Intensive Follow-up Strategies Research Articles

Diagnostic Performance of 18F-FDG PET/CT According to Delay After Treatment to Detect Subclinical Recurrence of Head and Neck Squamous Cell Carcinoma.

Head and neck squamous cell carcinoma (HNSCC) remains a malignancy with high rates of locoregional recurrence and poor prognosis for recurrent cases. Early detection of subclinical lesions is challenging but critical for effective patient management. Imaging surveillance after treatment, particularly 18F-FDG PET/CT, has shown promise in the diagnosis of HNSCC recurrence. The aim was to evaluate the diagnostic performance of 18F-FDG PET/CT according to delay after treatment in detecting subclinical recurrence (SCR) in HNSCC patients. Methods: In this retrospective study, all 18F-FDG PET/CT scans were performed at a single center. All adults with histologically proven HNSCC who were treated with curative intent between January 1, 2006, and December 31, 2021, were included. They had a normal clinical examination before each scan. Patients who underwent an intensive follow-up strategy after treatment had 18F-FDG PET/CT with an intravenous contrast agent at 3-6 mo and annually thereafter for 5 y. The primary endpoint was diagnostic performance (positive and negative predictive values, sensitivity, specificity, and accuracy). Results: In total, 2,566 18F-FDG PET/CT scans were performed among 852 patients, with an average of 3 scans per patient. The overall diagnostic performance measures were as follows: positive predictive value (88%), negative predictive value (98%), sensitivity (98%), specificity (89%), and accuracy (93%). There were no significant differences in diagnostic performance over time. The scans detected 126 cases of SCR (14.8%) and 118 cases of metachronous cancer (13.8%). The incidence of SCR decreased over time, with the highest detection rate in the first 2 y after treatment. Positive predictive value improved over time, reaching 90% for the digital Vision 600 system (third period) compared with 76% for the analog Gemini GXLi system (first period, P < 0.001). Multivariate analysis identified advanced stage, high body mass index, and initial PET/CT upstaging as predictive factors for detection of SCR. Conclusion: Our study demonstrates that 18F-FDG PET/CT has high diagnostic performance in detecting SCR during follow-up after treatment of HNSCC, especially in the first 2 y. Advanced tumor stage, initial PET/CT upstaging, and high body mass index were associated with a higher likelihood of SCR detection. The routine use of 18F-FDG PET/CT during follow-up seems justified for patients with HNSCC.

Risk factors and a nomogram for predicting local recurrence in adult patients with early gastric cancer after endoscopic submucosal dissection

Background and aimsEndoscopic submucosal dissection (ESD) is an effective treatment method for early gastric cancers. The aim of this study was to evaluate the risk factors of recurrence for patients with early gastric cancer after ESD and construct a nomogram for predicting recurrence. MethodsA retrospective observational study was conducted on patients with early gastric cancer who underwent ESD at Beijing Friendship Hospital between 2013 and 2018. The risk factors of gastric cancer recurrence after ESD were analyzed by univariate and multivariate Cox regression. ResultsA total of 238 patients with a median follow-up period of 70.5-month were enrolled in the study. Risk factors for recurrence included diabetes (HR = 3.68), alcohol consumption history (HR = 5.73), complications (HR = 5.22), lymphatic invasion (HR = 13.09) and multiple lesions (HR = 4.34). The analysis of the receiver operating characteristic curve, calibration curve, and model consistency index demonstrates that the graphical representation exhibits a good predictive capability. ConclusionsBased on identified risk factors, this study developed the first nomogram with high accuracy to predict the recurrence of early gastric cancer after ESD. This model offers valuable guidance to clinicians for identifying high-risk patient groups and planning more intensive follow-up strategies.

Intensive follow-up vs conventional follow-up for patients with non-metastatic colorectal cancer treated with curative intent: A meta-analysis.

The frequency and content of follow-up strategies remain controversial for colorectal cancer (CRC), and scheduled follow-ups have limited value. To compare intensive and conventional follow-up strategies for the prognosis of non-metastatic CRC treated with curative intent using a meta-analysis. PubMed, Embase, and the Cochrane Library databases were systematically searched for potentially eligible randomized controlled trials (RCTs) from inception until April 2023. The Cochrane risk of bias was used to assess the methodological quality of the included studies. The hazard ratio, relative risk, and 95% confidence interval were used to calculate survival and categorical data, and pooled analyses were performed using the random-effects model. Additional exploratory analyses were performed for sensitivity, subgroups, and publication bias. Eighteen RCTs involving 8533 patients with CRC were selected for the final analysis. Intensive follow-up may be superior to conventional follow-up in improving overall survival, but this difference was not statistically significant. Moreover, intensive follow-up was associated with an increased incidence of salvage surgery compared to conventional follow-up. In addition, there was no significant difference in the risk of recurrence between intensive and conventional follow-up strategies, whereas intensive follow-up was associated with a reduced risk of interval recurrence compared to conventional follow-up. Finally, the effects of intensive and conventional follow-up strategies differed when stratified by tumor location and follow-up duration. Intensive follow-up may have a beneficial effect on the overall survival of patients with non-metastatic CRC treated with curative intent.

MRI-based Multiregional Radiomics for Pretreatment Prediction of Distant Metastasis After Neoadjuvant Chemoradiotherapy in Patients with Locally Advanced Rectal Cancer

To develop and validate a nomogram based on intratumoral and peritumoral radiomics signatures for pretreatment prediction of distant metastasis-free survival (DMFS) in patients after neoadjuvant chemoradiotherapy (NCRT) with locally advanced rectal cancer (LARC). This retrospective study included 230 patients (161 training cohort; 69 validation cohort) with LARC who underwent NCRT and surgery. Radiomics features were extracted on T2-weighted images from gross tumor volume (GTV) and volumes of 4-mm, 6-mm, and 8-mm peritumoral regions (PTV4, PTV6, and PTV8). The least absolute shrinkage and selection operator (LASSO)-Cox analysis were used for features selection and models construction. The performance of each model in predicting DMFS was evaluated by the Concordance index (C-index) and time-independent receiver operating characteristic curve (ROC). The PTV4 radiomics model demonstrated superior performance compared to the PTV6 and PTV8 radiomics models, with C-indexes of 0.750 and 0.703 in the training and validation cohorts, respectively. The nomogram was constructed by integrating the GTV radiomics signature, PTV4 radiomics signature, and relevant clinical characteristics, including CA19-9 level, clinical T stage, and clinical N stage. The nomogram achieved C-indexes of 0.831 and 0.748, with corresponding AUCs of 0.872 and 0.808 for 5-year DMFS in the training and validation cohorts, respectively. Kaplan-Meier analysis revealed that a cut-off value of 1.653 effectively stratified patients into high- and low-risk groups for DM (P<0.001). The intra-peritumoral radiomics nomogram is a favorable tool for clinicians to develop personalized systemic treatment and intensive follow-up strategies to improve patient prognosis.

An Intensive 18F-Fludeoxyglucose–Positron Emission Tomography With Computed Tomography–Based Strategy of Follow-Up in Patients Treated for Head and Neck Squamous Cell Carcinoma Who Are Clinically Asymptomatic

Patients with head and neck squamous cell carcinoma (HNSCC) have a significant risk of locoregional recurrence within the first 2 years, with approximately two-thirds of patients experiencing such recurrence. While early recurrence detection may be associated with improved patient outcomes, the association of such detection with survival remains uncertain. To investigate the association of an intensive posttreatment follow-up strategy using 18F-fludeoxyglucose-positron emission tomography with computed tomography (18FDG-PET/CT) with survival among patients with HNSCC. This case-control study was conducted among patients treated at 1 of 3 locations in Brest, France (University Hospital, Military Hospital, or Pasteur Clinic). The statistical analysis was conducted from January to June 2023. All adults with histologically proven HNSCC who were treated with curative intent between January 1, 2006, and December 31, 2019, and achieved a complete response on imaging at 3 to 6 months were included. They had a minimum of 3 years of follow-up. Patients undergoing an intensive posttreatment follow-up strategy had 18FDG-PET/CT (PET/CT group) at months 12, 24, and 36, chosen at the discretion of ear, nose, and throat surgeons. Overall survival (OS) at 3 years. Among 782 patients with HNSCC (642 males [82.1%]; median [IQR] age, 61 [56-68] years), 497 patients had 18FDG-PET/CT during follow-up and 285 patients had conventional follow-up (CFU group). Cox regression analysis showed an association between undergoing 18FDG-PET/CT and lower risk of death (odds ratio, 0.71; 95% CI, 0.57-0.88; P = .002) after adjustment for covariates (age, sex, comorbidities, primary location, stage, surgeon, year of treatment, and treatment). The mean (SD) 3-year OS was significantly better in the PET/CT vs CFU group (72.5% [2.0%] vs 64.3% [2.9%]; P = .002). Analysis based on American Joint Committee on Cancer stage showed significantly better mean (SD) 3-year OS for advanced stages III and IV in the PET/CT group (373 patients) vs CFU group (180 patients; 68.5% [2.4%] vs 55.4% [3.8%]; P < .001), while no significant difference was observed between patients with stage I or II HNSCC. Analysis based on primary tumor site revealed significantly longer mean (SD) 3-year OS for oropharyngeal tumor in the PET/CT group (176 patients) than the CFU group (100 patients; 69.9% [3.5%] vs 60.5% [5.0%]; P = .04). This case-control study found that use of 18FDG-PET/CT in the standard annual CFU of HNSCC was associated with a 3-year survival benefit, with a larger benefit for patients with advanced initial tumor stage (III-IV) and oropharyngeal disease.

Prognostic predictors for recurrence following curative resection in grade I/II pancreatic neuroendocrine tumours.

Pancreatic neuroendocrine tumours (pNETs) have an excellent long-term survival after resection, but are associated with a high recurrence rate. Identification of prognostic factors affecting recurrences would enable identifying subgroup of patients at higher risk of recurrences, who may benefit from more aggressive treatment. A retrospective analysis of prospectively maintained database of patients undergoing pancreatectomy with curative intent for grade I and II pNETs between July 2007 and June 2021 was performed. Perioperative and long-term outcomes were analysed. A total of 68 resected patients of pNETs were included in this analysis. Fifty-two patients (76.47%) underwent pancreaticoduodenectomy, 10 (14.7%) patients had distal pancreatectomy, and 2 (2.9%) patients underwent median pancreatectomy, while enucleation was performed in 4 patients (5.8%). The overall major morbidity (Clavien-Dindo III/IV) and mortality rates were 33.82% and 2.94%, respectively. At a median follow-up period of 48 months, 22 (32.35%) patients had disease recurrence. The 5-year overall survival and 5-year recurrence-free survival (RFS) rates were 90.2% and 60.8%, respectively. While OS was unaffected by different prognostic factors, multivariate analysis showed that lymph node involvement, Ki-67 index ≥5%, and presence of perineural invasion (PNI) were independently associated with recurrence. While surgical resection gives excellent overall survival in grade I/II pNETs, lymph node positivity, higher Ki-67 index, and PNI are associated with a high risk for recurrence. Patients with these characteristics should be stratified as high risk and evaluated for more intensive follow-up and aggressive treatment strategies in future prospective studies.

IMPACT OF THE ESTIMATED GLOMERULAR FILTRATION RATE ON LONG-TERM MORTALITY IN PATIENTS WITH HYPERTENSIVE CRISIS VISITING THE EMERGENCY DEPARTMENT

Objective: The association between renal function and all-cause mortality among patients with hypertensive crisis is unclear. We aimed to identify the impact of the estimated glomerular filtration rate (eGFR) on all-cause mortality in patients with hypertensive crisis visiting the emergency department (ED). Design and method: This retrospective study included patients aged &gt; = 18 years admitted to the ED between 2016 and 2019 for hypertensive crisis (systolic blood pressure: &gt; = 180 mmHg and/or diastolic blood pressure: &gt; = 110 mmHg). They were classified into four groups according to the eGFR at admission to the ED: &gt; = 90, 60–89, 30–59, and &lt; 30 mL/min/1.73 m2. Results: Among the 4,821 patients, 46.7% and 5.8% had an eGFR of &gt; = 90 and &lt; 30 mL/min/1.73 m2, respectively. The patients with a lower eGFR were older and more likely to have comorbidities. The 3-year all-cause mortality was 7.7% and 41.9% in those with an eGFR of &gt; = 90 and &lt; 30 mL/min/1.73 m2, respectively. After adjustments for confounding variables, those with an eGFR of 30–59 (hazard ratio [HR], 2.00; 95% confidence interval [CI], 1.53–2.62) and &lt; 30 mL/min/1.73 m2 (HR, 2.45; 95% CI, 1.79–3.37) had significantly higher 3-year all-cause mortality risks than those with an eGFR of &gt; = 90 mL/min/1.73 m2. The patients with an eGFR of 60–89 mL/min/1.73 m2 had a higher mortality (21.1%) than those with an eGFR of &gt; = 90 mL/min/1.73 m2 (7.7%); however, the difference was not significant (HR, 1.23; 95% CI, 0.96–1.58). Conclusions: Renal impairment is common in patients with hypertensive crisis visiting the ED. There is a strong independent association between decreased eGFR and all-cause mortality in these patients. The eGFR provides useful prognostic information and permits early identification of patients with hypertensive crisis with an increased mortality risk. Intensive treatment and follow-up strategies are needed for patients with a decreased eGFR visiting the ED.

CLINICAL IMPLICATIONS OF CARDIAC TROPONIN-I IN PATIENTS WITH HYPERTENSIVE CRISIS VISITING THE EMERGENCY DEPARTMENTS

Objective: Cardiac troponin-I (cTnI) is the representative marker of myocardial injury. Elevation of cTnI is frequently accompanied in patients with hypertensive crisis, but there are few studies on its prognostic significance in hypertensive crisis. The aim of this study was to determine whether cTnI could predict the all-cause mortality in patients with hypertensive crisis visiting the emergency department (ED). Design and method: In this observational study, we enrolled patients aged &gt; = 18 years who visited an ED between 2016 and 2019 for hypertensive crisis, which was defined as systolic blood pressure &gt; = 180 mmHg and/or diastolic blood pressure &gt; = 110 mmHg. Among the 6,467 patient, 3,938 patients who performed assay for cTnI were finally analyzed. Results: Among the 3,938 patients, 596 (15.1%) patients had cTnI levels above the 99th percentile upper reference limit (elevated cTnI, &gt; 0.04 ng/mL) and 600 (15.2%) patients had cTnI levels between the detection limit (&gt; = 0.01 ng/mL) and the 99th percentile upper reference limit (borderline cTnI). The 3-year all-cause mortality in elevated cTnI group, borderline cTnI groups, and normal cTnI groups were 41.6%, 36.5%, and 12.8%, respectively. After adjusting for confounding variables, patients with elevated cTnI (adjusted hazard ratio [HR] 2.01; 95% confidence interval [CI], 1.61–2.52) and patients with borderline cTnI (adjusted HR 1.64; 95% CI, 1.32–2.04) showed significantly higher risk of 3-year all-cause mortality than patients with normal cTnI. Conclusions: In patients with hypertensive crisis, cTnI levels provide useful prognostic information and permit the early identification of patients with an increased risk of death. Moreover, borderline cTnI was also significantly associated with higher risk of all-cause mortality. More intensive treatment and follow-up strategies are needed for patients with hypertensive crisis with elevated cTnI.

ACE Score Identifies HBeAg-negative Inactive Carriers at a Single-point Evaluation, Regardless of HBV Genotype.

Hepatitis B virus (HBV) biomarkers have been used for a better categorization of patients, even though the lack of simple algorithms and the impact of genotypes limit their application. Our aim was to assess the usefulness of noninvasive markers for the identification of HBV inactive carriers (ICs) in a single-point evaluation and to design a predictive model for their identification. This retrospective-prospective study included 343 consecutive HBeAg-negative individuals. Clinical, analytical, and virological data were collected, and a liver biopsy was performed if needed. Subjects were classified at the end of follow-up as ICs, chronic hepatitis B and gray zone.A predictive model was constructed, and validated by 1000-bootstrap samples. After 39 months of follow-up, 298 subjects were ICs, 36 were chronic hepatitis B CHB, and nine were gray zone. Eighty-nine (25.9%) individuals required a liver biopsy. Baseline HBV DNA hazard ratio (HR) 6.0, p<0.001), HBV core-related antigen (HBcrAg) (HR 6.5, p<0.001), and elastography (HR 4.6, p<0.001) were independently associated with the IC stage. The ACE score (HBV DNA, HBcrAg, elastography), obtained by bootstrapping, yielded an area under the receiver operating characteristics (AUROC) of 0.925 (95% CI: 0.880-0.970, p<0.001) for identification of ICs. The AUROC for genotype D was 0.95, 0.96 for A, 0.90 for E, and 0.88 for H/F. An ACE score of <1 had a positive predictive value of 99.5%, and a score ≤12 points had a diagnostic accuracy of 93.8%. Low baseline HBV DNA, HBcrAg, and liver stiffness were independently associated with the IC phase. A score including those variables identified ICs at a single-point evaluation, and might be applied to implement less intensive follow-up strategies.

Impact of the estimated glomerular filtration rate on long-term mortality in patients with hypertensive crisis visiting the emergency department.

BackgroundThe association between renal function and all-cause mortality in patients with hypertensive crisis remains unclear. We aimed to identify the impact of estimated glomerular filtration rate (eGFR) on all-cause mortality in patients with hypertensive crisis visiting the emergency department (ED).MethodsThis retrospective study included patients aged ≥18 years admitted to the ED between 2016 and 2019 for hypertensive crisis (systolic blood pressure ≥180 mmHg and/or diastolic blood pressure ≥110 mmHg). They were classified into four groups according to the eGFR at admission to the ED: ≥90, 60–89, 30–59, and <30 mL/min/1.73 m2.ResultsAmong the 4,821 patients, 46.7% and 5.8% had an eGFR of ≥90 and <30 mL/min/1.73 m2, respectively. Patients with lower eGFR were older and more likely to have comorbidities. The 3-year all-cause mortality rates were 7.7% and 41.9% in those with an eGFR ≥90 and <30 mL/min/1.73 m2, respectively. After adjusting for confounding variables, those with an eGFR of 30–59 (hazard ratio [HR], 1.93; 95% confidence interval [CI], 1.47–2.54) and <30 mL/min/1.73 m2 (HR, 2.35; 95% CI, 1.71–3.24) had significantly higher 3-year all-cause mortality risks than those with an eGFR of ≥90 mL/min/1.73 m2. Patients with an eGFR of 60–89 mL/min/1.73 m2 had a higher mortality (21.1%) than those with an eGFR of ≥90 mL/min/1.73 m2 (7.7%); however, the difference was not significant (HR, 1.21; 95% CI, 0.94–1.56).ConclusionsRenal impairment is common in patients with hypertensive crisis who visit the ED. A strong independent association was observed between decreased eGFR and all-cause mortality in these patients. eGFR provides useful prognostic information and permits the early identification of patients with hypertensive crisis with an increased mortality risk. Intensive treatment and follow-up strategies are needed for patients with a decreased eGFR who visit the ED.

Clinical implications of cardiac troponin-I in patients with hypertensive crisis visiting the emergency department

Objectives Cardiac troponin-I (cTnI) is a representative marker of myocardial injury. Elevation of cTnI is frequently observed in patients with hypertensive crisis, but few studies have examined its prognostic significance in hypertensive crisis. We aimed to determine whether cTnI could predict all-cause mortality in patients with hypertensive crisis visiting the emergency department (ED). Methods This observational study included patients aged ≥18 years who visited an ED between 2016 and 2019 for hypertensive crisis, defined as systolic blood pressure (BP) ≥180 mmHg and/or diastolic BP ≥110 mmHg. Among 6467 patients, 3938 who underwent a cTnI assay were analysed. Results Among the 3938 patients, 596 (15.1%) had cTnI levels above the 99th percentile upper reference limit (elevated cTnI >40 ng/L) and 600 (15.2%) had cTnI levels between the detection limit (≥10 ng/L) and the 99th percentile upper reference limit (detectable cTnI). The 3-year all-cause mortality in the elevated, detectable and undetectable cTnI groups were 41.6%, 36.5% and 12.8%, respectively. After adjusting for confounding variables, elevated cTnI patients (adjusted hazard ratio [HR], 2.01; 95% confidence interval [CI], 1.61–2.52) and detectable cTnI patients (adjusted HR, 1.64; 95% CI, 1.32–2.04) showed a significantly higher risk of 3-year all-cause mortality than did patients with undetectable cTnI. Conclusions In patients with hypertensive crisis, elevated cTnI levels provide useful prognostic information and permit the early identification of patients with an increased risk of death. Moreover, putatively normal but detectable cTnI levels also significantly correlated with a higher risk of all-cause mortality. Intensive treatment and follow-up strategies are needed for patients with hypertensive crisis with elevated and detectable cTnI levels. Key messages Cardiac troponin-I level was an independent prognostic factor for all-cause mortality in patients with hypertensive crisis. Detectable but normal range cardiac troponin-I, which was considered clinically insignificant, also had a prognostic impact on all-cause mortality comparable to elevated cardiac troponin-I levels.

Adherence to NICE Guidelines on Colorectal Cancer Follow-Up: A Cross-Sectional Analysis

Purpose: Our aims were to determine adherence to National Institute of Clinical Excellence (NICE) guidelines on colorectal cancer (CRC) surveillance and to evaluate local practice patterns determine how it can be further improved. Patients and methods: Patients with colorectal cancer resection between January 1, 2017 and December 31, 2017 were identified, and their records retrospectively reviewed. Results: A total of 18 patients were eligible. Surveillance patterns, including blood tests and colonoscopies, were inconsistent with NICE recommendations in a significant proportion of patients. Follow up appointments and CT imaging occurred more frequently in line with the guidelines. For recurrences detected by surveillance, 66.6% were resectable whereas 0% of those detected by symptoms were resectable. Conclusions: The results prove that a moderately intensive follow-up strategy can positively identify resectable recurrence thus increasing overall survival. Our data highlights the need for local improvement to adherence to NICE guidelines regarding CRC follow-up. We have created a pro forma which is attached to the patient’s clinical notes. It will aid clinicians in reminding them when appropriates tests should be completed. A re-audit will be completed in December 2020 which will include looking at the effectiveness of the new pro forma.

APASL guidance on stopping nucleos(t)ide analogues in chronic hepatitis B patients

Chronic hepatitis B virus (HBV) infection is currently incurable. Long-term treatment with potent and safe nucleos(t)ide analogs (NAs) can reduce hepatocellular carcinoma (HCC) and cirrhosis-related complications through profound viral suppression. However, indefinite therapy raises several crucial issues with pros and cons. Because seroclearance of hepatitis B surface (HBsAg) as functional cure is not easily achievable, a finite therapy including sequential 48-week pegylated interferon therapy may provide an opportunity to facilitate HBsAg seroclearance by the rejuvenation of exhausted immune cells. However, the cost of stopping NA is the high incidence of virological relapse and surge of alanine aminotransferase (ALT) levels, which may increase the risk of adverse outcomes (e.g., decompensation, fibrosis progression, HCC, or liver-related mortality). So far, the APASL criteria to stop NA treatment is undetectable HBV DNA levels with normalization of ALT; however, this criterion for cessation of treatment is associated with various incidence rates of virological/clinical relapse and more than 40% of NA-stoppers eventually receive retreatment. A very intensive follow-up strategy and identification of low-risk patients for virological/clinical relapse by different biomarkers are the keys to stop the NA treatment safely. Recent studies suggested that decreasing HBsAg level at the end-of-treatment to < 100-200IU/mL seems to be a useful marker for deciding when to discontinue NAs therapy. In addition, several viral and host factors have been reviewed for their potential roles in predicting clinical relapse. Finally, the APASL guidance has proposed rules to stop NA and the subsequent follow-up strategy to achieve a better prognosis after stopping NA. In general, for both HBeAg-positive and HBeAg-negative patients who have stopped treatment, these measurements should be done every 1-3months at the minimum until 12months.

A varied approach to left ventricular assist device follow-up improves cost-effectiveness

Background Left ventricular assist device (LVAD) implantation improves outcomes in advanced heart failure, however, the optimal frequency of outpatient assessments to improve cost-effectiveness and potentially avert readmissions is unclear. Methods To test if varying the frequency of follow-up after LVAD implantation reduces readmissions and improves cost-effectiveness, a less intensive follow-up (LIFU) strategy with scheduled visits at 1 month and then every 6 months was compared to an intensive follow-up (IFU) group with scheduled visits at 1, 2, and 4 weeks, and then every 3 months post-implant. We developed a decision-tree model to evaluate the cost-effectiveness of different follow-up schedules at 3, 6, and 12-months. The readmission rates for LIFU and IFU, along with the associated costs, were estimated using data from the IBM MarketScan Commercial Claims Databases (2015–2018). A total of 349 patients were enrolled, with 193 and 156 in the IFU and LIFU groups. Results Patients with IFU were found to have a lower risk for readmission at 3 months (HR: 0.69, 95% confidence interval (CI): 0.60–0.79), but this difference diminished overtime at 6 months (HR: 0.84, 95% CI: 0.73–0.96) and 12 months (HR: 0.94, 95% CI: 0.83–1.06). The incremental net benefit of IFU, when compared with LIFU, is greatest in the first 3 months and also diminishes over time (3 months: $19616, 6 months $9257, 12 months $717). Conclusions An initial IFU strategy, followed by a period of de-escalation at the 6-month post-implant mark in lower-risk patients, may be a more cost-effective strategy to provide follow-up care while not predisposing patients to a higher risk of readmission.

A Varied Approach to LVAD Follow-Up Improves Cost-Effectiveness

<h3>Purpose</h3> Left ventricular assist device (LVAD) implantation has improved mortality and quality of life in end-stage HF. However, the optimal frequency of outpatient assessments to improve cost-effectiveness and potentially avert readmissions is unclear. <h3>Methods</h3> The readmission rate, cost of readmission, and follow-up visits were obtained via claims from the 2016-2017 IBM® MarketScan®Commercial Claims Databases. These databases contain de-identified patient claims data across the continuum of care (e.g., inpatient, outpatient, pharmacy) from large employers and health plans in the U.S. who provide private insurance coverage for their employees. Patients who received LVAD in 2016 and 2017 were identified and grouped into one of the two groups: The intervention group was intensivefollow-up (IFU) at 1 week, 2 weeks, 4 weeks, and then every 3 months post-implant, which was compared to a control of less intensive follow-up (LIFU) at one month and then every 6 months. We used the Cox proportional hazard regression to compare the risk of readmission between IFU and LIFU at 3, 6, and 12 months. The health utilities associated with post LVAD with and without readmission were extracted through literature review. <h3>Results</h3> 193 and 156 patients were identified for IFU and LIFU groups, respectively. Patients with IFU were found to have a lower risk for readmission at 3 months (HR:0.69, 95% confidence interval (CI): 0.60-0.79), but this difference diminished over time at 6 (HR: 0.84, 95% CI: 0.73-0.96), and 12 months (HR:0.94, 95% CI: 0.83-1.06). Results from our cost-effectiveness analysis indicate that the incremental net benefit of IFU, when compared with LIFU, increased when looking at a longer time window (3 month: $19616, 6 month $9257, 12 month $717, based on $50,000/ quality-adjusted life year) [Figure]. <h3>Conclusion</h3> An initial intensive follow-up strategy, followed by a period of de-escalation at the 6 month post-implant mark, maybe a more cost-effective strategy to provide follow-up care while not predisposing patients to a higher risk of readmission.

Inborn and acquired risk factors for severe liver disease in Europeans with type 2 diabetes from the UK Biobank

Background & AimsType 2 diabetes is a major driver of fatty liver disease and its long-term complications. The aim of this study was to investigate the individual contribution of inborn and acquired risk factors for severe liver disease in individuals with type 2 diabetes from the UK Biobank study.MethodsA total of 22,812 UK Biobank participants of European descent without clinical history of liver disease and liver cancer were prospectively followed for the development of severe liver disease, defined as a composite diagnosis of cirrhosis, decompensated liver disease, hepatocellular carcinoma, and/or liver transplantation from the National Health Service records. The contribution of inborn and acquired risk factors to the risk of incident severe liver disease was assessed by Cox proportional hazards models.ResultsDuring a median follow-up of 8.9 years (IQR 8.1–9.6), there were 279 individuals with severe liver disease, including 255 with cirrhosis and/or decompensated liver disease, 47 with hepatocellular carcinoma, and 5 with liver transplantation; death from severe liver disease occurred in 83 individuals. Risk factors independently associated with increased risk of incident severe liver disease included abnormal aspartate aminotransferase (adjusted hazard ratio [aHR] 4.85, 95% CI 2.76–8.54), decrease in serum albumin (aHR 2.39, 95% CI 1.76–3.24) and platelet count (aHR 1.12, 95% CI 1.09–1.16), cardiovascular disease (aHR 1.86, 95% CI 1.23–2.79), microalbuminuria (aHR 1.55, 95% CI 1.04–2.30), PNPLA3 rs738409 (aHR 1.67, 95% CI 1.27–2.18) and TM6SF2 rs58542926 (aHR 1.63, 95% CI 1.12–2.39), while the net effect of male sex was protective (aHR 0.49, 95% CI 0.26–0.94).ConclusionsThese findings may help in clinical care to identify individuals with type 2 diabetes at risk of severe liver disease, in turn leading to personalised risk prediction and prevention strategies.Lay summaryType 2 diabetes is a key driver of severe liver disease, namely cirrhosis, hepatocellular carcinoma, and liver-related mortality. In Europeans with type 2 diabetes from the prospective UK Biobank study, abnormal liver function, cardiovascular disease, microalbuminuria, and genetic variants in PNPLA3 and TM6SF2 genes are the major independent risk factors for severe liver disease. These findings may contribute in clinical care to identify and closely monitor individuals with type 2 diabetes at risk of developing severe liver disease, requiring more intensive follow-up strategies.

Cost-effectiveness analysis of PET/CT surveillance imaging to detect systemic recurrence in resected stage III melanoma: study protocol

IntroductionIn the new era of effective systemic therapies for advanced melanoma, early detection of lower volume recurrent disease using surveillance imaging can improve survival. However, intensive imaging follow-up strategies are...

Surveillance après un cancer du rectum

Along with the surgeon, the gastroenterologist and the general practitioner, the radiation oncologist is involved in the follow-up of patients with rectal cancer treated by radiation. Post-treatment follow-up is recommended by major professional expert groups and consists of clinical examination, monitoring of carcinoembryonic antigen, colonoscopy and computed tomography of the abdomen and pelvis. Three recent large phase III randomized trials demonstrated a lack of survival benefit from intensive follow-up strategies in comparison with minimal follow-up. However, a follow-up program is not only important for the detection of an early disease relapse but it can be also used for the identification and the management of long-term toxicity and sequalae related to rectal cancer treatment.

Intensive follow-up strategies after radical surgery for nonmetastatic colorectal cancer: A systematic review and meta-analysis of randomized controlled trials.

BackgroundIntensive follow-up after surgery for colorectal cancers is common in clinical practice, but evidence of a survival benefit is limited.ObjectiveTo conduct a systematic review and meta-analysis on the effects of follow-up strategies for nonmetastatic colorectal cancer.Data sourcesWe searched Medline, Embase, and CENTRAL databases through May 30, 2018.Study selectionWe included randomized clinical trials evaluating intensive follow-up versus less follow-up in patients with nonmetastatic colorectal cancer.InterventionsIntensive follow-upMain outcomes measuresOverall survival.ResultsThe analyses included 17 trials with a total of 8039 patients. Compared with less follow-up, intensive follow-up significantly improved overall survival in patients with nonmetastatic colorectal cancer after radical surgery (HR 0.85, 95% CI 0.74–0.97, P = 0.01; I2 = 30%; high quality). Subgroup analyses showed that differences between intensive-frequency and intensive-test follow-up (P = 0.04) and between short interval and long interval of follow-up (P = 0.02) in favor of the former one.LimitationsClinical heterogeneity of interventionsConclusionsFor patients with nonmetastatic colorectal cancer after curative resection, intensive follow-up strategy was associated with an improvement in overall survival compared with less follow-up strategy. Intensive-frequency follow-up strategy was associated with a greater reduction in mortality compared with intensive-test follow-up strategy.

Impacts of microsatellite status, RAS and BRAF mutation on postoperative follow-up strategy in stage II( and III( colorectal cancer

Colorectal cancer is the third tumor in the world, and nearly half of the stage II( and III( patients undergoing radical resection develop relapse. At present, the survival benefit of follow-up strategy is still unclear, partly due to the neglect of the risk of recurrence and the factors affecting prognosis. Studies found that microsatellite status, BRAF and RAS genotype had certain value for prognosis of colorectal cancer patients after radical resection, but there were differences in prediction among these three factors. Patients with high-frequency microsatellite instability in stage II( have good prognosis, so the follow-up strategy in this set of patients can be appropriately simplified. Locally advanced colorectal cancer patients with BRAF-V600E mutations usually have poor survival after recurrence, and survival benefit appears minimal by intensive follow-up strategy. Besides, standard follow-up strategy, or less intensive follow-up strategy seems an acceptable option for patients with this subtype. In contrast, for patients with wild-type BRAF and RAS in stage II( or III(, the prognosis is usually good after recurrence. Such patients are sensitive to both systemic treatment and local therapy. Therefore, for patients with wild-type BRAF and RAS, early detection of recurrence by intensive follow-up strategy can potentially increase the possibility of second radical resection and prolong survival. It is of clinical significance to explore the feasibility of individualized follow-up strategy for patients with different biological characteristics. In addition, the establishment of individual risk prediction model should take clinical, pathological and molecular features into consideration. Combination of TNM staging and molecular markers for more stratified management and establishment of individualized follow-up system are clinically meaningful in the future.