High-volume Group Research Articles

Combined angiotensin-converting enzyme and aminopeptidase inhibition for treatment of experimental ventilator-induced lung injury in mice.

Introduction: Ventilator-induced lung injury (VILI) may aggravate critical illness. Although angiotensin-converting enzyme (ACE) inhibition has beneficial effects in ventilator-induced lung injury, its clinical application is impeded by concomitant hypotension. We hypothesized that the aminopeptidase inhibitor ALT-00 may oppose the hypotension induced by an angiotensin-converting enzyme inhibitor, and that this combination would activate the alternative renin-angiotensin system (RAS) axis to counteract ventilator-induced lung injury. Methods: In separate experiments, C57BL/6 mice were mechanically ventilated with low (LVT, 6mL/kg) and high tidal volumes (HVT, 30mL/kg) for 4h or remained unventilated (sham). High tidal volume-ventilated mice were treated with lisinopril (0.15μg/kg/min) ± ALT-00 at 2.7, 10 or 100μg/kg/min. Blood pressure was recorded at baseline and after 4h. Lung histology was evaluated for ventilator-induced lung injury and the angiotensin (Ang) metabolite profile in plasma (equilibrium levels of Ang I, Ang II, Ang III, Ang IV, Ang 1-7, and Ang 1-5) was measured with liquid chromatography tandem mass spectrometry at the end of the experiment. Angiotensin concentration-based markers for renin, angiotensin-converting enzyme and alternative renin-angiotensin system activities were calculated. Results: High tidal volume-ventilated mice treated with lisinopril showed a significant drop in the mean arterial pressure at 4h compared to baseline, which was prevented by adding ALT-00 at 10 and 100μg/kg/min. Ang I, Ang II and Ang 1-7 plasma equilibrium levels were elevated in the high tidal volumes group versus the sham group. Lisinopril reduced Ang II and slightly increased Ang I and Ang 1-7 levels versus the untreated high tidal volumes group. Adding ALT-00 at 10 and 100μg/kg/min increased Ang I and Ang 1-7 levels versus the high tidal volume group, and partly prevented the downregulation of Ang II levels caused by lisinopril. The histological lung injury score was higher in the high tidal volume group versus the sham and low tidal volume groups, and was attenuated by lisinopril ± ALT-00 at all dose levels. Conclusion: Combined angiotensin-converting enzyme plus aminopeptidase inhibition prevented systemic hypotension and maintained the protective effect of lisinopril. In this study, a combination of lisinopril and ALT-00 at 10μg/kg/min appeared to be the optimal approach, which may represent a promising strategy to counteract ventilator-induced lung injury that merits further exploration.

Urinary tract injury during hysterectomy: Does surgeon specialty and surgical volume matter?

Ureteral injury is a known complication of hysterectomies. Recent studies have attempted to correlate surgeon volume and experience with incidence of urinary tract injuries during hysterectomies. Some studies have reported that as surgeon volume increases, urinary tract injury rates decrease. To our knowledge, no studies have assessed the relationship between surgeon subspecialty and the rate of urinary tract injury rates during minimally invasive hysterectomy. To determine the incidence of urinary tract injury between urogynecologists, gynecologic oncologists, and general gynecologists. The study took place from January 1, 2016 to December 1, 2021 at a large community hospital in Detroit, Michigan. We conducted a retrospective chart review of adult patients who underwent minimally invasive hysterectomy. After we identified eligible patients, the surgeon subspecialty was identified and the surgeon's volume per year was calculated. Patient demographics, medical history, physician-dictated operative reports, and all hospital visits postoperatively were reviewed. Urologic injury occurred in four patients (2%) in the general gynecologist group, in one patient (1%) in the gynecologic oncologist group, and in one patient (1%) in the urogynecologist group. When comparing high and low-volume surgeons, there was no statistically significant difference in urinary tract injury (1% vs 2%) or bowel injury (1% vs 0%). There were more complications in the low-volume group vs the high-volume group excluding urinary tract, bowel, or major vessel injury. High-volume surgeons had four (1%) patients with a complication and low-volume surgeons had 12 (4%) patients with a complication (P = 0.04). Our study demonstrated that there was no difference in the urinary tract injury rate in general gynecologists vs subspecialists, however our study was underpowered.

Veno-arterial extracorporeal membrane oxygenation for cardiogenic shock after acute myocardial infarction: Insights from a French nationwide database

BackgroundWe aimed to analyze the impact of timing of implantation (strategy-outcome relationship) and volume of procedures (volume-outcome relationship) on survival of veno-arterial extracorporeal membrane oxygenation (VA ECMO) for cardiogenic shock complicating acute myocardial infarction (AMI). MethodsWe conducted an observational retrospective study through two propensity score-based analyses using a nationwide database between January 2013 and December 2019. We classified patients into early implantation (VA ECMO on the day of primary percutaneous coronary intervention [PCI]) and delayed implantation (VA ECMO beyond the day of PCI) groups. We classified patients into low- or high-volume groups based on the median hospital volume. ResultsDuring the study period 649 VA ECMO were implanted across 20 French hospitals. Mean age was 57.1 ± 10.4 years, 80% were male. Overall, 90-day mortality was 64.3%. Patients in the early implantation group (n = 479, 73.8%) did not show a statistical difference in 90-day mortality than in the delayed group (n = 170, 26.2%) (HR: 1.18; 95% CI 0.94–1.48; p = 0.153). The mean number of VA ECMO implanted during the study period by low-volume centers was 21.3 ± 5.4 as compared to 43.6 ± 11.8 in high-volume centers. There was no significant difference in 90-day mortality between high-volume and low-volume centers (HR: 1.00; 95% CI: 0.82–1.23; p = 0.995). ConclusionsIn this real-world nationwide study, we did not find a significant association between early VA ECMO implantation as well as high-volume centers and lower mortality in AMI-related refractory cardiogenic shock.

Inspiratory Muscle Training Improves Maximal Inspiratory Pressure Without Increasing Performance in Elite Swimmers

To analyze the effect of inspiratory muscle training (IMT) on the maximal inspiratory mouth pressure (MIP) and performance of elite swimmers. Eight participants performed a 3000-m swimming test (T-3000), followed by blood lactate measurements at 1 and 5minutes postexercise.. The testing protocol was carried out before and after 6weeks of IMT, in which a high-volume IMT group (HV-IMT) (n = 4) performed IMT twice a day-in the morning in a seated position and in the afternoon in a concurrent session of IMT and core muscle training. Also, a low-volume IMT group (LV-IMT) (n = 4) performed IMT in the morning session only. After the intervention, both groups improved their MIP, HV-IMT (132.75 [27.42] to 156.75 [21.88] cmH2O; P = .010; d = 0.967) and LV-IMT (149.25 [22.82] to 171.50 [23.74] cmH2O; P = .013; d = 0.955), without a significant difference between groups (P = .855). Regarding swimming performance, there were no changes between groups in the T-3000 (P = .472) or lactate removal rate (P = .104). IMT increased inspiratory muscle strength in elite swimmers, but there was no association or meaningful impact on swimming performance.

Postoperative outcomes of right hemicolectomy for cancer in 11 countries of Latin America: A multicentre retrospective study.

There is scant evidence regarding surgical outcomes of patients with colon cancer in Latin America. The aim of this work was to compare perioperative (30 day) outcomes of patients undergoing surgery for right colon cancer in Latin America based on centre volume. This is a multi-institutional retrospective cohort study. Individuals operated on for right colon cancer with curative intent in an urgent or elective setting between 2016 and 2021 were eligible for inclusion in the study. Patients were divided into two groups according to whether they were operated on in low-volume or high-volume centres (defined as more than 30 cases/year). A total of 2676 patients from 46 hospitals in 11 countries of Latin America were included, with 389 (14.5%) in the low-volume group. The median age was 67.37 years. The high-volume group presented higher rates of laparoscopic procedures (56.8 vs. 35.7%, p < 0.001, OR 2.36), with lower conversion rates, fewer intraoperative complications and a shorter operating time. The high-volume group had a shorter length of hospital stay. The overall complication rate for the whole group was 15.9%, with a lower incidence of these events in the high-volume group (13.7 vs. 28.7%, p < 0.001, OR 0.40). Overall, anastomotic leakage, reoperation and mortality rates were 5.6%, 9.2% and 6.1%, respectively, with differences favouring high-volume centres. On multivariate analysis, low-volume group, history of cardiac disease, emergency surgery, operation performed by a general surgeon, open approach and intraoperative complications were independent predictors of major postoperative complications. This is the first study in Latin America to show better postoperative outcomes at a regional scale when surgery for right colon cancer is performed in high-volume centres. Further studies are needed to validate these data and to identify which of the factors can explain the present results.

Association of Epicardial Adipose Tissue With Left Ventricular Strain and MR Myocardial Perfusion in Patients With Known Coronary Artery Disease.

Epicardial adipose tissue (EAT) may have a paracrine effect on coronary microcirculation and myocardium. However, it is unclear whether EAT is linked to cardiac function and perfusion. To investigate the association of EAT with left ventricular (LV) strain and myocardial perfusion in patients with coronary artery disease (CAD). Retrospective. A total of 78 patients with CAD and 20 healthy controls. The patients were further divided into high (n=39) and low EAT volume (n=39) groups according to median EAT volume. A 1.5 T, balanced steady-state free precession, inversion recovery prepared echo-planar, and segmented-turbo fast low-angle shot (FLASH) phase-sensitive inversion recovery (PSIR) sequences. EAT volume was measured by manually tracing the epicardial border and the visceral layer of pericardium on the short-axis cine stacks. LV strain parameters included global radial (GRS), circumferential (GCS), and longitudinal peak strain (GLS). Perfusion indices included upslope, perfusion index, time-to-maximum signal intensity (TTM), and maximum signal intensity (MaxSI). One-way analysis of variance or Kruskal-Wallis rank tests, Chi-squared or Fisher exact tests. Multivariate linear regression analyses. A P value < 0.05 was considered statistically significant. The parameters of GRS GCS, GLS, upslope, perfusion index, and MaxSI were significantly lower in the patients when compared to the controls. Moreover, the high EAT volume group presented significantly longer TTM values and lower GRS, GCS, GLS, upslope, perfusion index, and MaxSI than the low EAT volume group. Multivariate linear regression analyses demonstrated that EAT was independently associated with GRS, GCS, GLS, upslope, perfusion index, TTM, and MaxSI in patients. EAT and upslope were independently associated with GRS, while EAT and perfusion index were both independently associated with GCS and GLS. EAT was associated with parameters of LV function and perfusion, and myocardial perfusion was independently associated with LV strain in patients with CAD. 3. Stage 3.

THE EFFECT OF SURGEON VOLUME AND RISK OF REVISION FOLLOWING TOTAL KNEE ARTHROPLASTIES WITH AND WITHOUT PATELLAR RESURFACING: A STUDY FROM THE AUSTRALIAN ORTHOPAEDIC ASSOCIATION NATIONAL JOINT REPLACEMENT REGISTRY

Strategy regarding patella resurfacing in total knee replacement (TKR) remains controversial. TKR revision rates are reportedly influenced by surgeon procedure volume. The study aim was to compare revision outcomes of TKR with and without patella resurfacing in different surgeon volume groups using data from the AOANJRR.The study population included 571,149 primary TKRs for osteoarthritis. Surgeons were classified as low, medium, or high-volume based on the quartiles of mean primary TKR volume between 2011 and 2020. Cumulative percent revision (CPR) using Kaplan-Meier estimates of survivorship were calculated for the three surgeon volume groups with and without patella resurfacing. Cox proportional hazards models, adjusted for age and sex, were used to compare revision risks.High-volume surgeons who did not resurface the patella had the highest all-cause CPR (20-year CPR 10.9%, 95% CI [10.0%, 12.0%]). When the patella was resurfaced, high-volume surgeons had the lowest revision rate (7.3%, 95% CI [6.4%, 8.4%]). When the high-volume groups were compared there was a higher rate of revision for the non-resurfaced group after 6 months. When the medium-volume surgeon groups were compared, not resurfacing the patella also was associated with a higher rate of revision after 3 months. The low-volume comparisons showed an initial higher rate of revision with patella resurfacing, but there was no difference after 3 months. When only patella revisions were considered, there were higher rates of revision in all three volume groups where the patella was not resurfaced.TKR performed by high and medium-volume surgeons without patella resurfacing had higher revision rates compared to when the patella was resurfaced. Resurfacing the patella in the primary procedure protected against revision for patella reasons in all surgeon volume groups.Level of evidence: III (National registry analysis)

THE EFFECT OF SURGEON VOLUME ON REVISION FOR DEEP PERIPROSTHETIC JOINT INFECTION: AN ANALYSIS OF 602,919 PRIMARY TOTAL KNEE ARTHROPLASTIES

Deep infection is a devastating complication of total knee arthroplasty (TKA). This study aimed to determine if there was a relationship between surgeon volume and the incidence of revision for infection after primary TKA.Data from the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR) from 1 September 1999 to 31 December 2020 for primary TKA for osteoarthritis that were revised for infection. Surgeon volume was defined by the number of primary TKA procedures performed by the surgeon in the year the primary TKA was performed and grouped as &lt;25, 25-49, 50-74, 75-99, &gt;100 primary TKA procedures per year. Kaplan Meir estimates for cumulative percent revision (CPR) and Cox Proportional Hazard Ratios were performed to compare rates of revision for infection by surgeon volume, with sub-analyses for patella and polyethylene use, age &lt;65 years and male gender.5295 of 602,919 primary TKA for osteoarthritis were revised for infection. High volume surgeons (&gt;100 TKA/year) had a significantly lower rate of revision for infection with a CPR at 1 and 17 years of 0.4% (95% CI 0.3, 0.4) and 1.5% (95% CI 1.2, 2.0), respectively, compared with 0.6% (95% CI 0.5, 0.7) and 2.1% (95% CI 1.8, 2.3), respectively, for low volume surgeons (&lt;25 TKR/year). Differences between the high-volume group and the remaining groups remained when sub-analysis for age, gender, ASA, BMI, patella resurfacing and the use of cross-linked polyethylene (XLPE).High volume surgeons have lower rates of revision for infection in primary TKA.

Association of hospital volume with perioperative and oncological outcomes of robot-assisted laparoscopic radical prostatectomy: a retrospective multicenter cohort study

BackgroundThis retrospective multicenter cohort study investigated the association of hospital volume with perioperative and oncological outcomes in patients treated with robot-assisted radical prostatectomy (RARP).MethodsWe collected the clinical data of patients who underwent RARP at eight institutions in Japan between September 2012 and August 2021. The patients were divided into two groups based on the treatment site—high- and non-high-volume hospitals. We defined a high-volume hospital as one where RARP was performed for more than 100 cases per year.ResultsAfter excluding patients who received neoadjuvant therapy, a total of 2753 patients were included in this study. In the high-volume hospital group, console time and estimated blood loss were significantly (p < 0.001) lower than that of the non-high-volume hospital group. However, the continence rate at 3 months after RARP, positive surgical margins, and prostate-specific antigen (PSA)-relapse-free survival showed no significant differences between the two groups. Furthermore, the console time was significantly shorter after 100 cases in the non-high-volume hospital group but not in the high-volume hospital group.ConclusionsA higher hospital volume was significantly associated with shorter console time and less estimated blood loss. However, oncological outcomes and early continence recovery appear to be comparable regardless of the hospital volume in Japan.

Complications in Burn Patients Following Fluid Over-Resuscitation

Background/Objective: Over-resuscitation of burn patients leads to dangerous edema-related sequelae. The Parkland formula is commonly used to predict fluid requirements in the 24 hours following burn injury, yet studies report widely varying resuscitation rates. This study aims to assess fluid resuscitation practices at Lutheran Hospital and evaluate correlations between resuscitation rates and fluid-overload complications.Methods: A retrospective chart review assessed fluid resuscitation of 36 adult patients withburns affecting at least 15% total surface body area (TBSA) between May 2020-May 2022 atLutheran Hospital. Intravenous fluid rates and urine output (UO) were recorded for the first 24 hours of each patient’s hospital stay. Complications and mortality were recorded for the entirety of a patient’s hospital stay. Patients who received volumes exceeding those recommended by the Parkland formula were placed in the high-volume group whereas patients who received a lesser volume were placed in the low-volume group. Statistical analyses were performed using Microsoft Excel (α = 0.05).Results: The study included 36 patients with an average fluid resuscitation of 4.13 ±2.14mL/kg/%TBSA in the first 24 hours following hospital admission. Average UO in the high-volume group (n=14) was 1.33 ±0.76 mL/kg/hr compared to 0.75 ±0.47 mL/kg/hr in the low-volume group (n=22). Fluid complications were more common in the high-volume group (41.7%)compared to the low-volume group (19.0%), but this difference was not statistically significant (p=0.230). No difference in mortality was observed (p=1.000).Conclusion: The high-volume group had an average UO exceeding the recommended range(0.5-1.0 mL/kg/hr) and experienced greater rates of fluid-overload complications (pulmonaryedema, compartment syndromes, etc.). Due to the small sample size and limited power of this study, the difference in fluid-related complications was not statistically significant.Clinical Impact and Implications: Physicians should limit fluid volumes exceeding theParkland formula when resuscitating burn patients to avoid fluid overload sequelae.

Assessment of comprehensiveness of Medicare Part B provider-level data sets within dermatology.

Publicly available provider-level Medicare Part B data sets have been increasingly utilized for health services research in dermatology. Despite offering detailed insights, an important limitation of these data sets is suppression of services performed for < 11 Medicare beneficiaries at the level of each provider. This longitudinal review assesses the magnitude of this limitation by comparing service counts in provider-level Medicare data sets to those in aggregate data sets, ultimately identifying a concordance rate of 94.3% for dermatology services. However, facility-based visits (52.5%), inpatient evaluation and management visits (59.7%), phototherapy (62.9%), incision and drainage (61.1%), and nail procedures (38.0%) were less well-represented in the provider-level data sets. Provider-level data sets are most suitable for assessing dermatology services in aggregate and among specific high-volume procedure groups but alternative data sets should be considered when investigating inpatient services, facility-based services (more common in certain states), or rarely performed procedures.

Physiological Regulation of Pulmonary Microcirculation under Mechanical Ventilation at Different Cardiac Outputs and Positive End-Expiratory Pressures in a Porcine Model.

This study was performed to visualize the hemodynamic effects of pulmonary microcirculation and ventilation/perfusion (V/Q) matching after mechanical ventilation under different cardiac outputs and positive end-expiratory pressures (PEEPs). Ten experimental pigs were randomly divided into high and low tidal volume groups, and ventilation/perfusion were measured by electrical impedance tomography (EIT) at different PEEPs. Then, all the pigs were redivided into high cardiac output (CO) and low CO groups and measured by EIT at different PEEP levels with a low tidal volume. Additionally, sidestream dark field (SDF) was used to measure pulmonary microcirculation. Hemodynamic parameters and respiratory mechanics parameters were recorded. As PEEP increased at high tidal volume, blood flow was impaired at a higher PEEP (20 cmH2O) compared with low tidal volume (shunt: 30.01 ± 0.69% vs. 17.95 ± 0.72%; V/Q ratio: 65.12 ± 1.97% vs. 76.57 ± 1.25%, p &lt; 0.01). Low tidal volume combined with an appropriate PEEP is the best option from the match between ventilation and pulmonary blood flow. Increasing PEEP can solve the problem of excessive shunt at high CO, and the V/Q ratio tends to match. At low CO, the increased dead space can reach as high as 64.64 ± 7.13% when PEEP = 20 cmH2O. With increasing PEEP, the microcirculation index deteriorates, including total vessel density (TVD), proportion of perfused vessel (PPV), perfused vessel density (PVD), and microcirculatory flow index (MFI). The periodic collapse of pulmonary capillaries or interruption of blood flow obviously occurred with high PEEP. The hemodynamic parameters indicated that the transpulmonary capillary wall pressure (Pcap) of the low CO group was negative at PEEP = 5 cmH2O, which determines the opening and closing of the pulmonary microcirculation and controls lung perfusion and the production of extravascular lung water. Therefore, it is essential to couple macrocirculation and pulmonary microcirculation during mechanical ventilation by improving shunting and optimizing Pcap.

College Soccer Student-Athletes Demonstrate Differences in Self-Reported Athlete Health When Grouped by Match Volume.

Physical changes following activity are well documented, but there is limited information about self-reported outcomes around competitive matches. High training volumes and poor recovery could predispose athletes to overuse injury. The purpose of this study was to identify the changes in daily athlete health measures before, during, and after the day of each match in high- and low-volume groups. Prospective cohort. Fifty-five soccer athletes (age: 19.8 [1.2]y, 26 males, 29 females) provided daily measures of readiness, physical fatigue, mental stress, sleep quality, and soreness intensity match days, days 1 (D01) and 2 (D02) following matches, and standard practice days. Participants were grouped into high volume and low volume, based off the minutes played during the season. Soreness increased, readiness decreased, and fatigue increased on D01 compared with match days (P < .008) in the high-volume group. Between groups, the high-volume group demonstrated higher soreness on D01 and D02, lower readiness on D01 and D02, and lower fatigue on D01, compared with the low-volume group (P < .008). Soccer athletes demonstrate significant changes in self-reported athlete health variables around competitive matches. These changes are similar to physical outcomes, potentially indicating that the athlete health variables may be used to track athlete recovery from competition, potentially limiting the impact of overuse injuries.

Evaluation of the impact of high-volume online hemodiafiltration on glycemic status, hydration status, and body fat content in diabetic patients

Abstract Background: The increasing patients with diabetes undergoing hemodialysis (HD) have concerned about the issue of glucose delivery with substitution fluid. We evaluate the effects of online high-volume hemodiafiltration (OL-HDF) versus high flux HD (HF-HD) on the influence of glycemic status and body fat content in patients with type 2 diabetes mellitus (T2DM) receiving HD. Objectives: The influence glucose in substitution fluid on glycemic status and body fat content in patients with type 2 diabetes mellitus. Methods: This study evaluated 117 patients receiving HD for more than 3 months (17 patients with T2DM receiving high-volume OL-HDF and the other 100 patients receiving HF-HD). Initially, we performed a cross-sectional study and later examined two modalities of high-volume OL-HDF in a 9-month cross-over study. Overall glycemic control was estimated from the fasting blood glucose (FBG) and the hemoglobin A1c (HbA1c) levels. Body composition and nutritional status were assessed by bioimpedance spectroscopy. Results: FBG and HbA1c were not significantly different in both groups of patients after having followed for 12 weeks. No significant differences were found in overhydration status and body fat content between the two therapy modalities. The blood hemoglobin (Hb) level increased in the high-volume OL-HDF group compared with the HF-HD group. Additionally, no differences were observed in glycemic status, body mass index, or body fat mass between both high-volume pre- and post-dilutional OL-HDF. Conclusion: High-volume OL-HDF did not have an adverse impact on glycemic status, body mass index, and body fat content in patients with diabetes undergoing HD in our short-term study. A large-scale and long-term follow-up study is required to confirm these results.

The Effectiveness of a Very Low-Volume Compared to High-Volume Laxative in Colon Capsule Endoscopy

Colon capsule endoscopy (CCE) is a promising modality for colonic investigations, but completion rates (CR) and adequate cleansing rates (ACR) must be improved to meet established standards for optical colonoscopy. Improvements should be made with patient acceptability in mind. We aimed to compare a very low-volume polyethylene glycol (PEG) laxative to a conventional high-volume laxative. We carried out a single-center retrospective comparative cohort study including patients referred for CCE. One hundred and sixty-six patients were included in the final analysis, with eighty-three patients in each group. We found a CR and ACR of 77% and 67% in the high-volume group and 72% and 75% in the very low-volume group, respectively. In the high-volume group, 54% had complete transit and adequate cleansing, whereas this was the case for 63% in the very low-volume group. No statistically significant difference in CR, ACR, or a combination of the two was found. A very low-volume bowel preparation regimen was non-inferior to a high-volume regimen before CCE in terms of CR and ACR.

Impact of image filtering and assessment of volume-confounding effects on CT radiomic features and derived survival models in non-small cell lung cancer.

No evidence supports the choice of specific imaging filtering methodologies in radiomics. As the volume of the primary tumor is a well-recognized prognosticator, our purpose is to assess how filtering may impact the feature/volume dependency in computed tomography (CT) images of non-small cell lung cancer (NSCLC), and if such impact translates into differences in the performance of survival modeling. The role of lesion volume in model performances was also considered and discussed. Four-hundred seventeen CT images NSCLC patients were retrieved from the NSCLC-Radiomics public repository. Pre-processing and features extraction were implemented using Pyradiomics v3.0.1. Features showing high correlation with volume across original and filtered images were excluded. Cox proportional hazards (PH) with least absolute shrinkage and selection operator (LASSO) regularization and CatBoost models were built with and without volume, and their concordance (C-) indices were compared using Wilcoxon signed-ranked test. The Mann Whitney U test was used to assess model performances after stratification into two groups based on low- and high-volume lesions. Radiomic models significantly outperformed models built on only clinical variables and volume. However, the exclusion/inclusion of volume did not generally alter the performances of radiomic models. Overall, performances were not substantially affected by the choice of either imaging filter (overall C-index 0.539-0.590 for Cox PH and 0.589-0.612 for CatBoost). The separation of patients with high-volume lesions resulted in significantly better performances in 2/10 and 7/10 cases for Cox PH and CatBoost models, respectively. Both low- and high-volume models performed significantly better with the inclusion of radiomic features (P<0.0001), but the improvement was largest in the high-volume group (+10.2% against +8.7% improvement for CatBoost models and +10.0% against +5.4% in Cox PH models). Radiomic features complement well-known prognostic factors such as volume, but their volume-dependency is high and should be managed with vigilance. The informative content of radiomic features may be diminished in small lesion volumes, which could limit the applicability of radiomics in early-stage NSCLC, where tumors tend to be small. Our results also suggest an advantage of CatBoost models over the Cox PH models.

High Metabolic Tumor Volume Is Associated with Higher Toxicity and Decreased Efficacy of BCMA CAR-T Cell Therapy in Multiple Myeloma

Background Recently, two chimeric antigen receptor T-cell (CAR-T) constructs have been FDA approved for relapsed/refractory multiple myeloma (RRMM) after exposure to at least 4 prior lines of therapy. High tumor burden has been associated with inferior outcomes, reduced CAR-T expansion and higher rates of toxicity. Patients relapsing after multiple lines of therapy more frequently have oligosecretory and extra-medullary disease that may not be well captured by serum-based markers of disease or bone marrow infiltration, respectively. Functional imaging with FDG-PET is well established as a useful tool in patients with myeloma but its prognostic impact in highly refractory patients or those proceeding with CAR-T has not been described. Metabolic tumor volume (MTV) capturing all metabolically active disease can be useful as a more global assessment of disease burden. We sought to evaluate tumor burden as measured by MTV in a cohort of patients presenting for anti-BCMA CAR-T with RRMM. Methods We identified all patients presenting to our center treated with anti-BCMA CAR-T with available restaging imaging performed within 60 days prior to lymphodepleting chemotherapy (LD-chemo). Baseline skull to midthigh with or without leg/whole-body 18F-FDG PET/CT scans were evaluated for MTV using a custom tool implemented on MIM PACS version 7.1 (MIM Software, Cleveland, OH) as previously reported (Dean et al, Blood Adv 2020). Briefly, images were semi-automatically analyzed to identify abnormal regions with reference to average metabolic activity of normal liver defined by PET SUV. Metabolically active volume at the lesion level were converged based on PERCIST criteria (41% of SUVmax). Summation of the metabolically active volumes across the human body is reported as the Metabolically Tumor Volume (MTV), measured in ml. Patient image scans were reviewed centrally by a radiologist blinded to outcomes, who removed any false positive uptake unrelated to metabolically active disease. Patients with the following FISH cytogenetics were considered high risk (HR): t(4;14), t(14;16) and deletion 17p/monosomy 17 whereas the remainder were standard risk (SR). The high and low tumor volume groups were selected based on the median MTV value in cohort. Baseline laboratory tests (e.g. beta2 microglobulin (b2M), C-reactive protein (CRP)) and repeat bone marrow biopsy were obtained prior to LD-chemo. Soluble BCMA (sBCMA) was measured by ELISA on patients with available serum samples (R&D Systems, MN, USA #DY193). All analyses were conducted in Stata (16.1, StataCorp LLC, College Station, TX). Results The study cohort consisted of 66 patients. Median age was 65 years (range 36 - 81), 55% were male, 55% had ECOG 0-1 prior to LD-chemo and 65% received bridging therapy. 25 (38%) were categorized as HR based on FISH cytogenetics. Patients had received a median of 6 prior lines of therapy and median interval between PET and date of CART infusion was 14.5 days (range 2-54). Median MTV was 26.3ml (0.26-1073.87ml) and only 3/66 (5%) had no measurable PET-avid lesions captured by this algorithm. Patients with high MTV (>26) were more likely to have elevated baseline CRP >0.5mg/dL (p=0.007) and receive bridging therapy (60% vs 40%, p=0.02). MTV correlated with sBCMA levels on day -6 (r=0.82, p=0.003), and with baseline b2M (r=0.47, p=0.005), but MTV did not correlate well with percentage plasma cells in pre-CAR-T bone marrow biopsy (r=0.12, p=0.3). The risk of ³G2 CRS was significantly higher (44% vs 12%, p=0.02) and any grade ICANS was numerically higher (27% vs 12%, p=0.1) in those with high vs low MTV, respectively. Finally, fewer patients with high MTV achieved CR by D30 (19% vs 31%, p=0.2) and with limited follow up 12/14 (86%) of deaths had occurred in patients with high baseline MTV (p=0.003). Conclusion These preliminary data confirm the added value of MTV calculated from baseline imaging as part of standard of care in patients with heavily pre-treated relapsed myeloma presenting for anti-BCMA CAR-T therapy. MTV correlated highly with sBCMA measured at day-6 and may be more representative for risk assessment than basing burden on bone marrow plasma cell percentage, which has not demonstrated a consistent relationship in predicting adverse events to date. High MTV appears to be associated with an increased risk of CAR-T specific adverse events and inferior outcomes and warrants further investigation. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

8344 The Impact of Surgeon Volume on Laparoscopic Hysterectomy Outcomes

<h3>Study Objective</h3> To evaluate the impact of surgeon volume on outcomes after laparoscopic hysterectomy for benign indications. <h3>Design</h3> Retrospective chart review. <h3>Setting</h3> Single tertiary care academic institution. <h3>Patients or Participants</h3> A total of 494 patients who underwent laparoscopic hysterectomy performed by 22 benign gynecologic surgeons. <h3>Interventions</h3> Laparoscopic or robotic-assisted hysterectomy performed between March 2019 and April 2020. <h3>Measurements and Main Results</h3> Of the total 494 benign laparoscopic hysterectomies performed, 448 hysterectomies were performed by high volume surgeons (9 surgeons) and 46 hysterectomies were performed by low volume surgeons (13 surgeons). High volume was defined as 12 or more hysterectomies completed during the study year. Low volume surgeons ranged from 1 to 8 hysterectomies performed during the study period. Demographic and preoperative characteristics were similar between groups except age (45 years vs 41 years, p=.033). The two groups had similar intraoperative characteristics including route of hysterectomy, operative time, estimated blood loss and uterine weight. Intraoperative complications were similar between groups including transfusion rates, viscus injury, and intraoperative consults. However, there was a significantly higher rate of intraoperative conversion to laparotomy in the lowvolume group (1% vs 9%, p=.004). Pathology results were similar between groups. No pathologic findings were seen in 16% of cases in the high-volume group and 26% of cases in the low volume group (p=.11). Endometriosis was confirmed on pathology similarly between groups (11% vs 9%, p=.78). Pathology outcomes of leiomyomas, adenomyosis, and endometrial hyperplasia were similar between groups. There were no differences in postoperative complications, emergency department visits, or readmissions. <h3>Conclusion</h3> Low volume surgeons had significantly higher rates of intraoperative conversion to laparotomy at time of laparoscopic hysterectomy. In this study, surgeon volume did not significantly impact other outcomes including pathology. However, a limitation of the study was the small sample size in the low volume group which was <10% of the cohort.

여성 건강운동 참여자의 자의식과 사회적 체형 불안의 관계 : 운동 전념의 조절효과 검증

The purpose of this study was to verify whether exercise commitment moderates the relationship between self-consciousness and social physique anxiety in women who ragularly participate in exercise. Also, the current study examined the group differences (body mass index and exercise volume) in self-consciousness, social physique anxiety, and exercise commitment. A cross-sectional survey was conducted among 249 women with the measure of self-consciousness, social physique anxiety, and exercise commitment. A sample size of 244 was employed, and ANOVA & t-test for the group difference and multiple regression analysis for moderating effect were conducted. Results indicated that the high BMI group has a more social physique anxiety than the low BMI group, and the high exercise volume group has less social physique anxiety and more exercise commitment than the low exercise volume group. The findings also demonstrated that the positive association between self-consciousness and social physique anxiety was buffered by cognitive exercise commitment, but not by behavioral commitment. Thus, it suggests that women exercising need to shift their focus on other things (i.e., exercise itself) rather than on self-things such as body image in order to alleviate social physique anxiety caused by self-consciousness.

Analgesia and spread of erector spinae plane block in breast cancer surgeries: a randomized controlled trial

BackgroundTo evaluate the analgesic efficacy and spread of variable volumes of local anesthetics (LA) in Erector spinae plane block (ESPB).MethodsSixty patients aged between 18 and 50 years with an ASA I-II and scheduled for breast cancer surgery were randomized to receive either ESPB with 20 ml 0.25% bupivacaine (Standard volume ESPB), or with 40 ml 0.125% bupivacaine (High volume ESPB), or no ESPB (GA only group). The primary outcome was pain intensity evaluated by the visual analogue scale (VAS), 12 hours after surgery. P-values < 0.05 were considered the cutoff point for statistical significance. The secondary outcomes were pain at rest and pain on movement evaluated by the VAS, craniocaudal injectate spread, to paravertebral (PV) and epidural spaces assessed by CT, clinical dermatomal spread, level of sedation or agitation, and patient satisfaction with anesthesia and analgesia.ResultsVAS at rest 12 h after surgery was less in both intervention groups compared to the control (1.75 ± 0.79 vs. 1.6 ± 0.88 vs. 3.4 ± 1.96, p = 0.001). The LA had extended further in the high volume group than the standard volume group (11.20 ± 3.07 vs. 9.15 ± 2.54 vertebral levels, p = 0.027). No difference of the spread to PV or epidural spaces between the 2 intervention groups. More dermatomes were covered in the high volume group (7.20 ± 2.12 vs. 5.75 ± 1.37 dermatomes, p = 0.014). Agitation was higher in the GA only group than both ESPB groups in the first 8 postoperative hours. Patients were more satisfied in both ESPB groups than the GA only group.ConclusionsPreoperative ESPB is an excellent analgesic modality and it can also attenuate both postoperative agitation and sedation. Doubling the injectate volume enhances the craniocaudal spreading and may be useful for surgeries requiring multiple dermatomes. However, larger volume has no effect on analgesic efficacy or patient satisfaction as there is no further spread to the PV, epidural spaces or spinal nerve rami.Trial registrationNCT04796363 (12/3/2021).