Long-term Institutional Experience Research Articles

Improvement in survival of acute myeloid leukemia and myelodysplastic syndrome patients following allogeneic transplant: a long-term institutional experience

BackgroundAllogeneic stem cell transplant (allo-SCT) plays a key role in the treatment of patients with both acute myeloid leukemia (AML) and myelodysplastic (MDS). Outcomes of allo-SCT have improved with optimization of transplant practices. We sought to evaluate trends in survival in AML and MDS patients undergoing allo-SCT at our institution from 1984 to 2018.MethodsA retrospective analysis of 900 consecutive AML and MDS patients undergoing allo-SCT was performed. Patients were divided by year of transplant for analysis. Primary endpoints were progression free survival (PFS) and overall survival (OS). Secondary endpoints included non-relapse mortality (NRM), graft-versus-host disease (GVHD), GVHD-free relapse free survival (GRFS), and transplant complications.ResultsWe found a significant improvement in survival from 1984 to 2018 with 5-year PFS and OS improving from 17% to 49% and 17% to 53%, respectively (statistically significant difference since 2004; p<0.001). There was a significant difference in rates of grade II-IV aGVHD (p<0.001) and chronic GVHD at day +365 with cumulative incidence of both highest from 2014-2018, however, NRM improved across the years with 5- year NRM decreasing from 45% to 21%. Rates of pulmonary infections, hemorrhagic cystitis, veno-occlusive disease, and fungal infections also decreased across the years (p<0.001).ConclusionsWe found a significant improvement in survival of AML and MDS patients undergoing allo-HCT over the past several decades. This likely reflects improvements in transplant practices and general supportive care. Post-transplant relapse remains the leading cause of transplant failure in this group.

Is an Antireflux Procedure Necessary for a Successful Appendicostomy? The Simplified Malone Antegrade Continence Enema Procedure.

The aim of this study was to present the long-term institutional experience and outcomes of our Malone antegrade continence enema (MACE) procedure using the proximal appendix without any antireflux procedure. A single-center prospective study of 29 children undergoing a simplified Malone antegrade continence enema (SMACE) procedure from 2006 to 2017 was conducted using the appendix, whole or split. The mean follow-up period was 11.5 years (ranging from 5 to 16 years). In 25 children, the proximal appendix was used, and in 4 cases, the whole appendix was used as a conduit. On follow-up, the MACE channel has been working well in 29/29 patients. Among the complications, seven patients had stomal stenosis, which was managed by home dilatation. There was no reflux of stools seen in any of the patients. The SMACE procedure, without incorporating an antireflux mechanism, is technically simpler and saves operative time. Most importantly, the results are satisfactory and comparable with procedures using antireflux techniques.

Improvement in Post-Autologous Stem Cell Transplant Survival of Multiple Myeloma Patients: A Long-Term Institutional Experience.

Multiple myeloma (MM) represents 1.8% of all new cancer cases in the U.S. While not curable, advances in treatment, including autologous stem cell transplant (ASCT) and maintenance therapy, have dramatically improved progression-free survival (PFS) and overall survival (OS). We performed a retrospective survival analysis on newly diagnosed MM (NDMM) patients receiving ASCT from 1992-2016 at the Ohio State University. A total of 1001 consecutive NDMM patients were eligible. Patients were split into five groups based on historic changes in novel agents for the treatment of MM. Across the years (1992-2016), there was a statistically significant improvement in both PFS (p < 0.01) and OS (p < 0.01). Significant improvements in both PFS and OS were seen in patients ≤65 years (p < 0.001 and p = 0.002) and >65 years old (p < 0.001 and p = 0.001), respectively. Improved PFS and OS were seen in both standard-risk (p < 0.001 and p < 0.001) and high-risk patients (p < 0.001 and p = 0.019). The post-transplant response showed statistically significant improvement across the years (p < 0.01). Survival rates for NDMM patients have significantly improved primarily due to the inclusion of novel therapies and post-ASCT maintenance.

Indications and Limitations of Carbonated Calcium Phosphate Cement for Secondary Contouring Cranioplasty: A Long-Term Institutional Experience.

Abstract The authors describe our long-term institutional experience utilizing carbonated calcium phosphate (CCP) cement for secondary cranioplasty refinements with the goals to The authors conducted a retrospective cohort study of patients undergoing secondary cranioplasty for forehead reshaping utilizing CCP between June 2007 and August 2018. Exclusion criteria included < 3-month follow-up. The primary outcome was aesthetic forehead correction determined by Whitaker classification, while secondary outcomes included complications and reoperations. In total, 107 patients met inclusion with a median age of 15.5 years. The majority of bony deficits were limited to the frontal region (90.7%), required onlay application (87.7%) of large (96.0 cm2) partial thickness (85.7%) cranial defects, in a clean setting (99.0%), and ASA grade II (69.7%). Median Whitaker classification decreased from 2.3 [IQR: 2, 2.3] preoperatively to 1.0 [1.0, 1.3] postoperatively (P < 0.01). There was no difference in Whitaker classification between early and late postoperative timepoints (P < 0.17). The complication rate was 13.2%, with the majority related to infection (5/14). Factors associated with complications included frontal sinus proximity (OR 3.6, P < 0.04) and the use of interposition titanium mesh for full-thickness reconstruction (OR 6.4, P < 0.02). CCP remains an effective alloplastic bone substitute with a complication rate of 13.2% in patients undergoing secondary, onlay cranioplasty. Early postoperative Whitaker classification may predict long-term aesthetic results. Complications may arise years following implantation, warranting long-term follow-up.

Free Flap Reconstruction of Posterior Trunk Soft-Tissue Defects: Single-Institution Experience and Systematic Literature Review

The posterior trunk is a technically demanding location for microvascular free tissue transfer. In this study, the authors report their own institutional experience with soft-tissue free flap reconstruction of the posterior trunk and provide a systematic review of the literature regarding this uncommon clinical scenario. A systematic review was performed using the PubMed database in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A single-institution retrospective review was also performed including all patients who received a soft-tissue free flap for a posterior trunk defect between 1990 and 2019. The database search yielded 15 articles, representing 61 patients; the most commonly used flap was the latissimus dorsi (45.9 percent) and the most commonly reported defect location was the lumbosacrum (42.3 percent). Retrospective review of the authors' database identified 26 patients, with the latissimus dorsi being the most common flap and the sacrum the most common defect site. The authors' institutional case series showed a 30.7 percent major complication rate and 7.7 percent total flap loss rate; 38.4 percent of flaps required vein grafting. In this study, the authors provided a systematic literature review and described their own long-term institutional experience with these rare and difficult reconstructions. Although the overall complication rate is high, these reconstructions are frequently necessary, and an algorithmic approach can improve outcomes. Therapeutic, IV.

To Sustain or not to Sustain: Varying Educational Sessions on Advanced Imaging of Low Back Pain and R-SCAN

The aim is to present our long-term institutional experience on the use of the American College of Radiology's (ACR's) Radiology Support, Communication, and Alignment Network (R-SCAN) via educational presentations and guideline dissemination in sustaining lumbar spine magnetic resonance imaging (MRI) appropriateness for low back pain. Initial educational presentations on appropriate use criteria for lumbar spine MRI were given to referring providers at three county clinics in April and May of 2016. A second educational refresher was given to the same 3 clinics in November 2017: Clinic A received guideline dissemination, Clinic B served as a control group, and Clinic C received a refresher presentation. Wilcoxon rank-sum test was used to compare the monthly MRI referral rate and ACR Appropriateness Criteria rating. There was no significant difference in monthly referral rates and ACR Appropriateness Criteria after the second education. Monthly referral rates were significantly lower than the baseline rates before the first education for Clinic A (P <0.001), C (P = 0.004), and the combined total (P = 0.002). ACR Appropriateness Criteria ratings were significantly higher than the baseline ratings before the first education for Clinic C (P = 0.002) and the combined total (P = 0.024). After the second education, inappropriateness, and referral rates remained significantly lower when compared to rates before but not after the first education. Radiology Support, Communication, and Alignment Network is an invaluable online tool for both radiology practices and referring clinicians to become familiar in preparing to comply with the Protecting Access to Medicare Act and satisfying the Improvement Activities category of the Merit Based Incentive Payment Systems.

Improvement in Survival of AML and MDS Patients Following Allogeneic Transplant: A Long-Term Institutional Experience

Improvement in Survival of AML and MDS Patients Following Allogeneic Transplant: A Long-Term Institutional Experience

Προβλήματα συμπεριφοράς εφήβων με μακρόχρονη εμπειρία σε ίδρυμα: Διαχρονική μελέτη

Η ΠΕΡΙΛΗΨΗ ΒΡΙΣΚΕΤΑΙ ΜΕΣΑ ΣΤΟ ΑΡΧΕΙΟ PDF

Surgical revision after percutaneous mitral valve repair by edge-to-edge device in high-risk patients.

Patients scheduled for surgery after unsuccessful MitraClip® intervention present increasingly with multiple comorbidities, and they are often referred to the heart team to suggest the most appropriate intervention. The publication of successful results of initial patient cohorts treated with the MitraClip device has resulted in recruitment of more seriously ill patients, who otherwise would have been denied catheter-based/surgical treatment. There has been increasingly reports on conventional surgery after failed mitral valve repair with the MitraClip device. However, data on such procedures remain scarce and mostly focused on individual case studies. The inevitable increase in use of MitraClip, however, will raise the number of patients in need of surgery post MitraClip, making it imperative for surgeons to understand challenges and outcome data related with surgery in this patient cohort. We present our long-term institutional experience with surgery after MitraClip intervention in highest risk patients. Eighteen patients underwent surgery of the mitral valve at our Institution between January 2015 and June 2020. These patients developed recurrent mitral regurgitation grade more than 2° at various intervals after MitraClip. Mitral valve repair was performed where possible and gross examination Valve/MitraClip were intra-operatively documented. Implanted MitraClip devices were analyzed histopathologically to evaluate the healing process and rule out inflammation. Regular patient follow-up was performed. Mean patient age was 74 (±9 years) and MitraClip implantation was performed at various tertiary institutions. Sixteen out of eighteen (16/18) patients received mitral valve replacement, whereas the remaining two patients received mitral valve repair and extracorporal membrane oxygenation, respectively. Four patients died of sepsis and intractable multi organ failure in-hospital. The remaining patients were discharged alive out of hospital to different rehabilitation centers. Follow-up was complete in all patients. Surgery is demanding when patients require surgery for persistent or recurrent mitral regurgitation after MitraClip therapy and can be successfully implemented as a possible therapy option for selective cases as an interdisciplinary approach despite calculated high perioperative mortality risk. These patients should not be denied surgery outright.

Long-Term Institutional Experience With Telemedicine Services for Radiation Oncology: A Potential Model for Long-Term Utilization

PurposeWith the development of the coronavirus disease 2019 (COVID-19) pandemic, health care practices and radiation oncology departments have begun to incorporate telemedicine services to practice social distancing and minimize the chances of disease spread. Given the severity of this pandemic, it will likely fundamentally affect the use of these services for years to come. Our institution and radiation oncology department have used telemedicine services for many years; we would like to report on our departmental experience to guide other radiation oncology practices on its long-term use for clinical evaluation and patient care. Methods and MaterialsOur institution’s telemedicine program provides clinical services for a number of remote locations and represents the largest telehealth network in the world, with over 300 sites and 60,000 patient encounters a year. ResultsSpecifically for our radiation oncology department, over 200 patient encounters occur via telemedicine a year. Patients report great appreciation and satisfaction with these encounters, as they eliminate the time and energy needed for travel from long distances. It has resulted in improved efficiency and cost-effectiveness as well. ConclusionsBased on our institutional experience, our long-term vision for telemedicine (after COVID-19 pandemic has hopefully subsided) is as an excellent and cost-efficient tool to provide long-term follow-up for patients, especially for those who live far away in rural or underserved areas.

Improvement in Survival of Multiple Myeloma Patients: A Long-Term Institutional Experience

Introduction-Multiple myeloma (MM) represents 1.8% of all new cancer cases in the U.S., with an estimated 32,110 new cases in 2019. While not curable, advances in treatment, including autologous stem cell transplant (ASCT) and maintenance therapy, have dramatically improved progression free survival (PFS) and overall survival (OS). The Ohio State University bone marrow transplant program began utilizing ASCT for newly diagnosed MM (NDMM) patients in 1992. With the introduction of new and more effective drugs used before and after ASCT, we performed survival analysis in NDMM patients from 1992-2016 receiving ASCT to examine our institutional progress. Method-We performed a retrospective analysis of 1002 consecutive transplant eligible NDMM patients. Patients were split into five groups based on historic changes in novel agents for treatment of MM: 1992-1998 (vincristine/doxorubicin/dexamethasone-group 1), 1999-2002 (thalidomide/dexamethasone-group 2), 2003-2008 (bortezomib/lenalidomide/dexamethasone-group 3), 2009-2013 (carfilzomib/pomalidomide/dexamethasone, and maintenance therapy-group 4), and 2014-2016 (agents used for relapsed MM, including daratumumab/elotuzumab/ixazomib/dexamethasone, and maintenance therapy-group 5). Pre-ASCT conditioning regimen was melphalan 140-200 mg/m2 in 94.4% of patients. Data were consistently obtained since 2003 for both standard and high-risk patients at diagnosis. High-risk patients had del17, t(4:14), t(14:16), hypodiploidy and/or 1q abnormality. Primary endpoints were PFS and OS. PFS was defined as time to progressive disease or death from any cause from the date of transplantation. OS was defined as time from transplantation to death from any cause, censoring those who were still alive at the last follow up. Kaplan Meier curves were used to calculate PFS and OS. Results-The median age of all patients at transplant was 58 years (range: 18-81 years) and 58.5% were male. The median patient age increased significantly, from 54 to 60 years, over 1992-2016 (p&lt;0.001). The majority of patients (53.6%) had IgG myeloma and 19.3% had light chain disease. 30% of patients with known cytogenetic data were high-risk. Melphalan 200 mg/m2 was used in 80.5% of patients. It was noted that across the years (1992-2016), there was a statistically significant improvement in both PFS (p&lt;0.01) and OS (p&lt;0.01). Median PFS and OS of all patients was 1.3 and 2.0 years in group 1 (1992-1998); 1.0 and 3.2 years in group 2 (1999-2002); and 2.0 and 5.8 years in group 3 (2003-2008), respectively. This response was further improved to PFS and OS of 4.1 years and not reached (NR) in group 4 (2009-2013), and 3.8 years and NR in group 5 (2014-2016), respectively (Figure 1). The 3 year PFS of groups 1 through 5 was 26%, 25%, 35%, 57% and 58%, respectively. The 3 year OS of groups 1 through 5 was 45%, 54%, 74%, 82% and 80%, respectively. On subset analysis, across years, significant increases in PFS (p&lt;0.01) and OS (p&lt;0.01) were seen in patients ≤65 years of age. For patients &gt;65 years old, there was a statistically significant improvement in PFS (p&lt;0.01) but not in OS (p=0.054). For both standard and high-risk disease, there was significant improvement in PFS (p&lt;0.01 and p&lt;0.01), and OS (p=0.02 and p=0.02), respectively. The rate of response both pre- and post-transplant showed statistically significant improvement across the years (p&lt;0.01). The pre-transplant rate of very good partial response (VGPR), or better, increased from 5.3% in early 1990's (group 1), 15.3% (group 2), 39.8% (group 3) to 51.2% (group 4) and 54% (group 5). The post-transplant rate of response (VGPR or better) also increased from 31.5% (group 1), 28.8% (group 2), 65.6% (group 3), to 79.6% (group 4) and 76.3 % (group 5). Conclusion-Our data show that NDMM patients' survival and response to standard of care treatment have improved dramatically since 1992, primarily due to inclusion of novel therapies and maintenance. For NDMM patients receiving ASCT, the 3 year overall survival rate has significantly improved from 45% in 1992-1998 to 80% in 2014-2016, which is similar to the post-ASCT OS shown in the 2012 study by McCarthy et al. The significantly increasing age of NDMM patients receiving ASCT over time suggests improving supportive care and expansion of standard of care therapies to more of the population, improving survival and quality of life. Disclosures Rosko: Vyxeos: Other: Travel support. Efebera:Takeda: Honoraria; Akcea: Other: Advisory board, Speakers Bureau; Janssen: Speakers Bureau.

What Are the Outcomes of Percutaneous Cholecystostomy Tube (PCT) in Cirrhosis Patients Deemed High-Risk Surgical Candidates With Acute Cholecystitis (AC)?

Introduction: AC affects over 20 million Americans and leads to an annual cost exceeding US$ 6 billion. Optimal treatment is early cholecystectomy (CCY). Liver cirrhosis is the 8th leading cause of death in the US. We aim to study our long-term institutional experience of cirrhosis patients undergoing PCT. Methods: Retrospective cohort study of high-risk surgical patients with AC hospitalized at the Cleveland Clinic between 2002 and 2017. AC, cirrhosis and PCT were identified by ICD9 codes. The primary outcome was inpatient mortality and number of PCT re-interventions. We adjusted for age, gender and BMI. We constructed multivariable logistic regression models using SAS software. Results: PCT was placed in 377 patients, 24 (6.4%) were patients with cirrhosis. Mean Child Pugh score was 9.2, whereas the mean MELD score was 20. 6 (25%) were Child Pugh class A, 7 (29%) were Child Pugh class B, and the majority, 11 (46%), were Child Pugh class C. After PCT placement, there was no significant difference between non-cirrhotic and cirrhotic patients in the occurrence of biliary colic (0.5% vs 0%, p=0.99), cholangitis (0.8% vs 4%, p=0.23), choledocholithiasis (2% vs 0%, p=0.49), or biliary pancreatitis (0.2% vs 0%, p=0.99). However, cirrhotic patients were more likely to have recurrence of acute cholecystitis than non-cirrhotic patients (12% vs 3%, p=0.019), and they were more likely to die in the hospital (50% vs 18%, p 2 months post-PCT, cirrhotic patients had almost 5 times higher risk of requiring a cholecystectomy than non-cirrhotic patients (HR 4.8, p<0.001). Conclusion: Limitations: Retrospective study, potential misclassification (some PTC patients will not have ICD9 code). Strength: Robust patient cohort. Long-term follow up in special population. Very limited data on PCT outcomes in cirrhosis. Adjusted for age, gender and race. Conclusion: Cirrhosis patients that undergo PCT during AC have higher inpatient mortality when compared to non-cirrhosis. Cirrhosis patients undergo CCY at a higher rate after >2 months of PCT placement. There was no difference on PCT complications, post-PCT biliary complications, ER visits and re-hospitalizations between cirrhotic and non-cirrhotic patients.865_A Figure 1. Outcomes of interest and cirrhosis865_B Figure 2. Post-PCT Cholecystectomy by Presence of Cirrhosis

What Are the Outcomes of Percutaneous Cholecystostomy Tube (PCT) in Pancreatobiliary Cancer (PBCA) Patients With Acute Cholecystitis (AC)?

Introduction: Background & Aim: AC affects over 20 million Americans and leads to an annual cost exceeding US$ 6 billion. Optimal treatment is early cholecystectomy. Patients with PBCA and AC may be very challenging to manage and often require multiple procedure interventions. We aim to study our long-term institutional experience of patients with PBCA undergoing PCT. Methods: Methods: Retrospective cohort study of high-risk surgical patients with AC hospitalized at the Cleveland Clinic between 2002 and 2017. AC, PBCA and PCT were identified by ICD9 codes. The primary outcome was inpatient mortality, PCT complications and re-interventions. We adjusted for age, gender and BMI. We constructed multivariable logistic regression models using SAS software. Results: Results: PCT was placed in 377 patients, 25 (6.7%) of these patients had a PBCA causing AC. Most common malignancy was pancreatic cancer, 13 (52%), followed by liver metastases, 7 (28%), ampullary masses, 3 (12%), and cholangiocarcinoma, 2 (8%). Patients with PBCA were more likely to have interventions done than patients without malignancy, as 12% vs 2% had PTHC placement (p=0.003) and 16% vs 5% had ERCP post PCT placement (p=0.039). Interestingly, patients with malignancy required less ICU admissions than patients without, 24% vs 59% (p<0.001), with less subsequent inhospital deaths, 12% vs 21%, although not statistically different (p=0.30). Conclusion: Limitations: Retrospective study, potential misclassification (some PTC patients will not have ICD9 code). Strength: Robust patient cohort. Long-term follow up. Adjusted for age, gender and race. Limited data on PBCA and PCT outcomes. Conclusion: PCT is a viable option for PBCA patients with AC not suitable for emergent cholecystectomy, However it is associated with high rate of other interventions (PTHC, ERCP). PBCA had lower mortality and ICU requirement, which is surprising. Further and larger studies are needed to further study this topic.35_A Figure 1. Outcomes of interest and cancer

V09-05 SIX-WEEK-OLD INFANT ROBOTIC PYELOPLASTY: KEY POINTS FOR SAFETY AND PROFICIENCY

You have accessJournal of UrologyPediatric Urology1 Apr 2018V09-05 SIX-WEEK-OLD INFANT ROBOTIC PYELOPLASTY: KEY POINTS FOR SAFETY AND PROFICIENCY Maria Veronica Rodriguez, Nimrod Barashi, Joseph Rodriguez, and Mohan S Gundeti Maria Veronica RodriguezMaria Veronica Rodriguez More articles by this author , Nimrod BarashiNimrod Barashi More articles by this author , Joseph RodriguezJoseph Rodriguez More articles by this author , and Mohan S GundetiMohan S Gundeti More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2018.02.2177AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Ureteropelvic junction obstruction (UPJO) is one of the most common pediatric urologic congenital anomalies. Anderson-Hynes dismembered pyeloplasty has been the gold standard for the intervention of this pathology. Nowadays, robotic surgery has provided a safe alternative to manage these patients with minimally invasive surgery and, even though the procedure is frequently performed by pediatric urologists across the US, there is still a steep learning curve to perform infant robotic pyeloplasty. We aim to describe a robotic-assisted laparoscopic pyeloplasty in a 6-week-old patient with grade 4 hydronephrosis and UPJO in addition to key technical points for safety and proficiency. METHODS The crucial points are patient positioning, proper port placement; particularly the inferior working ports, given the close proximity to the bladder, instrumentation and docking and the inherent bowel distension that children usually have. We present a robotic pyeloplasty in a 6-week old infant with UPJO. The patient was placed in a lateral position, close to the edge of the table. With an open Hassan technique approach, a 12-mm umbilical camera port and two 8-mm ports were placed in the midline in addition to a 5-mm assistant port that was positioned on the lower midclavicular line. There was a distended bowel, therefore an orogastric tube was placed to improve visualization and avoid bowel injury. The Gerota's fascia was incised and the pelvis was hitched with a subcutaneous suture. Then, the narrow ureteropelvic junction was recognized and the pelvis was transected just below the renal hilum vessels, which was followed by ureter spatulation. Ultimately, the anastomosis of the posterior wall with the spatulated ureter was performed in a continuous fashion and subsequently, a double J stent was placed percutaneously to complete the anterior wall anastomosis. RESULTS The patient tolerated the procedure well and was discharged on postoperative day 2 without any complications. Operative time was 143 minutes and, estimated blood loss was found to be less than 5 mL. The Foley catheter was removed prior to discharge. At 1 month follow-up, the patient had well healed abdominal surgical incisions, the double J stent was removed and, his renal bladder ultrasound scan showed improvement of the hydronephrosis. CONCLUSIONS We emphasize the key points for safety and proficiency when performing a robotic infant pyeloplasty, given our long-term institutional experience doing robotic surgery in such young patients to optimize outcomes and prevent complications. © 2018FiguresReferencesRelatedDetails Volume 199Issue 4SApril 2018Page: e904 Advertisement Copyright & Permissions© 2018MetricsAuthor Information Maria Veronica Rodriguez More articles by this author Nimrod Barashi More articles by this author Joseph Rodriguez More articles by this author Mohan S Gundeti More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Deconstructing normal pressure hydrocephalus: Ventriculomegaly as early sign of neurodegeneration.

Idiopathic normal pressure hydrocephalus (NPH) remains both oversuspected on clinical grounds and underconfirmed when based on immediate and sustained response to cerebrospinal fluid diversion. Poor long-term postshunt benefits and findings of neurodegenerative pathology in most patients with adequate follow-up suggest that hydrocephalic disorders appearing in late adulthood may often result from initially unapparent parenchymal abnormalities. We critically review the NPH literature, highlighting the near universal lack of blinding and controls, absence of specific clinical, imaging, or pathological features, and ongoing dependence for diagnostic confirmation on variable cutoffs of gait response to bedside fluid-drainage testing. We also summarize our long-term institutional experience, in which postshunt benefits in patients with initial diagnosis of idiopathic NPH persist in only 32% of patients at 36 months, with known revised diagnosis in over 25% (Alzheimer's disease, dementia with Lewy bodies, and progressive supranuclear palsy). We postulate that previously reported NPH cases with "dual" pathology (ie, developing a "second" disorder) more likely represent ventriculomegalic presentations of selected neurodegenerative disorders in which benefits from shunting may be short-lived, with a consequently unfavorable risk-benefit ratio. Ann Neurol 2017;82:503-513.

Optimal Radiotherapy Target Volumes in Intracranial Non-Germinomatous Germ Cell Tumors: Long-Term Institutional Experience with Chemotherapy, Surgery and Dose and Field Adapted Radiotherapy

Optimal Radiotherapy Target Volumes in Intracranial Non-Germinomatous Germ Cell Tumors: Long-Term Institutional Experience with Chemotherapy, Surgery and Dose and Field Adapted Radiotherapy

Rectal Cancer Improved Outcome with Preoperative Chemoradiation + Intraoperative Presacral Electron Boost: 15 Years Results of Practice-based Adjuvant (Neo) Institutional Program

Timing of pelvic chemoradiation has been controversial in the last 2 decades. The long-term institutional experience in a contemporary 15 year period (unselected academic practice-based upon referral) using neo or adjuvant chemoradiation (CRT) in patients (p) with locally advanced rectal cancer is analyzed. IOERT presacral boost was added to the treatment program in the neoadjuvant chemoradiation cohort of p, as an intensification treatment component.

More Than Clocks and Calendars: The Construction of Timekeepers by Eleven Kindergarten Children in Mexico and the United States

The purpose of this qualitative study was to investigate timekeeping constructs of 4- and 5-year-old children in Campeche, Mexico, and North Carolina, United States, as well as the sociocultural conditions that shaped changes in their ideas about timekeeping (methods to mark and measure time) before, during, and after their kindergarten year. Eleven children constituted the case studies. The children entered public school kindergarten during the fall of the research period and had no prior long-term institutional experience, such as preschool or child care. Data were collected in three phases over the course of one year through: 1) semi-structured interviews with children, parents, teachers, and education administrators; 2) semi-structured activities with children, including drawings of time-related objects and concepts, verbal descriptions of time-related photographic images from the home and classroom, and problem-solving constructions; 3) observational field notes of the homes, communities, schools, and physical surroundings with a special emphasis on time indicators; 4) classroom observations; 5) the completion of a classroom environmental rating scale focused on time; and 6) a review of national, state, and local education policies affecting time in public schools. Data were analyzed within and across cases, sites, and phases to look for commonalities and differences in the children's timekeeping constructs. Three methods for marking and measuring time emerged from the data: biological, environmental, and conventional timekeepers. Each of these timekeeping methods proved to be relative to individual children, as well as replete with common features across cultural, geographical, and biological boundaries. Environmental cues and activities not ordinarily considered timekeepers proved to be more temporally significant than anticipated, and formal school instruction was sometimes out of step with home and community practices. The results of this research suggest that many critical ideas about timekeeping change during a child's first year of formal schooling as children learn to adhere to external schedules, which may constrain or enhance their ability to fully engage in school activities.