Optimal Treatment Strategy Research Articles

What do we know about micronutrients in critically ill patients? A narrative review

AbstractMicronutrient (MN) status alterations (both depletion and deficiency) are associated with several complications and worse outcomes in critically ill patients. On the other side of the spectrum, improving MN status has been shown to be a potential co‐adjuvant therapy. This review aims to collect existing data to better guide research in the critical care setting. This narrative review was conducted by the European Society of Intensive Care Medicine Feeding, Rehabilitation, Endocrinology, and Metabolism MN group. The primary objective was to identify studies focusing on individual MNs in critically ill patients, selecting the MNs that appear to be most relevant and most frequently investigated in the last decade: A, B1, B2, B3, B6, folate, C, D, E, copper, iron, selenium, zinc, and carnitine. Given the limited number of interventional studies for most MNs, observational studies were included. For each selected MN, the review summarizes the main form and functions, special needs and risk factors, optimal treatment strategies, pharmacological dosing, and clinical implications all specific to critically ill patients. A rigorous rebalancing of research strategies and priorities is needed to improve clinical practice. An important finding is that high‐dose monotherapy of MNs is not recommended. Basal daily needs must be provided, with higher doses in diseases with known higher needs, and identified deficiencies treated. Finally, the review provides a list of ongoing trials on MNs in critically ill patients and identifies a priority list of future research topics.

A rare case of spinal myeloid sarcoma

Background: Myeloid sarcoma (MS), a rare extramedullary tumor composed of myeloid blast cells, is classified by the World Health Organization as a subtype of acute myeloid leukemia (AML). Isolated, primary, or nonleukemic MS has an incidence of 2/1,000,000 adults and constitutes only 0.7% of all AML cases. MS presentations vary widely, with spinal involvement being rare. Case Description: A-year-old male presented with interscapular pain radiating to the right upper arm/neck but was neurologically intact. Once diagnosed with isolated spinal MS, he underwent a surgical decompression followed by local irradiation, systemic chemotherapy, and bone marrow transplantation. Eight months postoperatively, however, he experienced a graft-versus-host rejection and required additional therapies. Conclusion: Establishing the diagnosis of MS is challenging and typically requires histological confirmation (i.e., the presence of myeloblasts and granulocytic cells). However, optimal treatment strategies remain elusive; despite radiation, chemotherapy, bone marrow transplant/other local therapies, the overall long-term prognosis for MS remains poor.

INTRACRANIAL ARTERIAL LOOP WITH A COMPLEX PARTIALLY THROMBOSED LARGE ANEURYSM ON THE POSTERIOR CIRCULATION: WHAT TO DO NEXT?

Introduction Managing intracranial aneurysms in the posterior circulation is particularly challenging due to anatomical complexities and the high risk of rupture. The presence of a large, partially thrombosed aneurysm adds another layer of difficulty. This report details the case of a 66-year-old female patient presenting with a symptomatic intracranial arterial loop and a large, partially thrombosed aneurysm in the posterior circulation, successfully treated through microsurgical clipping. Material and Methods A 66-year-old female with a history of intermittent headaches, vertigo, and diplopia underwent neuroimaging, including computed tomography angiography (CTA) and magnetic resonance imaging (MRI). Imaging revealed a large aneurysm in the posterior circulation, with partial thrombosis and an associated intracranial arterial loop. The patient was scheduled for a craniotomy to perform microsurgical clipping of the aneurysm. Two titanium aneurysm clips were applied to achieve complete occlusion. Results Intraoperative findings confirmed the large, partially thrombosed aneurysm arising from the basilar artery, with a complex arterial loop intricately intertwined with the aneurysm and adjacent neurovascular structures. The first clip was placed to secure the primary inflow, and the second clip provided additional reinforcement. Postoperative imaging demonstrated successful clipping with no residual aneurysm filling. The patient had an uneventful recovery with no immediate postoperative complications. Clinically, the patient reported significant improvement in symptoms, with a complete resolution of headaches and vertigo. Conclusions This case highlights the challenges and considerations in managing large, partially thrombosed aneurysms in the posterior circulation, particularly in the presence of an intracranial arterial loop. Successful management requires precise microsurgical technique and careful intraoperative decision-making. Further research is needed to optimize treatment strategies, potentially incorporating adjunctive endovascular techniques to enhance surgical outcomes.

Nanomaterials: breaking the bottleneck of breast cancer drug resistance

Drug resistance poses a significant challenge in the treatment of breast cancer. In recent years, a variety of nanomaterials have been discovered and synthesized that can selectively target tumor cells and play a crucial role in the advancement of breast cancer therapies. As our understanding of tumor heterogeneity deepens, the emerging potential of nanomaterials in addressing drug resistance has garnered considerable attention. These materials not only selectively target tumor cells but also possess unique properties that make them promising options for cancer treatment, including low toxicity, excellent biocompatibility, ease of preparation, the ability to carry antitumor drugs, and customizable surface functions. In this review, we will comprehensively summarize two key developments in breast cancer treatment: the application of antitumor drugs and nanomaterials. We will explore the mechanisms by which nanomaterials improve drug resistance in breast cancer, targeted nanotherapy strategies to mitigate this resistance, and recent research advancements in anticancer nanomaterials. This overview aims to highlight the significant role of nanomaterials in breast cancer treatment and provide a theoretical framework for identifying optimal treatment strategies in the future.

Identifying immunohistochemical biomarkers panel for non-small cell lung cancer in optimizing treatment and forecasting efficacy.

Chemotherapy and immunotherapy for non-small-cell lung cancer (NSCLC) are gaining momentum. However, its long-term efficacy remains limited to only a small fraction of patients. Hence, it is crucial to identify reliable immunohistochemical biomarkers to facilitate the formulation of optimal treatment strategies and to predict therapeutic outcomes. We retrospectively analyzed a cohort of 140 patients diagnosed with NSCLC who received chemotherapy or immunotherapy. Using bioinformatics analysis and machine learning techniques, we assessed the role of immunohistochemical biomarkers and clinical characteristics in developing a predictive model for treatment options and outcomes in this population. Our research has found that immunohistochemical biomarkers can accurately predict treatment regimens and progression-free survival in NSCLC patients with an accuracy rate of 82.1%. We identified an exclusive detection panel for the six vital biomarkers. Of particular note is the role of programmed cell death protein 1 ligand 1 (PD-L1) expression in guiding treatment selection, with high expression predicting better outcomes in the immunotherapy group at a cut-off value of 50%. Non-squamous patients who tested positive for thyroid transcription factor 1 had a longer median progression-free survival, while squamous patients who tested positive for p63 protein or cytokeratin 5/6 expression had a longer median progression-free survival. The results of our study are highly encouraging, as they revealed a significant correlation between immunohistochemical biomarkers, therapeutic regimens, and prognosis. These findings indicate that our immunohistochemical detection panel has great potential for facilitating customization of therapeutic regimens to improve patient care. The insights gained from this study could help clinicians optimize treatment protocols and ultimately enhance clinical outcomes.

Machine learning-based models for prediction of survival in medulloblastoma: a systematic review and meta-analysis.

Medulloblastoma (MB) is the pediatric population's most frequent malignant intracranial lesions. Prognostication plays a crucial role in optimizing treatment strategy in the MB setting. Several studies have developed ML-based models to predict survival outcomes in individuals with MB. In this systematic review and meta-analysis study, we aimed to evaluate the role of ML-based models in predicting survival in MB patients. Literature records were retrieved on May 14th, 2024, using the relevant key terms without filters in PubMed, Embase, Scopus, and Web of Science. Records were screened according to the eligibility criteria, and the data from the included studies were extracted. The quality assessment was performed using the QUADAS-2 tool. The meta-analysis and sensitivity analysis were conducted using R software. Six studies were included, with 2771 patients ranging from 46 to 1759 individuals. A total of 23 ML and DL models were developed, 20 of which were ML and three DL. Random forest (RF) was the most frequent classifier, as it was utilized in nine models, followed by support vector machine (SVM). Eight models were included in the meta-analysis. Our meta-analysis revealed a pooled AUC of 0.77 (95% CI: 0.75-0.80). In addition, the radionics-based and genomics-based models had a pooled AUC of 0.77 (95% CI: 0.76-079) and 0.76 (0.63-0.88), respectively (P = 0.77). Our results suggested that ML-based models, especially ML algorithms, could play a vital and efficient role in the prediction of survival of patients based on radiomics and genomics.

Abstract 4137113: The Effectiveness of Cardiac Resynchronization Therapy in Patients with Cardiac Sarcoidosis: A Retrospective Analysis

Background: Cardiac sarcoidosis (CS) manifests in a wide range of clinical presentations, including conduction system abnormalities, ventricular arrhythmias, and systolic heart failure. Although cardiac resynchronization therapy (CRT) has shown efficacy in treating select nonischemic cardiomyopathy patients, its specific impact on CS patients remains less explored. This study aimed to evaluate the outcomes of CRT therapy in CS patients, focusing on implantable cardioverter defibrillator (ICD) therapies, heart failure (HF) hospitalizations and mortality. Methods: We retrospectively reviewed all patients with a clinical or histological diagnosis of CS who underwent device implantation (ICD or Permanent Pacemaker (PPM)) with or without CRT therapy at Johns Hopkins Hospital between 2004 and 2024. Baseline characteristics and echocardiographic parameters were assessed. Heart failure hospitalizations, the frequency of ATP (Anti-Tachycardia Pacing) or ICD shocks, and all-cause mortality were also evaluated as the outcomes. Results: The study included 212 patients (40.1% female, average age 52.8 ± 11.1 years). Eighty-five patients underwent CRT implantation (82 CRT-D and 3 CRT-P), whereas the rest received either an ICD or a PPM without CRT therapy. Most CRT devices (58.82%) were upgrades from an initial PPM or ICD. Over a follow-up of 6.15 ± 4.43 years, 27 (12.74%) patients were hospitalized for heart failure (HF), 86 (40.56%) experienced ATP or ICD shocks, and 17 (8.02%) died. The composite outcome was observed in 103 patients (48.5%), with no significant differences between CRT and non-CRT groups ( P = .51). Survival analysis indicated significantly reduced freedom from HF hospitalizations in the CRT group compared to non-CRT group ( P = .01). However, ATP/ICD shocks did not have a significant difference. CRT recipients showed an improvement in left ventricular ejection fraction (LVEF) from 35.3 ± 12.6% to 38.9 ± 13.6% at 6 months ( P = .01). Non-recipients showed no significant change in LVEF ( P = .43). Conclusions: Over an average six-year follow-up period, CRT upgrade does not appear to affect ATP/ICD shock and mortality in CS patients, although it is associated with significantly higher rates of heart failure (HF) hospitalizations compared to CS patients with an ICD or PPM alone. These findings underscore the complex response of CS patients to CRT, highlighting the need for further research to optimize treatment strategies within this subgroup.

Abstract 4127664: Influences of Age on Improvement of Health-Related Quality of Life in Patients with Atrial Fibrillation following Initial Treatment

Background: The prevalence of Atrial Fibrillation (AF), the most cardiac common arrhythmia, increases with age. Various treatment strategies are available to improve health-related quality of life (HRQoL) in patients with AF; however, the impact of age on HRQoL treatment benefits is unknown. Aims: To investigate the association of age with HRQoL benefit across different treatment strategies. Methods: Using data from a multicenter registry for outpatients with early recognized AF, HRQoL at enrollment and 1 year later was measured with the Atrial Fibrillation Effect on Quality-of-life quesTionnaire (AFEQT). The association between age and the 1-year changes in AFEQT-overall summary (OS) and subdomain scores with either rate or rhythm control strategies were assessed using generalized additive models (GAM) to address non-linear relationships. To support clinical interpretation, multivariable linear regression models were performed with categories of age ranges. Results: Among 2786 patients (31.7% women, 54.7% rhythm control); 946 were <65 of age, 1019 were ≥65–75, and 821 were ≥75 years old. Rhythm (vs. rate) control was pursued in 76.6%, 58.0%, and 33.6% and mean AFEQT-OS changes were 11.1 (SD 16.6), 8.0 (17.0), and 4.7 (18.2) in those aged <65, 65–74, and ≥75, respectively. The GAM showed improvements in AFEQT-OS attenuated with advancing age with both treatment strategies ( Figure ). Linear regression analyses showed lesser improvements in AFEQT-OS as higher age categories (≥65–75 vs. <65, β -1.12 [95% CI, -2.33 – 0.09]; ≥75 vs. <65, β -3.86 [-5.29 – -2.42]), which were mainly driven by lesser improvement in AFEQT-daily activities scores, without differences in AFEQT scores for symptom or treatment concerns ( Table ). Conclusions: In AF patients, HRQoL benefits after treatment were attenuated by advancing age, primarily driven by less improvement in functional limitations, underscoring the need for further research to identify optimal treatment strategies for older adults.

The Evolving Role of Neoadjuvant Radiation Therapy in Pancreatic Adenocarcinoma

Background/Objectives: Pancreatic ductal adenocarcinoma (PDAC) is one of the deadliest cancers. Surgical resection is the most reliable chance for cure, but high rates of positive margins and local failure persist. Neoadjuvant therapies (NAT), including chemotherapy and radiation therapy (RT), are being explored to improve surgical outcomes, particularly in borderline resectable (BRPC) and locally advanced pancreatic cancer (LAPC). This review aims to summarize the current landscape and future directions for neoadjuvant RT (NART) in PDAC. Methods: The review includes a detailed analysis of past and ongoing clinical trials investigating various NART approaches in PDAC, with an emphasis on different RT techniques, fractionation schemes, and their integration into multimodal treatment strategies. Results: Early evidence suggests that NART can improve resection margins and local control. However, recent trials, including the Alliance A021501 and LAP-07 trials, have failed to demonstrate significant survival benefits with the addition of RT to NAT. Nevertheless, nuances in trial design and execution continue to keep the question of NART open. Newer approaches, such as stereotactic magnetic resonance-guided adaptive radiation therapy (SMART), show promise in improving local control and survival, but further phase 3 trials are needed. Conclusions: While NART has shown potential in improving local control in PDAC, its impact on overall survival remains unclear. Ongoing trials, particularly those utilizing advanced techniques like SMART, are critical in defining the role of RT in the neoadjuvant setting for PDAC. Collaboration across multidisciplinary teams is essential to optimize treatment strategies and trial outcomes.

Systemic therapy for non-clear cell renal cell carcinomas: A systematic review.

Renal cell carcinoma (RCC) is the most common kidney cancer, with clear cell RCC being the predominant subtype. However, non-clear cell RCC constitutes a significant proportion of cases, presenting distinct challenges in treatment due to its varied histological subtypes. Despite recent advancements, the optimal therapeutic approach for non-clear cell RCC remains uncertain due to limited high-quality evidence. This systematic review aims to evaluate the efficacy of systemic therapies in nccRCC subgroups. A comprehensive literature search identified studies from 2010 to 2024, using PubMed and Clinicaltrials.gov databases focusing on clinical trials and treatment outcomes. Results highlight the evolving therapeutic landscape, with targeted agents and immunotherapy demonstrating promising anti-tumor effects. Notably, tyrosine kinase inhibitors (TKIs) such as sunitinib and mTOR inhibitors like temsirolimus have shown efficacy across different subtypes. Combination therapies, including immunotherapy-based regimens, have also shown favorable outcomes. immune checkpoint inhibitors such as nivolumab and pembrolizumab demonstrated encouraging antitumor activity. Furthermore, specific targeting of signaling pathways, such as the c-MET pathway, has demonstrated efficacy in certain PapillaryRCC. While combination therapies, including immunotherapies, have shown positive outcomes, immune checkpoint inhibitors like nivolumab and pembrolizumab have demonstrated encouraging antitumor activity. Additionally, targeting the c-MET pathway has proven effective in certain papillary RCC. Further research is warranted to establish optimal treatment strategies and improve outcomes for patients with non-clear cell RCC. Systemic therapy for non-clear cell RCC is complex and evolving. Further research is needed to delineate optimal treatment strategies for different histological subtypes and improve patient outcomes.

SURG-41. OPTIMIZING PATIENT OUTCOMES IN PETROCLIVAL MENINGIOMA TREATMENT: EVALUATING SURGICAL, RADIOSURGICAL, RADIOTHERAPY AND COMBINED TREATMENT APPROACHES

Abstract Petroclival meningiomas pose a formidable challenge due to their proximity to critical neurovascular structures, necessitating complex surgical interventions with a high risk of complications. Stereotactic radiosurgery (SRS) offers an alternative or complementary treatment option, yet the optimal treatment strategy remains undefined. We aimed to evaluate the local control rates following surgical resection, radiotherapy, and SRS for petroclival meningiomas and to assess the incidence of cranial nerve palsies associated with each treatment modality. This retrospective study reviewed medical records of patients treated for petroclival meningiomas at Stanford University between 1980-April 2024. Pre- and post-treatment radiological data were analyzed to assess local control. Cranial nerve function was evaluated pre- and post-treatment, and at last follow-up. A total of 171 patients (129 females; median age 54.65 years) diagnosed with petroclival meningioma were identified. Treatment modalities included: 31 patients underwent surgical resection alone, 27 received SRS alone, 11 received radiotherapy alone, 36 underwent combined surgical resection and SRS, 28 received combined surgical resection and radiotherapy, 9 were treated with a triad of surgical resection, SRS, and radiotherapy, and 29 were managed with serial imaging alone. The percentage change of tumor volume from diagnosis to follow-up for these groups was -55.6%, 28.9%, 73.0%, -64.9%, -12.0%, 35.3%, and -8.8%, respectively. The incidence of new cranial nerve palsies was highest (68%) in patients who underwent surgical resection. The percentage of worsening pre-existing palsies was greater in patients receiving single-modality non-surgical treatment. Surgery, radiotherapy, and SRS demonstrated promising local control rates for specific patient cohorts with petroclival meningiomas. Patients receiving combination therapies generally fared better than those receiving single-modality treatments, with surgery followed by SRS yielding the best outcome. The incidence of cranial nerve palsies was lower following SRS and radiotherapy compared to surgery. Future research should focus on refining multi-modal treatment strategies to minimize complications and improve patient quality of life.

INNV-19. MULTIMODAL THERAPY FOR BRAF V600E MUTANT MELANOMA BRAIN METASTASES: CHARACTERIZATION OF CHRONOLOGICAL TREATMENT STRATEGIES AND ASSOCIATIONS WITH OVERALL SURVIVAL

Abstract BACKGROUND B-raf proto-oncogene (BRAF)-mutant melanoma brain metastases (BRAF MBM) are associated with poor prognosis. Amidst our large institutional experience treating patients with BRAF MBM with multimodality therapy, our aim was to identify disease and treatment-related prognostic features, accounting for longitudinal sequence of events, to inform clinical decision-making. METHODS We retrospectively reviewed electronic health records of 100 patients with primary cutaneous melanoma diagnosed with BRAF MBM. Demographic, disease, and clinical factors including treatment sequencing were tabulated. Descriptive statistics were used to summarize the study population and non-parametric tests were used to evaluate differences across groups. A multivariable Cox regression identified factors associated with overall survival (OS) following BRAF MBM diagnosis. RESULTS Median follow-up was 22 months and median OS was 33.5 months. Patients received an average [standard deviation (SD)] of 3.36 [1.06] unique therapies. After adjustment for covariates, greater number of brain metastases at initial diagnosis (hazard ratio (HR) 2.3 [1.14-4.62], p=0.01 for 3-10 metastases and HR 2.54 [1.01-6.36], p=0.04 for >10 metastases, respectively), receipt of combination IO and targeted therapy prior to BRAF MBM diagnosis (HR 2.91 [1.08-7.86], p=0.03), and receipt of no unique subsequent therapy after initial management strategy (HR 3.89 [1.48-10.16], p=0.005) were significantly associated with worse OS. CONCLUSIONS Despite heterogeneity in individual treatment sequences, patients with greater intracranial disease burden and those receiving combination targeted and immunotherapy prior to BRAF MBM diagnoses had the worst outcomes. Dynamic changes in therapy resistance may inform optimal treatment strategies for individuals with BRAF MBM.

CNSC-62. DIFFERENTIAL SURVIVAL IMPACT OF TRASTUZUMAB DERUXTECAN IN HER2-POSITIVE VERSUS HER2-LOW BREAST CANCER PATIENTS WITH BRAIN METASTASES

Abstract BACKGROUND Brain metastases (BM) in breast cancer (BC) present significant treatment challenges, with varying outcomes based on HER2 expression. There is limited real-world evidence of outcomes with the use of trastuzumab deruxtecan (T-DXd) on survival in patients (pts) with HER2-low and HER2-positive (HER2+) MBC with BM. METHODS We conducted a retrospective cohort study using data from seven US-based health systems within the Guardian Research Network (GRN). We included pts treated with T-DXd from December 2019 to December 2023, classified as HER2-low (IHC 1+ or IHC 2+/HER2 FISH non-amplified) or HER2+ (IHC 3+ or HER2+ with FISH amplified). Survival analysis was performed using Kaplan-Meier curves and the log-rank test. RESULTS 125 pts with BCBM treated with T-DXd were included in the final analysis, of which 70 (56%) were HER2+ and 55 (44%) were HER2-low. The median age at BM diagnosis was 60.5 years (range 21.6 to 87.1 years). HER2 low pts had a higher prevalence of ER+ disease than HER2+ pts (81.9% vs. 55.7%, p=0.01). Most of these pts (≥75%) had received multiple prior lines of therapy. HER2+ pts with BM had a median overall survival (mOS) of 9.3 months (95% CI: 6.79-11.88), significantly longer than 4.3 months (95% CI: 1.89-6.82) in HER2-low pts (p < 0.001). At 6 months, OS for HER2+ pts with BM was 40% compared to 25% in HER2-low pts. At 12 months, OS for HER2+ pts was 20% compared to 10% in HER2-low pts. CONCLUSIONS This study represents the largest real-world evidence to date on the effectiveness of T-DXd in treating BM from breast cancer. HER2+ BCBM exhibited longer mOS and 12-month survival rates than pts with HER2-low disease, suggesting HER2 expression is crucial in determining T-DXd’s effectiveness. Future research should explore combination therapies and identify predictive biomarkers to optimize treatment strategies through clinical trials.

NCOG-41. COMPARATIVE ANALYSIS OF MORTALITY AND SHORT-TERM SIDE EFFECTS IN PATIENTS WITH GLIOBLASTOMA MULTIFORME TREATED WITH TEMOZOLOMIDE VERSUS TEMOZOLOMIDE PLUS BEVACIZUMAB CHEMOTHERAPY

Abstract INTRODUCTION Glioblastoma multiforme (GBM) is a highly aggressive primary brain tumor in adults with limited treatment options and poor prognosis. Temozolomide (TMZ) chemotherapy is the standard treatment for GBM, but alternative therapies have shown limited success. Bevacizumab (BEV), a monoclonal antibody targeting vascular endothelial growth factor (VEGF), is used to restrict GBM growth and spread. This study evaluates the efficacy of combining TMZ with BEV compared to TMZ alone in managing GBM. METHODS A retrospective cohort study was conducted using TriNetX database data, focusing on patients diagnosed with GBM and receiving chemotherapy. Cohorts were defined by treatment: TMZ plus BEV versus TMZ alone. Propensity-score matching balanced baseline characteristics, including demographics and health conditions. Primary outcomes included mortality rates and short-term side effects within the first year of treatment, such as cognitive communication deficits, headache, dizziness, insomnia, and nausea/vomiting. RESULTS After matching, 922 patients were included in each cohort. There were no significant demographic differences post-matching. The mortality rate was higher in the TMZ plus BEV group compared to TMZ alone (51.30% vs. 36.98%, RR: 1.387, 95% CI: 1.249-1.541). However, TMZ plus BEV was associated with a lower incidence of cognitive communication deficits (1.95% vs. 4.34%, RR: 0.45, 95% CI: 0.26-0.779) and dizziness (7.27% vs. 10.52%, RR: 0.691, 95% CI: 0.513-0.93). No significant differences were found in headache, insomnia, or nausea/vomiting rates between the groups. CONCLUSION This study indicates that combining bevacizumab with temozolomide may increase mortality in GBM patients but reduce certain side effects such as cognitive deficits and dizziness. These findings emphasize the need to carefully consider the benefits and risks of different chemotherapy regimens for GBM and highlight the necessity for further research to optimize treatment strategies and improve patient outcomes.

INNV-02. BRAINMETS: A CLINICIAN-FRIENDLY SOFTWARE TO MANUALLY SEGMENT BRAIN METASTASES AND DETECT PRIMARY TUMOR ORIGIN USING DEEP LEARNING

Abstract Estimates suggest that around 20%-40% of cancer patients are affected by brain metastases. A subset of these patients first present with central nervous system manifestations with an unknown primary. The issue then arises regarding which region of the body should be imaged, if not the entire body, exposing the patient to more radiation. To address this issue, streamline workflows, and save precious time, we developed a software clinicians can use to identify primary tumor locus. “BrainMets” is a user-friendly software that handles a DICOM input, allows the user to segment the region(s) of interest manually, and uses a deep learning model to predict the most likely tumor origin. The model is a mixed-effects neural network pre-trained on radiomic features from open-source data by Ocaña-Tienda et al. (2023) using 637 high-resolution imaging studies from 10 different medical centers with an accuracy of 90.5%, precision of 92.7%, recall of 87.8%, and F1 score of 90.2%. The software leverages the open-source software 3D-Slicer to help segment regions of interest, extract radiomic features, and make predictions. It is built using Flask, a Python package for backend development. The frontend user interface is created using HTML/CSS and Bootstrap. The “BrainMets” software thus strives to enhance diagnostic workflow significantly, reduce appointment times for scans, and improve patient experience. Future enhancements include integrating more AI models, improving healthcare IT system compatibility, and updating datasets to boost predictive accuracy and generalizability. This tool sets a new standard in personalized medicine, optimizing treatment strategies for cancer patients with brain metastases. As adoption increases, it could substantially improve patient outcomes and reduce healthcare costs associated with misdiagnosis and overtreatment. Further research and development will focus on expanding its applicability across various types of cancers.

Optimizing Treatment Strategies for Distal Radius Fractures in Osteoporosis: A Comparative Review

Osteoporosis is a common yet underdiagnosed condition that increases the risk of fractures, contributing to substantial morbidity, mortality, and healthcare costs. Distal radius fractures (DRFs) are some of the most common fractures associated with osteoporosis and often precede more severe fractures. Managing DRFs in patients with osteoporosis can be a challenge due to altered bone quality, which can affect healing and surgical fixation. This review examines both operative and nonoperative management strategies for DRFs in osteoporotic patients, emphasizing the importance of individualized treatment. Surgical interventions, like open reduction and internal fixation (ORIF) with plating, can facilitate early mobilization and improved alignment, especially in more active patients. However, osteoporosis poses risks such as hardware failure, infection, and malunion, calling for careful patient selection. Conversely, nonoperative management may be more suitable for patients with lower functional demands or higher surgical risks, despite the increased risk of malunion. By adapting treatment strategies to individual patient characteristics, orthopedic surgeons can optimize outcomes, minimize complications, and potentially prevent future fractures. Both operative and nonoperative treatments can yield positive outcomes when personalized to the patient’s needs.

Perioperative Management of Takayasu Arteritis for Cardiac Surgery - Review and Single-Center Experience.

Takayasu arteritis (TAK) is classified as a large vessel vasculitis and often causes vascular stenosis, occlusion, and aneurysm formation. Although the principal treatment for TAK involves suppressing inflammation with glucocorticoids, the emergence of biological disease-modifying antirheumatic drugs has considerably changed the treatment landscape of TAK in recent years. Several biological disease-modifying antirheumatic drugs, such as tocilizumab (TCZ), have shown promising effects on TAK in clinical studies. Cardiologists and cardiovascular surgeons encounter patients receiving these drugs who require catheterization, endovascular treatment, or cardiovascular surgery. However, in patients treated with glucocorticoids and TCZ, there needs to be greater awareness of more complications than usual after surgery, such as delayed wound healing, systemic infection, and surgical site infection. In addition, in patients receiving TCZ, inflammatory markers, such as C-reactive protein, may not increase when complications arise from infection. Unfortunately, there are no guidelines or solid evidence that have clearly defined the optimal perioperative treatment strategy for patients with TAK who require cardiovascular surgery. This article reviews the evidence and our recent experience supporting the perioperative use of TCZ, and proposes a protocol that can reduce complications in patients with TAK undergoing invasive cardiovascular treatment.

Benefits and Harms of Coronary Revascularization in Non-Dialysis-Dependent Chronic Kidney Disease and Ischemic Heart Disease: A Systematic Review and Meta-Analysis.

Key Points In people with non–dialysis-dependent CKD, revascularization may lower all-cause mortality and risk of cardiovascular events.Adverse kidney events, which are often cited as a reason to avoid revascularization, were uncommon.Additional research on the effect of revascularization on patient-reported outcomes in people with non–dialysis-dependent CKD is needed. Background Cardiovascular disease is the leading cause of death in people with CKD. Coronary revascularization can improve cardiac function and prognosis in people with ischemic heart disease; however, in people with CKD, there is concern that potential harms could outweigh benefits of revascularization. Evidence on the balance of these risks and benefits, specifically in people with non–dialysis-dependent CKD, is lacking. Methods We conducted a systematic review of randomized controlled trials to assess the risks and benefits of revascularization, compared with medical management, among adults or children with ischemic heart disease and CKD not requiring KRT (dialysis or transplantation). We searched PubMed, Embase, and the Cochrane Central Register of Controlled Trials through December 12, 2023. Two people independently screened titles and abstracts followed by full-text review, serially extracted data using standardized forms, independently assessed risk of bias, and graded the certainty of evidence (COE). Results Evaluating data from nine randomized controlled trials, we found that people with CKD and ischemic heart disease treated with revascularization may experience lower all-cause mortality compared with people receiving medical management (risk ratio [RR], 0.80; 95% confidence interval [CI], 0.64 to 0.98; COE, low). Revascularization may reduce incidence of myocardial infarction (RR, 0.81; 95% CI, 0.64 to 1.04; COE, low) and heart failure (RR, 0.80; 95% CI, 0.52 to 1.23; COE, low). The effect on cardiovascular mortality is uncertain (hazard ratio, 0.67; 95% CI, 0.37 to 1.20; COE, very low). Evidence was insufficient for patient-reported outcomes and adverse kidney events. Data were limited by heterogeneity of patient populations and the limited number of trials. Conclusions In people with non–dialysis-dependent CKD, revascularization may be associated with lower all-cause mortality compared with medical management and may also lower the risk of cardiovascular events. Additional data surrounding kidney and patient-reported outcomes are needed to comprehensively engage in shared decision making and determine optimal treatment strategies for people with CKD and ischemic heart disease. Clinical Trial registry name and registration number: CRD42022349820 (PROSPERO).

Impact of the COVID-19 Pandemic on Microbial Profiles and Clinical Outcomes in Orbital and Preseptal Cellulitis

Orbital cellulitis and severe preseptal cellulitis are critical periocular infections with potential vision- and life-threatening implications. The COVID-19 pandemic is hypothesized to have had an influence on their presentation and pathogenesis; however, the real impact remains unclear. In this retrospective multicenter cohort study from January 2017 to December 2022, we analyzed 1285 cases with preseptal or orbital cellulitis in pre-pandemic (2017–2019) and pandemic (2020–2022) cohorts. A notable decrease in hospitalized cases during the pandemic period was observed (97 patients in the pre-pandemic group vs. 54 in the pandemic group, p = 0.004), particularly among individuals aged 30–39 (p = 0.028). Sinusitis remained the leading cause, but odontogenic cases increased (p = 0.025). In addition, microbial diversity decreased during the pandemic, with the effective number of species decreasing from 17.07 to 8.87, accompanied by a rise in antibiotic resistance, notably against erythromycin, oxacillin, penicillin, and metronidazole. While visual outcomes appeared worse in the pandemic group, statistical significance was not reached. These findings suggest that the characteristics, etiology, microbial profiles, resistance patterns, and visual outcomes of orbital and preseptal cellulitis have undergone alterations post-COVID-19 pandemic. Vigilance in clinical management and public health measures is crucial, with further research needed to optimize treatment strategies.

Prognosis and ablation success in thyroid cancer: overcoming the challenges of incomplete clinical profiles.

Differentiated thyroid carcinoma (DTC) is managed by surgery followed by radioiodine (RAI) therapy in most intermediate and high-risk patients. Most nonmetastatic patients have excellent treatment responses and have long-term disease-free status. A lack of comprehensive medical services in resource-limited nation leads to attrition of critical clinical prognostication information. This study aimed to identify readily available clinical, biochemical, and histopathological parameters to predict remnant ablation success and long-term outcomes. The study included DTC patients who underwent RAI after surgery. Ablation success was determined by thyroglobulin (Tg) and whole-body radioiodine scan. Patients were followed for at least 5 years to assess biochemical incomplete response (BIR) and structural recurrence. The study included 383 patients (a mean age of 37.8 ± 12.9 years). Successful ablation was noted in 251 (65.5%). High preablative stimulated serum Tg (presTg), papillary variants, and central and lateral compartment lymph nodal metastases were associated with ablation failure. PresTg (P < 0.001) was the most significant predictor. After a 102.9 ± 34.5 months follow-up, 280 (73.1%) patients were disease-free. BIR and structural recurrence were noted in 103 and 32 patients. PresTg (8.1 ± 27.7 vs. 92.3 ± 99.9 ng/ml), ATg (112.9 ± 389.8 vs. 43.2 ± 89.8 IU/ml), papillary variant, central [109 (66.1%) vs. 56 (33.9%)], and lateral compartment [65 (63.7%) vs. 37 (36.3%) lymph nodal metastases were associated (P < 0.05) with BIR. PresTg >10.5 has a sensitivity and specificity of 86.6 and 86.0% for predicting BIR. Patients with successful remnant ablation and a presTg level <10.5 ng/ml had a low risk of long-term disease recurrence (less than 5%). This ambispective study found that successful ablation and long-term disease-free survival were achievable in a significant proportion of DTC patients. BIR (26.9%) and structural recurrence (8.4%) were not uncommon. PresTg levels emerged as a crucial predictor of ablation success and subsequent outcomes. In resource-limited regions, presTg levels and ablation failure can aid in optimizing treatment strategies and improving patient care.