Similar Cohort Of Patients Research Articles

The impact of COVID-19 on the management and outcomes of patients with proximal femoral fractures: a multi-centre study of 580 patients

BackgroundOn the 11th March 2020, the World Health Organization declared the COVID-19 outbreak a pandemic. Multiple new guidelines were proposed and existing models of social, domestic and hospital care altered. Most healthcare systems were largely unprepared for this, and the pandemic has tested their adaptability. This study aimed to assess the impact of COVID-19 on the demographics, presentation, clinical management and outcomes of patients with proximal femoral (hip) fractures comparing them to a similar cohort of patients admitted a year earlier.MethodsThis retrospective multi-centre cohort study compared all patients admitted with hip fractures between 1st March and 30th May 2019 (group PC: pre-COVID-19) with hip fracture patients admitted over the same time period during the pandemic in 2020 (group C: COVID-19). The data was obtained from the hospitals’ local and National Hip Fracture Databases. Mortality data was checked with the Office for National Statistics (ONS). Primary outcomes were time to theatre, in-patient length of stay and 30-day mortality.ResultsA total of 580 patients were included (304 group PC, 276 group C). Patient demographics including Charlson Comorbidity Index and Nottingham Hip Fracture Scores were broadly similar across the two cohorts. There was a significant reduction in the percentage of total hip replacements (11 to 5%, p = 0.006) in group C. There was an increase in conservative management (1 to 5%, p = 0.002) in group C. Time to theatre was significantly delayed in group C (43.7 h) vs group PC (34.6 h) (p ≤ 0.001). The overall length of hospital stay was significantly longer in group PC (16.6 days) vs group C (15 days) (p = 0.025). The 30-day mortality rate in group C was 9.8% compared to 8.2% in group PC (p = 0.746), but for COVID-19 (+) patients, it was significantly higher at 38.2% vs 5.8% in COVID-19 (−) patients (p < 0.001).ConclusionThis is one of the largest multi-centre comparative cohort study in the literature to date examining the impact of the COVID-19 pandemic on the management of hip fracture patients. Whilst mortality rates were similar in both groups, COVID-19-positive patients were almost seven times more likely to die, reflecting the seriousness of the COVID-19 infection and its sequelae in such elderly, vulnerable patients.

Incremental costs of fragility fractures: a population-based matched -cohort study from Ontario, Canada

SummaryUsing a matched cohort design, the 1-year excess cost of incident fragility fractures at any site was $26,341 per patient, with 43% of total excess costs attributed to hospitalization. The high economic burden of fractures in Ontario underscores the urgency of closing the secondary fracture prevention gap.IntroductionThis retrospective real-world observational study was conducted to document the incremental costs associated with fragility fractures in Ontario, Canada.MethodsPatients aged >65 years with an index fragility fracture occurring between January 2011 and March 2015 were identified from administrative databases and matched 1:1 to a cohort of similar patients without a fracture. Healthcare resource utilization data were extracted from healthcare records and associated costs were calculated on a per-patient level and for the province of Ontario. Costs were presented as 2017 Canadian dollars.ResultsThe eligible cohort included 115,776 patients with a fragility fracture. Of these, 101,773 patients were successfully matched 1:1 to a non-fracture cohort. Overall, hip fractures (n = 31,613) were the most common, whereas femur fractures (n = 3002) were the least common type. Hospitalization and continuing care/home care/long-term care accounted for more than 60% of 1-year direct costs, whereas 5% was attributed to medication costs. First-year costs per patient in the fracture cohort were approximately threefold higher versus the non-fracture cohort (mean $37,362 versus $11,020, respectively). The incremental first-year direct healthcare costs of fragility fractures for the province of Ontario were calculated at $724 million per year.ConclusionsFragility fractures were associated with a threefold increase in overall mean healthcare costs per patient compared to patients without fractures. With an aging population, there is an urgent need for improved prevention strategies for patients at high-risk of fracture to decrease the economic burden of fragility fractures on the Canadian healthcare system.

Characteristics and Outcomes Among Hospitalized COVID-19-Positive Patients in a Nonurban Environment.

ABSTRACTIntroductionVirtually all hospitalized coronavirus disease-2019 (COVID-19) outcome data come from urban environments. The extent to which these findings are generalizable to other settings is unknown. Coronavirus disease-2019 data from large, urban settings may be particularly difficult to apply in military medicine, where practice environments are often semi-urban, rural, or austere. The purpose of this study is compare presenting characteristics and outcomes of U.S. patients with COVID-19 in a nonurban setting to similar patients in an urban setting.Materials and MethodsThis is a retrospective case series of adults with laboratory-confirmed COVID-19 infection who were admitted to Hershey Medical Center (HMC), a 548-bed tertiary academic medical center in central Pennsylvania serving semi-urban and rural populations, from March 23, 2020, to April 20, 2020 (the first month of COVID-19 admissions at HMC). Patients and outcomes of this cohort were compared to published data on a cohort of similar patients from the New York City (NYC) area.ResultsThe cohorts had similar age, gender, comorbidities, need for intensive care or mechanical ventilation, and most vital sign and laboratory studies. The NYC’s cohort had shorter hospital stays (4.1 versus 7.2 days, P < .001) but more African American patients (23% versus 12%, P = .02) and higher prevalence of abnormal alanine (>60U/L; 39.0% versus 5.9%, P < .001) and aspartate (>40U/L; 58.4% versus 42.4%, P = .012) aminotransferase, oxygen saturation <90% (20.4% versus 7.2%, P = .004), and mortality (21% versus 1.4%, P < .001).ConclusionsHospitalists in nonurban environments would be prudent to use caution when considering the generalizability of results from dissimilar regions. Further investigation is needed to explore the possibility of reproducible causative systemic elements that may help improve COVID-19-related outcomes. Broader reports of these relationships across many settings will offer military medical planners greater ability to consider outcomes most relevant to their unique settings when considering COVID-19 planning.

Personalized treatment options for chronic diseases using precision cohort analytics

To support point-of-care decision making by presenting outcomes of past treatment choices for cohorts of similar patients based on observational data from electronic health records (EHRs), a machine-learning precision cohort treatment option (PCTO) workflow consisting of (1) data extraction, (2) similarity model training, (3) precision cohort identification, and (4) treatment options analysis was developed. The similarity model is used to dynamically create a cohort of similar patients, to inform clinical decisions about an individual patient. The workflow was implemented using EHR data from a large health care provider for three different highly prevalent chronic diseases: hypertension (HTN), type 2 diabetes mellitus (T2DM), and hyperlipidemia (HL). A retrospective analysis demonstrated that treatment options with better outcomes were available for a majority of cases (75%, 74%, 85% for HTN, T2DM, HL, respectively). The models for HTN and T2DM were deployed in a pilot study with primary care physicians using it during clinic visits. A novel data-analytic workflow was developed to create patient-similarity models that dynamically generate personalized treatment insights at the point-of-care. By leveraging both knowledge-driven treatment guidelines and data-driven EHR data, physicians can incorporate real-world evidence in their medical decision-making process when considering treatment options for individual patients.

Commentary: Sight-threatening intraocular infection in patients with COVID-19 in India.

We congratulate Nayak et al. for their excellent article.[1] Besides infective etiology, ocular inflammation and hypercoagulability status may be possible causes leading to loss of vision post COVID-19.[234] Previously, we had reported sight-threatening cases of multifocal retinitis with vascular occlusions[3] and a case of panuveitis with optic neuritis.[4] The authors can illustrate more about COVID-19-related systemic complication in their case series. Our series from a similar cohort of patients (unpublished data, submitted for publication), with final visual outcomes ranging from no perception of light to 20/36, again predominantly males, showed that D-dimer and serum ferritin were disproportionately raised during their ocular manifestations in patients with endophthalmitis/panophthalmitis post COVID-19 and were statistically significant compared to the patients with milder and non-vision-threatening manifestations. Lactate dehydrogenase levels, erythrocyte sedimentation rate, and C-reactive protein were also raised but were not statistically significant. Diabetes and hypertension were also the systemic risk factors in our series. We were not able to isolate the SARS-CoV-2 virus on ocular sampling, but we had polymerase chain reaction positive for eubacteria and panfungal genome. The level (primary, secondary, or tertiary care) and details of COVID-19 care received by individual patients, including duration of hospital admission, intravenous fluid administration, oxygen supplementation, and assisted ventilation details, will provide additional information to study the risk factors that may also have affected the final outcomes. The fact that the patients reported belong to a specific geographic location (South India) could attribute to the COVID-19 treatment protocol in that region, which could contribute to the spike in the cases. A detailed description of the clinical presentation of the pediatric case who had a secondary viral infection (HSV-1 infection) with additional information regarding management with antiviral therapy can give additional insight into this clinical entity. Following vitrectomy, intravitreal antiviral agent injection would have helped faster resolution of retinal lesions secondary to HSV-1 infection. There have been reports of acute retinal necrosis in patients following COVID-19[56] where the authors have hypothesized that SARS-Cov-2 may have decreased the peripheral CD3+ and CD8+ T lymphocytes, consequently inhibiting both the regulatory and protective mechanisms against latent HSV. The authors have mentioned the duration of corticosteroids during COVID-19 as one of the risk factors, which has been similar in our cohort too. Additional information regarding systemic status such as preexisting diabetic status and de novo diabetes during COVID-19 will add additional information, especially because there was a greater percentage of fungal endophthalmitis in the study group. Shroff et al.[7] also reported a series of fungal endophthalmitis in patients who received intensive corticosteroid therapy, with Candida sp. being the most common fungal organism isolated from ocular samples. Additional information of systemic disease status in patients who had extraocular specimens suggestive of infective organisms, such as renal biopsy and paranasal sinus biopsy, may reveal important clues for future diagnosis and management of sight-threatening complications of this dreadful disease.

Patient-reported quality of life with interstitial partial breast brachytherapy and external beam whole breast radiotherapy: a comparison using propensity-score matching.

PurposeThe aim of this study was to compare patient-reported quality of life (QOL) scores after accelerated partial breast irradiation (APBI) using interstitial brachytherapy vs. external beam whole breast radiotherapy (WBRT) for breast cancer.Material and methodsWomen with breast cancer treated with WBRT or APBI after breast conservation surgery were enrolled in this prospective study. Single cross-sectional QOL assessment was performed using EORTC QLQ-C30 and BR-23 questionnaires. Patients treated with APBI were propensity-score matched to similar cohort of patients treated with WBRT. QOL scores were analyzed for the entire unmatched cohort and compared between the two matched cohorts using Student’s two-tailed t-test. P-value of < 0.05 was considered statistically significant, and a 10-point difference between mean scores was considered clinically meaningful.ResultsA total of 64 APBI patients were matched with 99 WBRT patients out of the entire study cohort of 320 cases. QOL scores for functional scales of QLQ-C30 were similar between the two groups for both matched and unmatched cohorts, while symptom scores of QLQ-C30 did not show any clinically significant difference. Functional scales of BR-23 did not show any clinical or statistically significant difference. Among symptom scales of BR-23, scores were similar for APBI and WBRT groups except for a worse score of “upset by hair loss” sub-scale in the brachytherapy group of the matched cohort (51.9 vs. 22.7, p = 0.006).ConclusionsPatients undergoing APBI reported similar QOL compared to WBRT when matched for various factors.

Procedure for optimal implementation of automatic tube potential selection in pediatric CT to reduce radiation dose and improve workflow.

It is important to employ radiation dose reduction techniques in pediatric computed tomography (CT) to reduce potential risks of radiation‐induced malignancy. Automatic tube potential (kV) selection tools have been developed and become available on many CT scanners, which select the optimum kV based on the patient size and clinical task to improve the radiation dose efficiency. However, its use in pediatric CT has been mostly empirical, following manufacturer’s default recommendation without solid demonstration for quality improvement. This study aimed to implement an automatic tube potential tool (CAREkV, Siemens Healthcare) into routine pediatric CT practice, using the “Plan‐Do‐Study‐Act” quality improvement process, in place of an existing kV/mAs technique chart. The design of this quality improvement project involved Plan‐Do‐Study‐Act stages. Plan and Do stages identified the criteria for optimal automatic kV selection; a range of phantoms representing typical pediatric groups were scanned on a dual‐source 128‐slice scanner using a fast‐pitch scanning mode. The identified CAREkV settings were implemented into the CT protocol and evaluated after a 6‐month period. In the Study stage, an objective evaluation of the image metrics and radiation dose for two similar patient cohorts using CAREkV and the technique‐chart, respectively, were compared. The kV selected, image quality and radiation dose determined by CAREkV were comparable to those obtained while using the technique‐chart. The CAREkV was successfully implemented into our pediatric abdominopelvic CT practice. By utilizing the “PDSA” process optimal image quality and radiation dose reduction were achieved with an automatic kV selection tool to improve CT workflow.

Healthcare resource utilization following unilateral versus bilateral radiation therapy for oropharyngeal carcinoma

PurposeTo describe differences in healthcare resource utilization between patients treated with bilateral vs. unilateral neck radiation therapy (RT) for lateralized oropharyngeal cancer. MethodsA propensity score matching strategy was used to identify two otherwise clinically similar cohorts of tonsillar cancer patients treated with either bilateral or unilateral neck RT. Cohorts were matched based on similar propensity scores for age, sex, ECOG performance status, pack-year smoking history, cT-category, cN-category, HPV-status, and use of concurrent chemotherapy. Short term (from start of RT to 3 months following end of RT) resource utilization included: 1) outpatient supportive care visits, 2) hospital admission, and 3) interventions (feeding tube insertion and outpatient intravenous hydration). Long-term resource utilization included feeding tube dependency at 1-year. ResultsAmong 559 patients with tonsillar cancer treated between 2004–2017, propensity score matching identified a unilateral neck RT cohort (n = 81) and bilateral neck RT cohort (n = 81) with similar clinical and treatment characteristics. Bilateral neck RT was associated with a higher likelihood of hospitalization (33% vs 12%, p < 0.01), outpatient IV hydration (33% vs 17%, p = 0.03), and feeding tube insertion (33% vs 10%, p < 0.001); a greater number of total days of hospitalization (110 vs 47 days, p < 0.01) and outpatient IV hydration (135 vs 72 days, p = 0.02); and higher total number of supportive clinic visits (1226 vs 1053 days, p = 0.04). In the long-term, bilateral RT was associated with higher rate of feeding tube dependency at 1-year (7% vs 0%, p < 0.001). ConclusionBilateral RT for tonsillar cancer resulted in significant increase in health resource utilization.

Early results with a bicruciate-retaining total knee arthroplasty: a match-paired study.

The aim of this study is to compare 2 groups of total knee arthroplasties (TKAs): the bicruciate-retaining (BCR-group) and cruciate-retaining total knee arthroplasty (CR-group), evaluating the functional results in the short-term follow-up. 24 BCR were included in the study and were compared with a group of 24 TKAs performed with the same implant, but with sacrifice of the ACL and retention of the posterior cruciate ligament. For preoperative and postoperative clinical evaluation, the visual analogue score (VAS) and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) were used. Radiological evaluation included weight-bearing long-leg view, a Rosemberg view, lateral view of the knee and tangential view of the patella. Hip-knee-ankle angle (HKA) was recorded pre and postoperatively. Radiolucent lines (RLLs) were evaluated according the Knee Society Roentgenographic Evaluation System (KSRES). At last follow-up the mean VAS score was 1.81 for BCR group and 1.43 for CR group (p = 0.61). The mean WOMAC score was 8.68 for BCR group and 12.81 for CR group (p = 0.33). As for the radiological evaluation, preoperative HKA angle was 0.53° varus for BCR group and 3.14° varus for CR group (p = 0.24); postoperative HKA was 0.72° valgus for BCR group and 0.38° valgus for CR group (p = 0.75). The percentage of RLLs was similar between the two groups (12% versus 15%). BCR-TKA has showed to give similar functional and radiographic outcomes compared to conventional CR-TKA in a similar cohort of patients. An higher operative times and higher number of complications respect were found in BCR group. These results can be explained by the early learning curve experiences. Future randomized controlled trials should be performed to support new implant designs such as BCR. Level of evidence Case-control study, level III.

Abstract 16649: Natural History of Ascending Aortic Aneurysms With Bicuspid and Tricuspid Aortic Valves

Introduction: Patients with bicuspid aortic valves (BAV) and tricuspid aortic valves (TAV) with ascending aortic aneurysms (AAA) are at risk for aortic complications. Meticulous follow-up and assessment of risk factors can mitigate the adverse aortic events. Hypothesis: We hypothesized that BAV and TAV with AAA can be managed conservatively with acceptable survival, low aortic complication rate, and timely surgery. Methods: From 2016 to 2018, 188 patients were seen for an isolated AAA. 147 patients had two or more CT scans (631-patient-years) which allowed measurement of aortic growth. We used a 1:1 greedy matching algorithm in R to identify similar cohorts of BAV and TAV patients matched by age, sex, hypertension, family history of aortic disease, coronary artery disease, and hyperlipidemia. Univariate and multivariate analysis of the unmatched cohorts were performed. Echocardiogram data was evaluated for each patient. Results: Initial mean AAA diameter was 4.3±0.58 cm (Table 1). The mean time between scans was 4.2 ± 3.3 years. 20 patients had an ascending aortic aneurysm ≥ 5cm with mean diameter 5.2 ± 0.23 cm (range 5.0-6.0 cm). Five patients had an aortic event (1 BAV and 4 TAV). Three of these aortic events lead to patient deaths (1 BAV and 2 TAV), in addition to one death (TAV) unrelated to aortic pathology. From time of enrollment, survival at 10 years was 90 ± 32%. Our model suggests that given the absence of known high risk factors, BAV patients do not have an accelerated ascending or root growth rate in comparison to their TAV counterparts. BAV patients do have higher rates of aortic stenosis (p &lt;.05), a factor that influenced the need for aortic repair. Conclusion: In conclusion, regardless of aortic valve type, the associated AAA has a similar natural history and low adverse event rate. In the absence of risk factors, conservative management of AAA can be accomplished with minimal risk to the patient.

COVID-19 in Patients with Hematologic Malignancies: A Single-Center Experience

Introduction:The emergence of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and subsequent coronavirus-19 (COVID-19) pandemic has impacted hematologic malignancies (HM) care worldwide. Reported risk factors for severe COVID-19 presentation include older age, medical comorbidities, and cardiac disease - many of which apply to patients with HM (Guan et al., 2020; Zhou et al., 2020). Additionally, patients with HM may be at even higher risk of infections with or complications from SARS-CoV-2 due to immune dysfunction from their underlying disease or treatment (He et al., 2020). However, data regarding rates of infection and outcomes in this population are limited. Here we describe the demographic characteristics, coexisting conditions, presenting symptoms, treatment, and outcomes of a cohort of patients with HM and COVID-19 infection at network sites across the Sidney Kimmel Cancer Center- Jefferson Health.Methods: We created an HM-specific COVID-19 database within our health system. Patients were identified for inclusion in the database by physician referral and query of the electronic medical record. Epidemiological, clinical, and laboratory data, therapy details, and outcomes on patients were obtained by accessing electronic medical records. A retrospective study of patients with a diagnosis of a HM- within 5 years of COVID-19 diagnosis-and a confirmed diagnosis of COVID-19 were was conducted using this database. A confirmed diagnosis of COVID-19 was defined as a positive result on a real-time RT-PCR assay of a specimen collected by nasopharyngeal swab.Results: More than 3,000 telehealth or in-person patient visits were conducted for patients with HM in the Jefferson Health Network between March 9, 2020 and July 15, 2020. During that period, 21 patients with HM had a confirmed diagnosis of COVID-19. Median age was 67 years (range 21-89). The majority of patients (86%) had at least 1 comorbid medical condition, and 76% had a history of tobacco use. The most common HM was multiple myeloma (7/21, 33%), followed by diffuse large B-cell lymphoma (3/21, 14%). 12/21 (52%) patients were on active cancer treatment at the time of COVID-19 diagnosis, and patients had received a median of 2 lines of cancer therapy (range 0-6). All 12 patients who were on active therapy at the time of COVID-19 diagnosis experienced a treatment interruption. Two patients had undergone prior autologous stem cell transplant (SCT) and 1 had undergone prior allogeneic SCT. Details on HM diagnosis and treatment are presented in Table 1.Twenty patients required hospital admission at the time of COVID-19 diagnosis, 7/21 were admitted to the ICU, and 6/21 required intubation. The most common presenting symptoms were fever (48%), cough (43%), and shortness of breath (43%), and lymphopenia (absolute lymphocyte count (ALC) <1,000 B/L) was common at presentation (56%). More than half (13/21, 62%) of patients received some COVID-19 directed therapy, while 8 were treated with supportive care alone. As of July 15, 2020 18/21 (86%) patients were alive. Characteristics of the 3 patients who died are described in Table 2.Conclusion: In contrast to published reports, we found that the number of confirmed COVID-19 in patients with HM at our center was surprisingly low, with only 21 cases in 4 months. Furthermore, the mortality rate of 14% was lower than expected when compared to published cohorts of similar patients, which have shown mortality rates as high as 40% (He et al., 2020; Malard et al., 2020; Martín-Moro et al., 2020). Postulated reasons for the low number of infections include the early adoption of universal masking and robust utilization of telehealth to promote social distancing. In our small cohort, multiple myeloma was the most frequent HM diagnosis associated with COVID-19 infection, but this may be related to the prevalence of MM in our geographic area. The vast majority of HM patients with symptomatic COVID-19 were former smokers.DisclosuresBinder:Janssen: Membership on an entity's Board of Directors or advisory committees; Sanofi: Consultancy. Alpdogan:Seattle Genetics: Consultancy; Kiowa Kirin: Consultancy. Kasner:Otsuka Pharmaceutical: Research Funding; Jazz Pharmaceuticals: Membership on an entity's Board of Directors or advisory committees, Research Funding. Martinez-Outschoorn:Otsuka Pharmaceutical: Research Funding. Palmisiano:Genentech: Research Funding; AbbVie: Research Funding. Flomenberg:Tevogen: Consultancy, Honoraria. Porcu:Cell Medica: Research Funding; Daiichi: Consultancy, Honoraria; Galderma: Research Funding; Innate Pharma: Membership on an entity's Board of Directors or advisory committees, Research Funding; Kiowa Kirin: Research Funding; Kura Oncology: Research Funding; Miragen: Research Funding; Verastem: Consultancy; Viracta Therapeutics: Membership on an entity's Board of Directors or advisory committees; Celgene: Research Funding.

382 The Effect of Advanced Practice Provider Discharge on Patient Throughput in an Emergency Department Fast Track

To determine if advance practice providers (APP) would be able to safely identify patients who do not require nursing care thereby decreasing time to disposition. The study site is New York Presbyterian Queens, an urban, ACS verified level 1 trauma center in Flushing, Queens that has 120K annual visits with 25K seen in the Fast Track area. This is a retrospective chart review of all patients who presented to our Fast Track area during the months of February 2019 and February 2020. For the month of February 2020, patients who the APP felt did not require nursing care were seen and discharged by the APP after the patient was triaged and evaluated. This was communicated to the nurse by changing the patient’s team assignment to grey. This "grey team" represents the intervention group. These patients were compared to a similar cohort of fast track patients from February 2019 using comparable ESI levels and final diagnosis. Data was collected regarding patient length of stay. 72-hour return rates for the study period were compared to evaluate for safety. In February 2020, 2,291 patients, 79 a day, were seen in our fast track area. The turnaround time (TAT) was 214 minutes for discharged patients. Of those, 528 were designated as grey team and not seen by a nurse in our fast track area. Patients on the grey team, discharged by the APP, had a turnaround time of 163 minutes. In February 2019 1,960 patients, 70 a day, were seen in our fast track area. The TAT was 143 minutes for discharged patients. We compared TAT for three diagnoses seen by the grey team in 2020 and seen in EDS in 2019. For suture removal/wound care the TAT was 56 minutes in 2020 vs 64 minutes in 2019 (p=0.155), for contusion the times were 145 minutes vs 154 minutes (p=0.106), and for cellulitis was 81 vs 184 (p=0.024). There was no significant difference in return rates, with 3.2% returning in the grey team and 2.5% returning in the overall fast track cohort with grey team patients removed. Despite having increased volume, APP’s were able to safely identify patients who did not require nursing care and expedite their throughput and discharge from the ED. Only one cohort reached statistical significance; however, the trend was for quicker turnaround in all groups. The unstated benefit of this workflow is that it saves nursing time and allows them to focus care on patients who require it in the area.

Socially determined cervical cancer care navigation: An effective step toward health care equity and care optimization.

Despite being the standard of care for patients with locoregional cervical cancer, many patients do not complete all components of primary chemoradiotherapy (pCRT): external beam radiotherapy, chemosensitization, and brachytherapy. Incomplete or protracted pCRT is associated with worse survival. The authors implemented a socially determined cervical cancer care navigation program at a public safety-net hospital to improve treatment adherence. Patients with International Federation of Gynecology and Obstetrics (FIGO) stage IB1 to IVA cervical cancer who underwent pCRT from 2012 to 2016 were prospectively enrolled into this navigation program spanning the medical, financial, and psychosocial aspects of care. This patient cohort was compared with a similar cohort of consecutive nonnavigated patients who were treated from 1998 to 2008. Patient characteristics, treatment data, and patient outcomes were collected. A database of navigation encounters was maintained prospectively. A total of 46 patients composed the navigated cohort and 85 patients composed the nonnavigated cohort. After implementation of the cervical cancer care navigation program, the percentage of patients receiving ≥5 cycles of weekly cisplatin increased from 74% to 93% (P<.01) and rates of the initiation of brachytherapy during external beam radiotherapy increased from 49% to 78% (P<.01). The median treatment time was reduced from 67 days in the nonnavigated patients to 55 days in the navigated patients (P<.01). Approximately 95% of navigated patients who completed pCRT did so within 63 days, compared with 52% of nonnavigated patients (P<.01). Treatment completion within 63 days was associated with significantly improved overall survival. Socially informed cervical cancer care navigation can significantly improve the timeliness of guideline-based care, enhance access to resources for underserved minority patients receiving pCRT, and may improve overall patient outcomes.

Recommendations for patient similarity classes: results of the AMIA 2019 workshop on defining patient similarity

Defining patient-to-patient similarity is essential for the development of precision medicine in clinical care and research. Conceptually, the identification of similar patient cohorts appears straightforward; however, universally accepted definitions remain elusive. Simultaneously, an explosion of vendors and published algorithms have emerged and all provide varied levels of functionality in identifying patient similarity categories. To provide clarity and a common framework for patient similarity, a workshop at the American Medical Informatics Association 2019 Annual Meeting was convened. This workshop included invited discussants from academics, the biotechnology industry, the FDA, and private practice oncology groups. Drawing from a broad range of backgrounds, workshop participants were able to coalesce around 4 major patient similarity classes: (1) feature, (2) outcome, (3) exposure, and (4) mixed-class. This perspective expands into these 4 subtypes more critically and offers the medical informatics community a means of communicating their work on this important topic.

Efficacy of Implantable Cardioverter-defibrillators for Secondary Prevention of Sudden Cardiac Death in Patients with End-stage Renal Disease.

End-stage renal disease (ESRD) constitutes a major burden on the health-care system in the United States, with more than 300,000 patients nationwide being treated with renal replacement therapy. Very few studies to date have evaluated the benefit of implantable cardioverter-defibrillator (ICD) implantation for secondary prevention in patients with ESRD. In this study, we evaluated the efficacy of secondary-prevention ICDs in reducing all-cause mortality in patients on dialysis using the United States Renal Data System (USRDS) database. We queried the USRDS for relevant data between 2004 and 2010. Patients with diagnoses of ventricular fibrillation (VF), ventricular tachycardia (VT), or sudden cardiac arrest (SCA) were included in the study. Patients were excluded from the analysis if they were younger than 18 years; had missing age, sex, or race/ethnicity information; had experienced myocardial infarction; or had an ICD in situ at the time of VF, VT, or SCA diagnosis. The primary endpoint of this study was to determine the efficacy of secondary-prevention ICDs in reducing all-cause mortality in patients on dialysis. A total of 1,442 patients (3.4%) with ESRD had ICD insertion. Patients who received an ICD were predominantly younger, white males with lower Charlson Comorbidity Index and with fewer cardiovascular events. Survival at two years was 53% among those with an ICD relative to 27% among those without an ICD. In this study, we observed a substantial decrease in mortality in patients receiving an ICD for secondary prevention when compared with a cohort of similar patients with a history of VF, VT, or SCA.

Comparison of Hiraoka's Transurethral Detachment Prostatectomy and Transurethral Resection of the Prostate Effects on Postoperative Erectile Function in Patients With Benign Prostatic Hyperplasia: A Prospective Randomized Controlled Study

BackgroundCurrently, no study has focused on the postoperative erectile function in patients with benign prostatic hyperplasia (BPH) by comparing Hiraoka's transurethral detachment of prostate (TUDP) and transurethral resection of prostate (TURP). AimTo compare the effects of Hiraoka's TUDP and TURP on postoperative erectile function in patients with BPH after long-term follow-up. MethodsA total of 104 consecutive patients with BPH treated in our hospital between September 2018 and February 2019 were included in the study. All patients who met the inclusion criteria were randomly divided into the Hiraoka's TUDP (n = 52) and TURP (n = 52) groups. Patient baseline data were collected. The international index of erectile function (IIEF-5), minimal clinically important difference (MCID), and quality of life scale (QOLS) were used to evaluate erectile function and quality of life 3, 6, and 12 months after surgery. Primary study endpoints were IIEF-5 and MCID. Secondary study endpoints were QOLS and independent prognostic factors for MCID. OutcomesHiraoka's TUDP experienced greater improvement in postoperative IIEF5 scores than patients who underwent TURP. ResultsPatients in the Hiraoka's TUDP group had significantly higher mean IIEF-5 scores than those in the TURP group 6 and 12 months after surgery (6 months: 18.9 vs 14.8, P < .001; 12 months: 18.1 vs 15.7, P < .001). The percentages of patients in the TUDP group who achieved an MCID were 88.5% and 80.8%, compared to 30.8% and 46.2% in the TURP group (P < .001 for both), 6 and 12 months after the operation, respectively. Patients in the TUDP group had lower QOLS scores than those in the TURP group after the surgery. The surgical method was an independent prognostic factor for MCID (odds ratio = 0.218). Clinical ImplicationsUntil now, no study has focused on the postoperative erectile function in patients with BPH by comparing Hiraoka's TUDP and TURP. Our study addressed this issue, which can add a new paradigm in the management to BPH. Strength & LimitationsThe comparison between Hiraoka's TUDP and TURP using a statistically appropriate, adequately powered methodology is the strength of the study. The single center and less participants are the limitations of the study. We believe that multicenter and large-sample studies are needed to further verify these study conclusions. ConclusionsAmong similar cohorts of patients with BPH who underwent TUDP and TURP, patients who underwent Hiraoka's TUDP experienced greater improvement in postoperative IIEF5 scores than patients who underwent TURP, while improvement in IPSS was similar among both groups.Pan C, Zhan Y, Zhao Y, et al. Comparison of Hiraoka's Transurethral Detachment Prostatectomy and Transurethral Resection of the Prostate Effects on Postoperative Erectile Function in Patients With Benign Prostatic Hyperplasia: A Prospective Randomized Controlled Study. J Sex Med 2020;17:2181–2190.

Clinical Assessment of an Ipsilateral Cervical Spinal Nerve Block for Prosthetic Laryngoplasty in Anesthetized Horses.

The nociceptive blockade of locoregional anesthesia prior to surgical stimulation can decrease anesthetic agent requirement and thereby potential dose-dependent side effects. The use of an ipsilateral second and third cervical spinal nerve locoregional anesthetic block for prosthetic laryngoplasty in the anesthetized horses has yet to be described. Anesthetic records of 20 horses receiving locoregional anesthesia prior to laryngoplasty were reviewed and compared to 20 horses of a similar patient cohort not receiving locoregional anesthesia. Non-blocked horses were 11 times more likely to require adjunct anesthetic treatment during surgical stimulation (P = 0.03) and were 7.4 times more likely to receive partial intravenous anesthesia in addition to inhalant anesthesia (P = 0.01). No horse in the blocked group received additional sedation/analgesia compared to the majority of non-blocked horses (75%) based on the anesthetist's perception of anesthetic quality and early recovery movement. No difference in recovery quality was observed between groups (P > 0.99). Cervical spinal nerve locoregional anesthesia appears well-tolerated and useful in reducing cumulative anesthetic agent requirement and may decrease the need for additional sedation/analgesia in horses undergoing anesthetized prosthetic laryngoplasty.

Comparative Effectiveness of Carotid Endarterectomy vs Initial Medical Therapy in Patients With Asymptomatic Carotid Stenosis

Carotid endarterectomy (CEA) among asymptomatic patients involves a trade-off between a higher short-term perioperative risk in exchange for a lower long-term risk of stroke. The clinical benefit observed in randomized clinical trials (RCTs) may not extend to real-world practice. To examine whether early intervention (CEA) was superior to initial medical therapy in real-world practice in preventing fatal and nonfatal strokes among patients with asymptomatic carotid stenosis. This comparative effectiveness study was conducted from August 28, 2018, to March 2, 2020, using the Corporate Data Warehouse, Suicide Data Repository, and other databases of the US Department of Veterans Affairs. Data analyzed were those of veterans of the US Armed Forces aged 65 years or older who received carotid imaging between January 1, 2005, and December 31, 2009. Patients without a carotid imaging report, those with carotid stenosis of less than 50% or hemodynamically insignificant stenosis, and those with a history of stroke or transient ischemic attack in the 6 months before index imaging were excluded. A cohort of patients who received initial medical therapy and a cohort of similar patients who received CEA were constructed and followed up for 5 years. The target trial method was used to compute weighted Kaplan-Meier curves and estimate the risk of fatal and nonfatal strokes in each cohort in the pragmatic sample across 5 years of follow-up. This analysis was repeated after restricting the sample to patients who met RCT inclusion criteria. Cumulative incidence functions for fatal and nonfatal strokes were estimated, accounting for nonstroke deaths as competing risks in both the pragmatic and RCT-like samples. Receipt of CEA vs initial medical therapy. Fatal and nonfatal strokes. Of the total 5221 patients, 2712 (51.9%; mean [SD] age, 73.6 [6.0] years; 2678 men [98.8%]) received CEA and 2509 (48.1%; mean [SD] age, 73.6 [6.0] years; 2479 men [98.8%]) received initial medical therapy within 1 year after the index carotid imaging. The observed rate of stroke or death (perioperative complications) within 30 days in the CEA cohort was 2.5% (95% CI, 2.0%-3.1%). The 5-year risk of fatal and nonfatal strokes was lower among patients randomized to CEA compared with patients randomized to initial medical therapy (5.6% vs 7.8%; risk difference, -2.3%; 95% CI, -4.0% to -0.3%). In an analysis that incorporated the competing risk of death, the risk difference between the 2 cohorts was lower and not statistically significant (risk difference, -0.8%; 95% CI, -2.1% to 0.5%). Among patients who met RCT inclusion criteria, the 5-year risk of fatal and nonfatal strokes was 5.5% (95% CI, 4.5%-6.5%) among patients randomized to CEA and was 7.6% (95% CI, 5.7%-9.5%) among those randomized to initial medical therapy (risk difference, -2.1%; 95% CI, -4.4% to -0.2%). Accounting for competing risks resulted in a risk difference of -0.9% (95% CI, -2.9% to 0.7%) that was not statistically significant. This study found that the absolute reduction in the risk of fatal and nonfatal strokes associated with early CEA was less than half the risk difference in trials from 20 years ago and was no longer statistically significant when the competing risk of nonstroke deaths was accounted for in the analysis. Given the nonnegligible perioperative 30-day risks and the improvements in stroke prevention, medical therapy may be an acceptable therapeutic strategy.

Prostate SBRT With Intrafraction Motion Management Using a Novel Linear Accelerator–Based MV-kV Imaging Method

PurposeThis study reports clinical experience using a linear accelerator-based MV-kV imaging system for intrafraction motion management during prostate stereotactic body radiation therapy (SBRT). Methods and MaterialsFrom June 2016 to August 2018, 193 prostate SBRT patients were treated using MV-kV motion management (median dose 40 Gy in 5 fractions). Patients had 3 fiducials implanted then simulated and treated with a full bladder and empty rectum. Pretreatment orthogonal kVs and cone beam computed tomography were used to position patients and evaluate internal anatomy. Motion was tracked during volumetric modulated arc therapy delivery using simultaneously acquired kV and MV images from standard on-board systems. Treatment was interrupted to reposition patients when motion >1.5-2 mm was detected. Motion traces were analyzed and compared with Calypso traces from a previously treated similar patient cohort. To evaluate “natural motion” (ie, if we had not interrupted treatment and repositioned), intrafraction couch corrections were removed from all traces. Clinical effectiveness of the MV-kV system was explored by evaluating toxicity (Common Terminology Criteria for Adverse Events v3.0) and biochemical recurrence rates (nadir + 2 ng/mL). ResultsMedian number of interruptions for patient repositioning was 1 per fraction (range, 0-9). Median overall treatment time was 8.2 minutes (range, 4.2-44.8 minutes). Predominant motion was inferior and posterior, and probability of motion increased with time. Natural motion >3 mm and >5 mm in any direction was observed in 32.3% and 10.2% of fractions, respectively. Calypso monitoring (n = 50) demonstrated similar motion results. In the 151 MV-kV patients with ≥3-month follow-up (median, 9.5 months; range, 3-26.5 months), grade ≥2 acute genitourinary/gastrointestinal and late genitourinary/gastrointestinal toxicity was observed in 9.9%/2.0% and 11.9%/2.7%, respectively. Biochemical control was 99.3% with a single failure in a high-risk patient. ConclusionsThe MV-kV system is an effective method to manage intrafraction prostate motion during SBRT, offering the opportunity to correct for prostate clinical target volume displacements that would have otherwise extended beyond typical planning target volume margins.

Has the modern design of Attune total knee replacement improved outcome in patients with isolated patellofemoral arthritis?

Modern knee replacements aim to improve patient function in arthritis affecting different compartments of the knee. This study evaluates the Patient Reported Outcome Measure (PROM) and functional outcome of a modern total knee replacement (Attune, DePuy) in patients with isolated patellofemoral arthritis. A total of 50 consecutive patients with isolated unilateral patellofemoral arthritis having had Attune total knee replacements at a single institution between 2010 and 2016 were prospectively studied. Five patients who developed symptoms on the opposite side during the study and two patients lost to follow-up were excluded. One patient needed early revision for loosening, leaving a total of 42 patients to be followed up over a period of 4 years. The Oxford Knee score (OKS) and Knee Injury and Osteoarthritis Outcome Score (KOOS) recorded pre-operatively and at follow-up was compared. A Functional assessment at around 8 months after operation was undertaken. At average follow-up of 24 months the mean OKS score improved by 15 points and the KOOS score improved by 20 points. Final KOOS sub-score for Pain was 80, Symptom 80, and ADL 82, Sports & Recreation 32 and QOL 60. Functional assessment at mean 8 months showed that a significant number of patients were able to Kneel (50%); Sit cross legged (23%); sit on their heel (23%) and were able do a single leg dip test (86%). This unique study of a modern design total knee replacement (Attune) in patients with isolated unilateral patellofemoral arthritis shows good PROM scores at 2 years and good functional assessment results at 8 months. The PROM scores are marginally better than the published results with Attune's predecessor, in a similar cohort of patients, but falls short of the published results of patellofemoral replacement implants. Large randomised comparative studies between traditional and the modern implant design is recommended to answer the question if design modification has influenced clinical outcome in patients with patellofemoral arthritis.