (P < .001) were significant outcome predictors. Patients with FAIS after first-time unilateral hip arthroscopy showed significant improvement in PROs at mid-term follow-up, with a low revision surgery rate. Young patients and those with low postoperative Pain VAS showed excellent outcomes at a minimum 5 years' follow-up. Level IV, retrospective case series.

Five-Year Outcomes From the United States Pivotal Trial of Valiant Captivia Stent Graft for Blunt Aortic Injury

The Clinical PeRformancE of the Valiant Thoracic Stent Graft with Capitvia Delivery System for the EndovaSCUlar treatment of Blunt Thoracic Aortic Injuries (RESCUE) study evaluating thoracic endovascular repair using the Valiant Captivia endograft for blunt thoracic aortic injury reported promising 30-day outcomes. We now describe 5 years of follow-up of this cohort. Fifty patients (mean age 40.7 ± 17.4 years, 76% male, mean injury severity score 38 ± 14.4) were treated for blunt thoracic aortic injury (2010 to 2012) with this endograft. Seventy percent (n= 35) of blunt thoracic aortic injury extent was grade III or higher. Extent of arch repair required full (40%) or partial (18%) left subclavian artery coverage. At 5 years, clinical and imaging compliance was 90.3% (28 of 31) and 67.7% (21 of 31), respectively. Thirty-day mortality was 8%. Three additional patients died of non-device-related causes (respiratory failure, infection, metastatic cancer) through 5-year follow-up, yielding a Kaplan-Meier survival of 85.2% through 5 years. Neither stroke nor spinal cord ischemia was observed at 5 years. Two type II endoleaks seen at 30 days resolved spontaneously, and no additional endoleaks were described in the study cohort through 5 years. No secondary endovascular procedures or conversion to open surgery were reported through 5 years. Four subjects underwent left subclavian revascularization for symptomatic indications. Finally, complete exclusion of the traumatic injury was maintained with no incidences of stent graft kinking, fracture, loss of patency, or migration through 5 years in all patients. This multicenter clinical trial describes excellent 5-year outcomes and durable exclusion of blunt thoracic aortic injury using a novel stent graft system. Thoracic endovascular repair with this endograft appears to be a safe and effective treatment option for patients with blunt thoracic aortic injury.

Case report: Can a patient with an active cancer receive a kidney transplant?

Introduction: An active cancer is an absolute contraindication for kidney transplantation and a frequent cause of wait-list patient exclusion for long periods. Waiting time for kidney transplantation after the cancer diagnosis/treatment depends on multiple factors such as type of cancer, stage, histological type, prognosis, and physicians’ opinions. Case description: In this study, we describe a case of a 52-year-old man with medullary thyroid carcinoma classified as T1N1bM0 stage IV-A, who received a human leukocyte antigen identical living donor kidney transplantation despite not being biochemically cured. He received maintenance immunosuppression with tacrolimus, prednisone, and mycophenolic acid, switched to everolimus plus prednisone after 8 months. After 5 years, kidney function is excellent and there is no structural recurrence of the disease on imaging tests, although serum calcitonin levels remain elevated but stable. Conclusion: This is the first report that exposes the case of a patient with an active thyroid neoplasm receiving kidney transplantation. The good prognosis of the active neoplasm and the fact of having an identical human leukocyte antigen optimal donor made us proceed with the transplant with an excellent 5-year outcome.

Five-Year Outcomes of Ultrathin Descemet Stripping Automated Endothelial Keratoplasty.

To report 5-year outcomes of ultrathin Descemet stripping automated endothelial keratoplasty (UT-DSAEK) with a central graft thickness intended to be <100 μm. This retrospective, consecutive, interventional case series included 354 eyes with endothelial decompensation due to various causes (Fuchs endothelial dystrophy, pseudophakic or aphakic bullous keratopathy, failed previous graft, herpetic endothelitis, or buphthalmos). Donor tissue was prepared using the microkeratome-assisted double-pass technique aiming at a graft thickness <100 μm. The Descemet membrane was stripped under air. The graft was delivered into the anterior chamber using the pull-through technique through a 3.2-mm clear corneal incision using a modified Busin glide. The best spectacle-corrected visual acuity (BSCVA), endothelial cell loss, graft survival rates, and immunologic rejection rates were evaluated. Follow-up data at 1, 2, 3, and 5 years after UT-DSAEK were collected from 214, 172, 147, and 105 eyes, respectively. After excluding eyes with comorbidities, BSCVA better than or equal to 20/20 was recorded in 36.3%, 37.4%, 46.4%, and 53.4% of eyes, respectively, whereas BSCVA better than or equal to 20/40 was documented in 95.5%, 95.3%, 96.0%, and 96.6% of eyes, respectively. The mean endothelial cell loss was 35.4%, 42.3%, 43.3%, and 52.3%; Kaplan-Meier graft survival probability was 99.1%, 96.2%, 94.2%, and 94.2%, and Kaplan-Meier cumulative probability of a rejection episode was 3.4%, 4.3%, 5%, and 6.9% at 1, 2, 3, and 5 years, respectively. UT-DSAEK grafts allow excellent 5-year outcomes, including BSCVA, endothelial cell density, and survival rates comparable with those recorded post-Descemet membrane endothelial keratoplasty, but with a higher immunologic rejection rate.

Potential cytotoxic risk and chronical inflammation after exposure to graphene platelets

The Clinical PeRformancE of the Valiant Thoracic Stent Graft with Capitvia Delivery System for the EndovaSCUlar treatment of Blunt Thoracic Aortic Injuries (RESCUE) study evaluating thoracic endovascular repair using the Valiant Captivia endograft for blunt thoracic aortic injury reported promising 30-day outcomes. We now describe 5 years of follow-up of this cohort.Fifty patients (mean age 40.7 ± 17.4 years, 76% male, mean injury severity score 38 ± 14.4) were treated for blunt thoracic aortic injury (2010 to 2012) with this endograft. Seventy percent (n = 35) of blunt thoracic aortic injury extent was grade III or higher. Extent of arch repair required full (40%) or partial (18%) left subclavian artery coverage. At 5 years, clinical and imaging compliance was 90.3% (28 of 31) and 67.7% (21 of 31), respectively.Thirty-day mortality was 8%. Three additional patients died of non–device-related causes (respiratory failure, infection, metastatic cancer) through 5-year follow-up, yielding a Kaplan-Meier survival of 85.2% through 5 years. Neither stroke nor spinal cord ischemia was observed at 5 years. Two type II endoleaks seen at 30 days resolved spontaneously, and no additional endoleaks were described in the study cohort through 5 years. No secondary endovascular procedures or conversion to open surgery were reported through 5 years. Four subjects underwent left subclavian revascularization for symptomatic indications. Finally, complete exclusion of the traumatic injury was maintained with no incidences of stent graft kinking, fracture, loss of patency, or migration through 5 years in all patients.This multicenter clinical trial describes excellent 5-year outcomes and durable exclusion of blunt thoracic aortic injury using a novel stent graft system. Thoracic endovascular repair with this endograft appears to be a safe and effective treatment option for patients with blunt thoracic aortic injury.

Use of Biomarkers and Multigene Assays in Breast Cancer.

All patients with early breast cancer should be classified by subgroup through testing estrogen receptor, progesterone receptor, and HER2 status, with or without Ki-67 proliferation percentage. Genomic expression profiling aids clinical decision-making in most patients, because most are estrogen receptor-positive. The commercially available classifiers are prognostic for distant recurrence in node-negative and also node-positive patients. Patients at genomically low risk have excellent 5-year outcomes with endocrine therapy alone. Some assays also predict for benefit from adjuvant endocrine therapy and chemotherapy in node-negative and node-positive patients, but with varying levels of evidence. Genomic classifiers are also prognostic of late relapse and may predict benefit from extended adjuvant endocrine therapy.

Polyomavirus Reactivation and Immune Responses to Kidney-Specific Self-Antigens in Transplantation.

Humoral immune responses against donor antigens are important determinants of long-term transplant outcomes. Reactivation of the polyomavirus BK has been associated with de novo antibodies against mismatched donor HLA antigens in kidney transplantation. The effect of polyomavirus reactivation (BK viremia or JC viruria) on antibodies to kidney-specific self-antigens is unknown. We previously reported excellent 5-year outcomes after minimization of immunosuppression for BK viremia and after no intervention for JC viruria. Here, we report the 10-year results of this trial (n=193) along with a nested case-control study (n=40) to explore associations between polyomavirus reactivation and immune responses to the self-antigens fibronectin (FN) and collagen type-IV (Col-IV). Consistent with 5-year findings, subjects taking tacrolimus, compared with those taking cyclosporin, had less acute rejection (11% versus 22%, P=0.05) and graft loss (9% versus 22%, P=0.01) along with better transplant function (eGFR 65±19 versus 50±24 ml/min per 1.73 m2, P<0.001) at 10 years. Subjects undergoing immunosuppression reduction for BK viremia had 10-year outcomes similar to those without viremia. In the case-control study, antibodies to FN/Col-IV were more prevalent during year 1 in subjects with polyomavirus reactivation than in those without reactivation (48% versus 11%, P=0.04). Subjects with antibodies to FN/Col-IV had more acute rejection than did those without these antibodies (38% versus 8%, P=0.02). These data demonstrate the long-term safety and effectiveness of minimizing immunosuppression to treat BK viremia. Furthermore, these results indicate that polyomavirus reactivation associates with immune responses to kidney-specific self-antigens that may increase the risk for acute rejection through unclear mechanisms.

Low-dose rate brachytherapy with I-125 seeds has an excellent 5-year outcome with few side effects in patients with low-risk prostate cancer

Background: Low-dose rate brachytherapy (LDR-BT) has been used in Sweden for more than a decade for treatment of low-risk prostate cancer. This study presents the outcome for patients treated with LDR-BT at a single institution with focus on the association between dose and biochemical failure-free survival (BFFS).Methods: In total 195 patients were treated with LDR-BT between 2004 and 2008. The patients were followed systematically for side effects for at least one year. PSA levels were followed regularly from three months and for at least five years. Outcome was analyzed in relation to clinical variables at baseline and to radiotherapy data.Results: Kaplan-Meier estimated BFFS at five years was 95.7%. Dose to the prostate in terms of D90% was significantly associated with BFFS [HR 0.90 (95%CI 0.83−0.96), p = 0.002].Conclusion: Out data confirmed that absorbed dose is a predictive factor for BFFS for low-risk patients without androgen deprivation therapy. With our treatment routines and dosimetry, a D90% in the range of 170−180 Gy gives excellent outcomes with acceptable toxicity for patients with low-risk prostate cancer.

Five-Year Outcome in Stroke Patients Submitted to Thrombolysis.

Little is known on long-term follow-up after thrombolysis in ischemic stroke patients because the majority of studies evaluated outcome at 3 to 12 months. We aimed to assess 5-year outcome after intravenous thrombolysis (IVT). Cohort study based on the prospective registry of all consecutive ischemic stroke patients submitted to IVT in our Stroke Unit. Five-year outcome, including living settings, functional outcome, stroke recurrence, and mortality, was ascertained by telephonic interviews and additional review of clinical records. Multivariate analyses were performed to identify predictors of outcome and mortality. Excellent outcome was defined as modified Rankin scale 0 to 1. Five-year outcome was available for 155/164 patients submitted to IVT. At 5 years, 32.9% of patients had an excellent outcome (95% confidence interval (CI) =25.5-43.3) and mortality was 43.9% (95%CI=36.1-51.7). Increasing age (odds ratio =0.93, 95% CI =0.90-0.97) and increasing National Institute of Health Stroke Scale (NIHSS) 24 h after thrombolysis (odds ratio =0.81, 95% CI =0.74-0.90) were independently associated with a lower likelihood of an excellent 5-year outcome. Age (hazards ratio =1.07, 95% CI =1.03-1.11) and excellent functional outcome 3 months after thrombolysis (hazards ratio =0.28, 95%CI=0.12-0.66) were independently associated with mortality during follow-up. One third of ischemic stroke patients have excellent 5-year outcome after IVT. Younger age, lower NIHSS 24 h after IVT, and excellent 3-month functional outcome are independent predictors of excellent 5-year outcome.

Acute coronary syndromes: Right direction--moving proximally in timing of STEMI care.

Major controversy exists about whether to treat patients with ST-segment elevation myocardial infarction using fibrinolysis or percutaneous intervention. A study of 1,492 patients from approximately 60% of French hospitals demonstrates that similarly excellent 5-year outcomes can be achieved with either reperfusion strategy. Therefore, one size need not necessarily fit all.

Predictors of Local Recurrence Following Accelerated Partial Breast Irradiation: A Pooled Analysis

To analyze a pooled set of nearly 2,000 patients treated on the American Society of Breast Surgeons (ASBS) Mammosite Registry Trial and at William Beaumont Hospital (WBH) to identify factors associated with local recurrence following accelerated partial breast irradiation (APBI). A total of 1,961 women underwent partial breast irradiation between April 1993 and November 2010 as part of the ASBS Registry Trial or at WBH. Rates of ipsilateral breast tumor recurrence (IBTR), regional recurrence (RR), distant metastases (DM), disease-free survival (DFS), cause-specific survival (CSS), and overall survival (OS) were analyzed for each group and for the pooled cohort. Clinical, pathologic, and treatment-related variables were analyzed including age, tumor stage/size, estrogen receptor status, surgical margins, and lymph node status to determine their association with IBTR. The two groups weres similar, but WBH patients were more frequently node positive, had positive margins, and were less likely to be within the American Society for Radiation Oncology-unsuitable group. At 5 years, the rates of IBTR, RR, DM, DFS, CSS, and OS for the pooled group of patients were 2.9%, 0.5%, 2.4%, 89.1%, 98.5%, and 91.8%, respectively. The 5-year rate of true recurrence/marginal miss was 0.8%. Univariate analysis of IBTR found that negative estrogen receptor status (odds ratio [OR], 2.83, 95% confidence interval 1.55-5.13, p = 0.0007) was the only factor significantly associated with IBTR, while a trend was seen for age less than 50 (OR 1.80, 95% confidence interval 0.90-3.58, p = 0.10). Excellent 5-year outcomes were seen following APBI in over 1,900 patients. Estrogen receptor negativity was the only factor associated with IBTR, while a trend for age less than 50 was noted. Significant differences in factors associated with IBTR were noted between cohorts, suggesting that factors driving IBTR may be predicated based on the risk stratification of the patients being treated.

Water under the Bridge: 5-Year Outcomes after Percutaneous Ablation of Obstructing Parapelvic Renal Cysts

There have been no large case series reporting on the success of percutaneous transparenchymal endocystolysis for obstructing parapelvic renal cysts. We report the largest series to date with 5-year outcomes. Percutaneous endocystolysis was performed in eight patients with obstructing parapelvic cysts between September 1998 and May 2002. The patients ranged in age from 52 to 79 years. Each patient underwent preoperative CT and retrograde pyelography. Postoperative follow-up, ranging from 60 to 103 months (mean 83.9 months), has included both symptomatic and radiologic assessment. There were no intraoperative or postoperative complications. The mean operative time was 55 minutes (range 34-135 minutes). The mean decrease in the hematocrit was 2.7% (range 0.2-4.9%), with no patient requiring blood transfusion. The mean hospital stay was 1.3 days (range 1-2 days). Two patients have persistent small fluid-filled cysts but no clinical or radiographic evidence of obstruction. The six remaining patients have no evidence of symptomatic or radiographic recurrence. Percutaneous endocystolysis is an effective minimally invasive treatment option for obstructing parapelvic cysts and is associated with excellent 5-year outcomes.

Excellent 5-year outcomes for laparoscopic partial nephrectomy

Excellent 5-year outcomes for laparoscopic partial nephrectomy