Optimal Treatment Guidelines Research Articles

ETMR-23. CNS SARCOMAS WITHCIC- ORATXN1-ALTERATIONS — A META-ANALYSIS OF CLINICAL AND MOLECULAR FEATURES IN A LARGE SERIES OF PATIENTS

Abstract BACKGROUND In 2021, the 5th WHO classification of central nervous system (CNS) tumors acknowledged CNS sarcomas with CIC alterations as a distinct tumor type, which may also expand to non-CIC alterations including ATXN1. To tackle the lack of treatment protocols for these highly aggressive tumors, we conducted a meta-analysis to provide an overview of clinical and molecular characteristics, define clinically relevant subtypes, and ultimately advise on treatment guidelines. METHODS We collected molecular and clinical data for >200 patients with CIC- or ATXN1-altered CNS sarcomas by screening our in-house DNA methylation database (581 potential patients initially identified), publication databases (50 patients), and contacting centers worldwide (60 patients). Tumor tissue (FFPE and fresh frozen) for further molecular characterization was obtained from a subset of patients. DNA methylation-based clustering analyses (t-SNE, UMAP, consensus partitioning) were performed, integrating gene fusion details (RNAseq, FISH), copy-number variations, and clinical patient data to identify associations between (epi-)genetic and clinical parameters. RESULTS Most prominent fusion partners for CIC (n=47) and ATXN1 (n=9) were NUTM1 (n=18), LEUTX (n=17) and DUX4 (n=15). Clustering analyses of DNA methylation patterns indicated several epigenetic subtypes associated with different fusion types. Potential clinical implications are still under evaluation. Age distribution of patients at diagnosis in this cohort ranged from two months to 71 years (median=7.5 years). We observed no gender bias. Survival analyses are currently being performed, first results on survival and follow-up studies will be shown at the symposium. CONCLUSION We show first-of-its-kind data describing a large cohort of CNS sarcomas with CIC or ATXN1 alterations, outlining molecular and clinical characteristics, which may facilitate the development of guidelines for optimal treatment of these tumors based on retrospective response data. New molecular insights may also open up an avenue for targeted therapeutic approaches.

Chloroquine has shown high therapeutic efficacy against uncomplicated Plasmodium vivax malaria in southern Ethiopia: seven decades after its introduction

BackgroundPlasmodium vivax malaria is a leading cause of morbidity in Ethiopia. The first-line treatment for P. vivax is chloroquine (CQ) and primaquine (PQ), but there have been local reports of CQ resistance. A clinical study was conducted to determine the efficacy of CQ for the treatment of P. vivax malaria in southern Ethiopia.MethodsIn 2021, patients with P. vivax mono-infection and uncomplicated malaria were enrolled and treated with 25 mg/kg CQ for 3 consecutive days. Patients were followed for 28 days according to WHO guidelines. The data were analysed using per-protocol (PP) and Kaplan‒Meier (K‒M) analyses to estimate the risk of recurrent P. vivax parasitaemia on day 28.ResultsA total of 88 patients were enrolled, 78 (88.6%) of whom completed the 28 days of follow-up. Overall, 76 (97.4%) patients had adequate clinical and parasitological responses, and two patients had late parasitological failures. The initial therapeutic response was rapid, with 100% clearance of asexual parasitaemia within 48 h.ConclusionDespite previous reports of declining chloroquine efficacy against P. vivax, CQ retains high therapeutic efficacy in southern Ethiopia, supporting the current national treatment guidelines. Ongoing clinical monitoring of CQ efficacy supported by advanced molecular methods is warranted to inform national surveillance and ensure optimal treatment guidelines.

Understanding the Korean Dialysis Cohort for Mineral, Vascular Calcification, and Fracture (ORCHESTRA) Study: Design, Method, and Baseline Characteristics

Introduction: End-stage renal disease (ESRD) is a growing disease worldwide, including Korea. This is an important condition that affects patient outcome. To provide optimal management for mineral disturbance, vascular calcification, and bone disease in ESRD patients, the Korean dialysis cohort for mineral, vascular calcification, and fracture (ORCHESTRA) study was conducted by enrolling Korean dialysis patients. Methods: Sixteen university-affiliated hospitals and one Veterans’ Health Service Medical Center participated in this study. This prospective cohort study enrolled approximately 900 consecutive patients on dialysis between May 2019 and January 2021. Enrolled subjects were evaluated at baseline for demographic information, laboratory tests, radiologic imaging, and bone mineral densitometry (BMD) scans. After enrollment, regular assessments of the patients were performed, and their biospecimens were collected according to the study protocol. The primary outcomes were the occurrence of major adverse cardiovascular events, invasive treatment for peripheral artery disease, and osteoporotic fractures. The secondary outcomes were hospitalization for cerebrovascular disease or progression of abdominal aortic calcification. Participants will be assessed for up to 3 years to determine whether primary or secondary outcomes occur. Results: Between May 2019 and January 2021, all participating centers recruited 900 consecutive dialysis patients, including 786 undergoing hemodialysis (HD) and 114 undergoing peritoneal dialysis (PD). The mean age of the subjects was 60.4 ± 12.3 years. Males accounted for 57.7% of the total population. The mean dialysis vintage was 6.1 ± 6.0 years. The HD group was significantly older, had a longer dialysis vintage, and more comorbidities. Overall, the severity of vascular calcification was higher and the level of BMD was lower in the HD group than in the PD group. Conclusion: This nationwide, multicenter, prospective cohort study focused on chronic kidney disease-mineral and bone disorder and aimed to provide clinical evidence to establish optimal treatment guidelines for Asian dialysis patients.

Heart failure related to contemporary breast cancer treatment.

This article addresses cardiotoxicity in patients with breast cancer who are treated with anthracyclines and/or anti-human epidermal growth factor 2 (HER2) therapy, namely doxorubicin and trastuzumab. Development of concise clinical guidelines for chemotherapy-induced heart failure is ongoing. Through identification of specific risk factors and clinical predictors of cardiotoxicity, clinicians are able to better understand and define effective monitoring strategies and optimize patient care. Close cardiac monitoring is recommended for patients throughout treatment with anthracyclines and anti-HER2 therapy. Pretreatment risk assessment with echocardiography and evaluation of cardiovascular risk factors aid in predicting the development of left ventricular (LV) dysfunction. Further clinical trials are needed to increase understanding and optimize treatment guidelines for LV dysfunction in patients taking anthracyclines or anti-HER2 therapy.

Factors associated with trachoma in persistently endemic setting in Southern Ethiopia: a community-based cross-sectional study.

in Ethiopia, despite implementing decades-long surgery, antibiotics, facial cleanliness, and environmental improvement interventions, commonly known as the SAFE strategies, persistence and recrudescence of trachoma are common. There is limited evidence that explained the reasons. This study assesses factors associated with trachoma in persistently endemic settings. using a World Health Organization (WHO)-endorsed Global Trachoma Mapping Methodology, a two-stage cluster sampling technique was applied to select 1538 study respondents from 52 clusters. Data was collected using ODK and analysed using SPSS 28. A total of 1522 respondents were enrolled. the mean age of the respondents was 33.4 and 50.5% of the respondents were females. About 32.3% (CI 30%, 34%) of the households reported the presence of at least one member of the family having one or more symptoms of trachoma. Being from poorer household (AOR=1.36, 95% CI: 1.0,1.75), presence of a household member who did not receive optimum treatment (AOR=2.8, 95% CI: 1.5, 5.2), and less than 3 doses of treatment (AOR=1.94, 95% CI: 1.32, 2.86) and presence of children ever not treated (AOR= 2.5, 95% CI: 1.5, 4.2) are associated with increased risk of manifesting symptoms of trachoma. In contrast, having optimally treated members of household (AOR=11.2,95% CI: 6.5, 19.3) and face washing with soap (AOR=0.59, 95% CI 36, 0.97) were preventive. trachoma is a persistent problem in the study districts. Generally, persistent, and recrudescent districts are characterised by segments of population missing optimum treatment as well as poor sanitation and hygiene practices. Our evidence supports the importance of adhering to optimal treatment guidelines, leaving no one behind, and the need for adequate treatment coverage.

FORWARD Study of GORE VIABAHN Balloon-Expandable Endoprostheses and Bare Metal Stents in the United States, European Union, United Kingdom, Australia, and New Zealand When Placed to Treat Complex Iliac Occlusive Disease: Protocol for a Randomized Superiority Trial.

The recommendations for the use of and selection of covered stent grafts in patients with aortoiliac occlusive disease are limited. The GORE VBX FORWARD clinical study aims to demonstrate the superiority of the GORE VIABAHN VBX Balloon Expandable Endoprosthesis (VBX device) for primary patency when compared to bare metal stenting (BMS) for the treatment of complex iliac artery occlusive disease. A prospective, multicenter, randomized control study in the United States, European Union, United Kingdom, Australia, and New Zealand will enroll patients with symptomatic, complex iliac artery occlusive disease. In this study, iliac artery occlusive disease is defined as a unilateral or bilateral disease with single or multiple lesions (with >50% stenosis or chronic total occlusion) each between 4 and 11 cm in length. In an attempt to more closely match real-world practices, patients with minor tissue loss (Rutherford class 5) and patients requiring hemodialysis will be included. Baseline aortoiliac angiography will be performed to assess target lesion characteristics and determine final patient eligibility. Once the patient is confirmed and guidewires are in place across the target lesions, the patient will be randomized in a 1:1 format to treatment with either the VBX device or a BMS. The BMS can be balloon- or self-expanding and must be approved for the iliac artery occlusive disease indication. Patients, the independent core laboratory reviewers, and Clinical Events Committee members will be blinded from the assigned treatment. Dual antithrombotic medical therapy is required through a minimum of 3 months post procedure. The primary end point is 12‑month primary patency and will be adjudicated by an independent imaging core laboratory and Clinical Events Committee. Key secondary end points will be tested for superiority and include technical, acute procedural, and clinical success; changes in Ankle-brachial index; patient quality of life; primary patency; freedom from restenosis; primary-assisted patency; secondary patency; freedom from target lesion revascularizations; cumulative reintervention rate; amputation-free survival; survival; and change in Rutherford category. Study follow-up will continue through 5years. Outcomes will be reported following study completion. Enrollment is anticipated to start in October 2023. The results of this study will provide definitive, level 1 clinical evidence to clinicians on the optimal choice of stent device to use for the treatment of complex iliac artery occlusive disease. The FORWARD study is powered for superiority and includes only complex, unilateral, or bilateral lesions involving the common or external iliac arteries. This study is a multidisciplinary endeavor involving vascular surgery, interventional cardiology, and interventional radiology across multiple countries with a blinded core laboratory review of end points in hopes that the outcomes will be widely accepted and incorporated into practice guidelines for optimal treatment of patients with complex iliac artery occlusive disease. ClinicalTrials.gov NCT05811364; https://clinicaltrials.gov/study/NCT05811364. PRR1-10.2196/51480.

Predicting Clonal Evolution to Secondary Myeloid Neoplasms in Aplastic Anemia through Machine Learning

Background: One of the major long-term complications in aplastic anemia (AA) is the clonal evolution to secondary myeloid neoplasms (sMNs) such as acute myeloid leukemia (AML) and myelodysplastic syndrome (MDS) 1. Hematopoietic stem cell transplantation (HSCT) is largely considered a curative treatment option for AA and is effective at preventing the clonal evolution of sMNs 2. However, patients over 40 years old or those with poor donor options are contraindicated for HSCT due to elevated post-transplant mortality rates 3. When treated with non-transplant strategies, patients with AA have indeed a high risk for acquisition/expansion of somatic myeloid mutations, with some harbingers of future clonal progression to full-blown MDS or AML. Older age, presence of myeloid mutations other than BCOR/L and PIGA at onset, and lack of response to standard immunosuppressive treatment (IST) have been identified as factors predictive for subsequent sMN evolution 4,5,6. If an individual patient's risk of developing a sMN could be assessed through a predictive model that uses information collected at initial AA diagnosis, providers may consider HSCT for traditionally contraindicated patients. However, no such predictive model that could aid in risk assessment currently exists. Methods: In our study, we utilized a large, multi-institutional cohort of patients diagnosed with AA to generate a comprehensive dataset. This dataset contained 76 variables, encompassing relevant clinical and molecular annotations. On this dataset, we trained a machine learning (ML) model to predict patients who would evolve sMNs. Variables with the highest feature impact score (FIS) in predicting clonal evolution to sMN were then chosen to be included in the final ML model, and the algorithm's fitness was calculated using the Leave-One-Out cross-validation method. Variables missing in more than 30% of subjects were imputed using K-Nearest Neighbors (N=20). Of our initial cohort of 455 patients, 213 patients were excluded from the study. 35 patients were excluded because they were treated with HSCT. 39 pediatric cases (defined as <18 years old at the time of diagnosis) were excluded from the study. 91 patients were removed for not receiving specific treatment (IST or HSCT). The remaining 77 patients were excluded due to having a sMN detected at the time of or prior to AA diagnosis, insufficient data, or detection of a germline mutation indicative of an inherited pathophysiology. Our final cohort included a total of 242 acquired AA patients from UT Southwestern Medical Center and Cleveland Clinic. Results: Among our final cohort of 242 patients, 119 (49.2%) were male. The cohort's mean and median ages at AA diagnosis were 53.1 years (SD = 18.9 years) and 58.1 years, respectively. The median follow-up time was 4.04 years. 80 (33.1%) of our patients had a clinically significant PNH clone (defined as >0.001%). 29 patients developed sMNs, with 24 developing MDS and 5 developing AML. Of patients who underwent clonal evolution to sMNs, the median age at the time of AA diagnosis and sMN diagnosis was 63.1 years and 67.2 years, respectively. The median time elapsed from initial AA diagnosis to sMN evolution was 3.78 years. The median time elapsed between initial AA diagnosis and earliest IST administration was 51 days. Chi-squared analysis showed that patients who received ATG treatment were more likely to develop sMNs, with 78.0% of all patients receiving ATG, while 96.6% of patients who developed sMNs had received ATG (p=0.00927). Our ML model achieved a sensitivity of 0.759, a specificity of 0.728, and an AUC of 0.78 using the ten variables with the highest feature impact score (FIS) to predict clonal evolution [Table 1]. All of the variables except for the presence of a PNH clone are positively correlated with sMN evolution. Nine of these variables are supported by existing literature 7,8. The feature with the third highest feature impact score, the time elapsed (days) between diagnosis and IST treatment, has not been established by previous studies and may be an important consideration in establishing optimal AA treatment guidelines. Conclusion: The strategic combination of this ML algorithm with clinical expertise has tremendous potential in improving health outcomes. Identification of patients at high risk for sMN and offering HSCT as a curative option upfront may lead to improved overall survival in AA patients.

Whole Genome Sequencing for Studying Helicobacter pylori Antimicrobial Resistance.

Antibiotic resistance (AMR) is an alarming concern worldwide and Helicobacter pylori, one of the most prevalent bacteria, is not an exception. With antibiotics being its primary therapy, increasing resistance leads to a higher rate of treatment failure. Understanding the genomic mechanisms of resistance to clarithromycin, levofloxacin, metronidazole, amoxicillin, tetracycline, and rifampicin through next-generation sequencing-based molecular tools, such as whole genome sequencing (WGS), can be of great value, not only to direct a patient's treatment, but also to establish and optimize treatment guidelines according to the local epidemiology and to avoid the use of inappropriate antibiotics. WGS approaches allow us to gain insight into the genomic determinants involved in AMR. To this end, different pipelines and platforms are continuously being developed. In this study, we take a more detailed view of the use and progression of WGS for in-depth study of H. pylori's AMR.

When to treat: A multicenter retrospective study of timing of radiation therapy in 1p19q co-deleted, IDH mutated oligodendrogliomas.

e14036 Background: Oligodendrogliomas, molecularly defined by IDH mutation and 1p19q codeletion, have a protracted natural history and are more chemoresponsive compared to astrocytomas. While the addition of chemotherapy to radiation improves survival, if chemoradiation should be initiated following diagnosis or at progression remains unknown. Given the potential for early and late radiation-related toxicity, a careful evaluation of timing of treatment is critical to optimize treatment guidelines for oligodendroglioma. We aimed to evaluate the benefit of initial adjuvant radiation therapy (RT) on survival in patients with oligodendrogliomas. Methods: We conducted a multicenter retrospective study of patients treated at the University of Washington and Stanford Medical Center with oligodendrogliomas using both 1p19q codeletion and IDH mutation to define the diagnosis, reflecting the World Health Organization 2021 diagnostic criteria. Survival probability, overall survival (OS) and time to first progression (PFS), were calculated using Kaplan-Meier method with distributions compared using log-rank test in GraphPad Prism. Propensity Score Matching was completed using XLSTAT. Results: 243 patients were identified as oligodendroglioma and 229 had treatment and survival data available with a median follow up of 5.8 years(y). Median OS was 22.5y and median PFS was 5.35y. 110 patients were treated with adjuvant radiation (aRT) within 1y of diagnosis and 119 underwent observation or chemotherapy alone (delayed RT, or dRT). PFS was comparable between aRT (7.7y) and dRT (4.6y) but OS was longer in dRT (27.8y) than aRT (13.7y) (p < 0.001). Given imbalance in baseline characteristics, propensity score matching was used to adjust for high risk factors of age, grade and presence of residual disease resulting in 63 pairs. In this matched cohort, aRT prolonged PFS (aRT = 7.75y v. dRT = 4.33y, p = 0.006) however dRT still demonstrated a survival benefit (p = 0.017). 59 dRT patients were treated with RT at progression and also had longer medan OS of 22.6y compared to 13.7y in the aRT (p = < 0.0001). The time to RT for this cohort ranged be 1.1-19y. Conclusions: To our knowledge this is the largest retrospective study of molecularly defined oligodendrogliomas that includes treatment information. This study confirms the protracted natural history of this disease. In our multi-institution cohort, early adjuvant radiation therapy may increase PFS but was not found to prolong OS. Prospective studies evaluating the timing of treatment in patients with oligodendroglioma are needed. [Table: see text]

Gastrointestinal Bleeding Because of Hepatic Arteriobiliary Fistula

ABSTRACT Hepatic artery aneurysms are a rare phenomenon, representing 20% of visceral aneurysms. Hepatic artery aneurysm can rarely cause fistulization with the bile duct, also known as common hepatic artery-bile duct fistula. In acute settings, patients present with abdominal pain, jaundice, and gastrointestinal bleeding. Radiographic findings confirm the diagnosis. Given the rarity of this condition, there are no optimal treatment guidelines; therefore, treatment is multidisciplinary and involves definitive surgical and endoscopic management. We present a case of a common hepatic artery-bile duct fistula presenting as gastrointestinal hemorrhage.

A Preliminary Assessment of the Effects of Pharmacist-Driven Methadone Stewardship for the Treatment of Neonatal Abstinence Syndrome at a Tertiary Children's Hospital.

Lack of a standardized opioid wean guideline for the treatment of neonatal abstinence syndrome (NAS) has the potential to increase the length of the wean and subsequently the length of stay for neonates in the neonatal intensive care unit (NICU). The purpose of this study was to assess the effect of a pharmacist-driven methadone stewardship program for NAS treatment. The NAS stewardship program consisted of provider, pharmacist, and nursing education, a pharmacy surveillance system rule, and an updated clinical practice guideline. The pre- and post-intervention period were defined as patients admitted to the NICU from July 2019-October 2019 and August 2020-November 2020, respectively. The primary objective was to assess the effect of the stewardship program on the duration of opioid treatment in days. Secondary outcomes included number of dose titrations and length of hospital stay. A total of 21 patients were included in this study. Neonates treated following the adoption of the stewardship program (n = 8) experienced a 34% decreased median duration of treatment (29 days vs 19 days; p = 0.84). Secondary endpoints of median number of titrations and length of stay were decreased by 15% (1.5 titrations; p = 0.52) and 24% (8 days; p = 0.85), respectively, leading to an average cost savings of $60,020 per patient. Implementation of a standardized stewardship guideline for treatment of NAS resulted in a favorable decrease in all considered endpoints. Implications of the study further support the need for more evidence-based standardized guidelines for optimal treatment of patients with NAS.

To Analyze the Outcomes of Various Methods of Treatment of Periprosthetic Fracture Following Hip Arthroplasty- A Restrospective Study to form the Optimal Treatment Guidelines

Background: Periprosthetic fracture of femur after total hip arthroplasty (THA) is a well known complication. Mayo clinic joint registry has reported 1.1% incidence of periprosthetic femoral fractures after primary THA and 4% incidence after revision THA. This study was conducted to analyse the results of various methods of treatment of periprosthetic fractures following THA and to form the optimal treatment guidelines for fixation or revision surgeries.

343.7: COVID-19 and Allograft Damage After Simultaneous Pancreas And Kidney Transplantation: Clinical Case Series And Literature Review

Introduction: The risk for morbidity and mortality from coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), is high in transplant recipients due to the continued immunosuppression regimen for allograft maintenance. While SARS-CoV-2 primarily affects the lungs and causes pulmonary sequelae, evidence suggests that infection by the virus affects other organ systems as well. Simultaneous pancreas-kidney (SPK) transplantation is a treatment for patients with insulin-dependent diabetes and end-stage renal failure. Management of COVID-19 is especially challenging in patients who received SPK transplantation due to the complex interaction between the viral pathogenesis, pancreas and kidney allografts, and immunosuppressive therapies. Therefore, examining the clinical management and recovery process of allograft damage in post-SPK transplant patients who contacted COVID-19 could be valuable in establishing optimal treatment guidelines for this vulnerable population. Methods: We present a series of patients who contacted COVID-19 and developed allograft damage after receiving SPK transplantation at our institution. The following information was retrieved and collated: demographics, baseline health following transplantation, clinical management of COVID-19 infection and allograft damage. Results: Out of 10 post-SPK transplant patients who tested positive for COVID-19, 5 patients (50%) also developed elevation of amylase and/or lipase levels 3 times the upper limit of normal. The average AlloSure level of these 5 patients was 5.67% at the time of pancreatic damage. One patient contacted COVID-19 after being admitted for acute rejection and inflammation of the pancreas, and recovered after receiving remdisivir, dexamethasone, plasmapheresis, and high dose prednisone with aggressive diuresis. The other patient was diagnosed with pancreatitis and acute kidney injury on admission and had symptomatic improvements after receiving thymoglobulin induction, IVIG, and rituximab. The patient subsequently contacted COVID-19 after discharge and fully recovered after receiving Bamlanivimab infusion, which occurred concurrently with a precipitous decline in amylase and lipase levels. The remaining 3 patients did not meet the criteria for acute pancreatitis, and they recovered after receiving tixagevimab with cilgavimab, remdisivir with dexamethasone, and Bamlanivimab infusion, respectively, along with supportive treatments. Conclusion: Damage to the allograft via immunological processes and infectious agents is a recurring concern for patients who received SPK transplantation. Notwithstanding the clinical overlap of COVID-19 infection and allograft damage in the reported patients, it is still unclear if COVID-19 infection directly elicits damage. Further research is required to clarify the relationship between these two phenomena and establish an optimal treatment guideline.

Achilles Tendon Ruptures and Repair in Athletes-a Review of Sports-Related Achilles Injuries and Return to Play.

Achilles tendon ruptures (ATR) are detrimental to sports performance, and optimal treatment strategy and guidelines on return to play (RTP) remain controversial. This current review investigates the recent literature surrounding nonoperative versus operative management of ATR, clinical outcomes, and operative techniques to allow the athlete a successful return to their respective sport. The Achilles tendon (AT) is crucial to the athlete, as it is essential for explosive activities such as running and jumping. Athletes that sustain an ATR play in fewer games and perform at a lower level of play compared to age-matched controls. Recent studies also theorize that ATRs occur due to elongation of the tendon with fatigue failure. Biomechanical studies have focused on comparing modes of fixation under dynamic loading to recreate this mechanism. ATRs can be career-ending injuries. Fortunately, the recent incorporation of early weight-bearing and functional rehabilitation programming for non-operative and operative patients alike proves to be beneficial. Especially for those treated nonoperatively, with the incorporation of functional rehabilitation, the risk of re-rupture among non-operative patients is beginning to approach the historical lower risk of re-rupture observed among patients treated operatively. Despite this progress in decreasing risk of re-rupture particularly among non-operative patients, operative managements are associated with unique benefits that may be of particular interest for athletes and active individuals. Recent studies demonstrate that operative intervention improves strength and functional outcomes with more efficacy compared to nonoperative management with rehabilitation. The current literature supports operative intervention in elite athletes to improve performance and shorten the duration to RTP. However, we acknowledge that surgical intervention does have inherent risks. Ultimately, most if not all young and/or high-level athletes with an ATR benefit from surgical repair, but it is crucial to take a stepwise algorithmic approach and consider other factors, which may lead towards nonoperative intervention. These factors include age, chronicity of injury, gap of ATR, social factors, and medical history amongst others in this review.

Executive summary of the Korean Society of Nephrology 2021 clinical practice guideline for optimal hemodialysis treatment.

The Korean Society of Nephrology (KSN) has published a clinical practice guideline (CPG) document for maintenance hemodialysis (HD). The document, 2021 Clinical Practice Guideline on Optimal HD Treatment, is based on an extensive evidence-oriented review of the benefits of preparation, initiation, and maintenance therapy for HD, with the participation of representative experts from the KSN under the methodologists’ support for guideline development. It was intended to help clinicians participating in HD treatment make safer and more effective clinical decisions by providing user-friendly guidelines. We hope that this CPG will be meaningful as a recommendation in practice, but not on a regulatory rule basis, as different approaches and treatments may be used by health care providers depending on the individual patient’s condition. This CPG consists of eight sections and 15 key questions. Each begins with statements that are graded by the strength of recommendations and quality of the evidence. Each statement is followed by a summary of the evidence supporting the recommendations. There are also a link to full-text documents and lists of the most important reports so that the readers can read further (most of this is available online).

Perceptions towards breast and cervical cancer development and screening in transgender and nonbinary persons.

e18500 Background: Approximately 1.4 million adult Americans identify as transgender (TG) or non-binary (NB), a number that has steadily increased over time. In this population, cancer risk is unclear, and screening and treatment guidelines are lacking. We sought to assess TG and NB persons’ perceptions towards breast and cervical cancer screening, risk of cancer development, and thoughts towards gender-affirming hormone therapy in the setting of a hormone-receptor positive breast cancer. Methods: A single-institution online survey was administered from October 2021-January 2022 at our comprehensive LGBTQ+ Inclusion Health Clinic. Participants with female sex at birth were asked about breast and cervical cancer, while those assigned male sex at birth were exclusively asked about breast cancer. A 5-point Likert scale was used to assess attitudes toward cancer screening and concerns regarding cancer development. Results: 40 patient responses were collected: 13% were TG women, 45% TG men, 23% NB, and 20% identified as other (i.e., agender, genderqueer, etc). 71% were assigned female sex at birth (59% of whom had chest masculinization surgery), 27% were assigned male sex at birth, and one individual was intersex at birth. 52.5% were age < 30, 84% were Caucasian, 65% had at least a bachelor’s degree, and all but one respondent had health insurance. The majority reported they were not familiar with breast (77%) or cervical (60%) cancer screening recommendations for their sex-assigned at birth or current gender identity. 23% reported concern regarding breast cancer development and cited family history as the primary reason. In patients age > 40, 50% had a mammogram (MMG) in the past 10 years. When presented with information regarding screening MMG and automated breast ultrasonography (ABUS), 78% reported they would prefer ABUS over MMG for breast cancer screening. 84% of respondents were currently using or had previously used gender-affirming hormone therapy, and of these, 61% reported they would stop therapy in the event they developed a hormone-receptor positive breast cancer. In patients assigned female sex at birth, 25% had a hysterectomy and, in those who still had a cervix, 50% reported having a Pap smear in the past 5 years and 38% were concerned about cervical cancer development. Conclusions: This survey identified that > 60% of TG and NB individuals are unaware of breast and cervical cancer screening guidelines, > 20% are concerned about breast and cervical cancer development, and < 50% of patients eligible for breast and cervical cancer screening had undergone screening in recent years. Additionally, in the setting of a hormone-receptor positive breast cancer, only 61% would consider stopping gender-affirming hormone therapy. Further data on the risk of breast and cervical cancer development and incidence in TG and NB persons is needed to inform optimal screening and treatment guidelines.

Epigenetic Influences on Wound Healing and Hypertrophic-Keloid Scarring: A Review for Basic Scientists and Clinicians.

Primary care physicians and dermatologists are challenged by patients affected by keloid or hypertrophic scarring resulting from accidental wounding, surgical incisions, tattooing, or “branding” procedures to demonstrate their association with a specific culture, fraternity, or cult. The dysregulated wound healing associated with keloids and hypertrophic scarring adversely affects genetically susceptible individuals, especially persons of color with Fitzpatrick Skin types IV-VI. Although the specific mechanisms of bulky hypertrophic/keloid scarring and its association with oxidative stress and inflammation remain unclear, the current knowledge base is sufficient to provide some guidance to health practitioners who must serve, treat, and counsel affected individuals. This review focuses on providing insight to healthcare professionals about the role of epigenetics, oxidative stress, poor local oxygenation, and its relationship to impaired wound healing. The goal is to promote further research on bulky hypertrophic and keloid scarring for its prevention and to develop evidence-based clinical guidelines for optimal treatment.

Executive Summary of the Korean Society of Nephrology 2021 Clinical Practice Guideline for Optimal Hemodialysis Treatment.

The Korean Society of Nephrology (KSN) has published a clinical practice guideline (CPG) document for maintenance hemodialysis (HD). The document, 2021 Clinical Practice Guideline on Optimal HD Treatment, is based on an extensive evidence-oriented review of the benefits of preparation, initiation, and maintenance therapy for HD, with the participation of representative experts from the KSN under the methodologists’ support for guideline development. It was intended to help clinicians participating in HD treatment make safer and more effective clinical decisions by providing user-friendly guidelines. We hope that this CPG will be meaningful as a recommendation in practice, but not on a regulatory rule basis, as different approaches and treatments may be used by health care providers depending on the individual patient’s condition. This CPG consists of eight sections and 15 key questions. Each begins with statements that are graded by the strength of recommendations and quality of the evidence. Each statement is followed by a summary of the evidence supporting the recommendations. There is also a link to full-text documents and lists of the most important reports so that the readers can read further (most of this is available online).

Incidence, Treatment and Outcomes of Cervical Cancer in Low- and Middle-income Countries

Cervical cancer is one of the most common cancers in developing nations. It has had a tremendous impact on the lifetime of millions of women over the last century and continues to do so. In this collaborative clinicians' review, we highlight the incidence, treatment and clinical outcomes of cervical cancer in low-income (LICs) and low- and middle-income countries (LMICs) across Asia, South America, South Africa and Eastern Europe. With the cervical cancer burden and locally advanced cancers being high, the majority of LICs/LMICs have been striving to adhere to optimal evaluation and treatment guidelines. However, the huge gap in resource availability, rural versus urban disparity and access to resources have led to poor compliance to evaluation, treatment and post-treatment rehabilitation. To mitigate the overwhelming numbers, various treatment strategies like neoadjuvant chemotherapy, hypofractionation radiation schedules (both external and brachytherapy) have been attempted with no major success. Also, the compliance to concurrent chemoradiation in various regions is a major challenge. With the burden of advanced cancers, the lack of palliative care services and their integration in cancer care is still a reality.

Early pharmacologic conversion of atrial fibrillation after off-pump coronary artery bypass grafting.

BackgroundThe aim of this study was to evaluate the efficacy of early amiodarone-based pharmacological cardioversion for postoperative atrial fibrillation (POAF) following off-pump coronary bypass grafting (OPCAB).MethodsA total of 507 patients who underwent OPCAB between 2015 and 2017 were categorized into POAF (n=94) and no-POAF (n=413) groups. Patients in the POAF group were treated according to the following institutional protocol: 150 mg loading dose of intravenous amiodarone, followed by oral administration with sequential maintenance doses at 600, 400, and 200 mg per day. If sinus rhythm was restored before discharge, patients were discharged without amiodarone or anticoagulants, except for dual antiplatelets.ResultsBefore discharge at index hospitalization, 97.8% of POAF patients had restored sinus rhythm. Independent risk factors for POAF were age, unstable angina, prior percutaneous transluminal coronary angioplasty, and left atrial diameter. The mean follow-up duration was 41.1±12.8 months. Freedom from overall mortality and composite events, including mortality, major bleeding requiring admission and cerebrovascular events, were similar between the 2 groups. Results were consistent after propensity-score matching.ConclusionsAmiodarone-based rapid pharmacological cardioversion of POAF resulted in a high sinus rhythm conversion rate (97.9%). Rate of late adverse cardiovascular events including stroke, were low even without anticoagulation. As optimal treatment and anticoagulation guidelines for POAF after OPCAB have not yet been established, amiodarone-based treatment protocols may be considered as a useful option.