Single Institution Research Articles

It has been suggested that chemoradiotherapy may cause fibrosis of the internal anal sphincter, resulting in sclerosis. However, no report has quantitatively investigated this relationship by using real-time tissue elastography. To clarify the relationship between fibrosis and elasticity of the internal anal sphincter in patients undergoing surgery for lower rectal cancer with or without preoperative chemoradiotherapy from a histological perspective. A single-center, prospective cohort study. The surgical and pathological departments in a tertiary referral university hospital. Eighteen patients with rectal cancer who underwent abdominoperineal resection between May 2019 and May 2022 were included in the study. Real-time tissue elastography was performed before surgery to measure internal anal sphincter hardness as "elasticity" (hardest (0) to softest (255); decreased elasticity indicated sclerotic changes). Internal anal sphincter fibrosis was evaluated using Masson's trichrome and Elastica van Gieson staining. We evaluated internal anal sphincter elasticity after preoperative chemoradiotherapy and preoperatively in patients who did not undergo preoperative chemoradiotherapy and analyzed the correlation with the percentage of internal anal sphincter fibrosis in the resected specimens. Of the 18 patients, 10 underwent preoperative chemoradiotherapy. A significantly higher percentage of internal anal sphincter fibrosis was observed in the chemoradiotherapy group. Post-chemoradiotherapy elasticity was significantly lower in patients undergoing chemoradiotherapy compared to pre-chemoradiotherapy elasticity and that in patients not undergoing chemoradiotherapy. The analysis of the correlation between internal anal sphincter elasticity and fibrosis showed that elasticity decreased as the percentage of fibrosis increased. This study was conducted at a single institution, and the number of cases was small. The radiation dose to the anal canal may have differed depending on the location of the tumor, which may have affected internal anal sphincter elasticity. Internal anal sphincter elasticity may reflect tissue sclerosis associated with fibrosis caused by chemoradiotherapy.

Minimally invasive approaches to lumbar spine surgery are increasingly popular. Current guidelines highlight the importance of preoperative HbA1c in optimizing spine surgery outcomes. However, the role of preoperative HbA1c in minimally invasive lumbar spine surgery remains unclear. We sought to assess the association of HbA1c with readmissions, reoperations, and complications following minimally invasive lumbar spine surgery. We retrospectively reviewed all adult patients at a single institution from 2011 to 2023 who underwent minimally invasive lumbar decompression or decompression with instrumented fusion using CPT and ICD9/10 codes. Multivariate logistic regressions were performed to assess the effect of high HbA1c on readmissions and reoperations. In total, 1013 [median age 64 (IQR 54-71)] patients met the inclusion criteria. The median preoperative HbA1c was 5.99% (IQR 5.62 - 6.39). Upon multivariate regression analysis adjusting for frailty, socioeconomic status, and other confounders, patients with high HbA1c (> 7.1) had increased odds of unplanned readmission within 90days (OR 2.02, 95% CI 1.10- 3.56, p = 0.019) and reoperation within 90days (OR 2.82, 95%CI 1.14-6.31) of the index operation. Patients with high HbA1c also had increased odds of requiring reoperation due to persistent symptoms (OR 2.9, 95%CI 0.91-7.87, p = 0.048). After propensity score matching, patients with high HbA1c also had prolonged hospital lengths of stay (1.32days vs 1.24days, p = 0.006), post operative UTI (4.7% vs 0.9%, p = 0.034). Our results suggest high preoperative HbA1C may be associated with increased rates of readmission and reoperation following minimally invasive lumbar spine surgery. Preoperative HbA1C control may be indicated for surgical optimization in minimally invasive lumbar spine surgery.

Endoscopic sleeve gastroplasty (ESG) has gained recognition as a minimally invasive endoscopic treatment for obesity; however, clinical data in Japan is lacking. A retrospective review was conducted of 91 individuals with obesity who underwent ESG between January 2023 and November 2024. Eligibility included BMI ≥ 27.5 with at least one obesity-related comorbidity and preference for non-surgical therapy. Primary outcomes were the percentage of total weight loss (%TWL) at 1 month, 6 months and 1 year, and the rate of complications. The mean %TWL was 10.1% at 1 month, 15.2% at 6 months and 19.8% at 1 year. The follow-up completion rates were 100% at 1 month, 96.7% at 6 months and 87.9% at 12 months. Improvement in obesity-related comorbidities was observed in 57.1% of individuals with hypertension, 94.7% with dyslipidemia, 91.7% with diabetes, 96.9% with fatty liver disease and 75.0% with obstructive sleep apnea. One adverse event (1.1%) occurred, a pyriform sinus injury that resolved with conservative management; no severe complications were observed. ESG demonstrated favourable short-term weight loss and safety outcomes in Japan. These findings suggest ESG as a viable treatment option for Japanese individuals with obesity.

The advent of novel robotic platforms, like the hinotori™ Robotic Surgical System, introduced in our institution in 2024, has provided an alternative to the widely adopted da Vinci® Surgical System. Our study aims to investigate the initial outcomes and technical insights with using the hinotori™ for robot-assisted radical prostatectomy (RARP). Consecutive patients undergoing RARP from October 2024 to April 2025 within a single institution were included. A retrospective analysis of baseline characteristics and perioperative data was performed. For this study, the primary endpoint was perioperative safety and feasibility, defined by console time and intraoperative complications. Secondary endpoints included estimated blood loss, length of hospital stay, positive surgical margins, and total setup time trends. Technical insights and workflow considerations were qualitatively described. A total of 50 first initial and consecutive patients undergoing RARP using hinotori™ were analysed. The median age of patients was 69 (IQR: 65-72) years with a median PSA of 6.6 ng/mL (IQR 5.5-8.1). Most patients had EAU intermediate risk prostate cancer (76%). Median setup time was 33min (IQR 27-39) and median console time was 203.5min (IQR 185.8-232.0). Estimated blood loss was 150 mL and there were no cases requiring intra- or post-operative transfusion. Positive surgical margin rate was 12%. No Clavien-Dindo grade ≥ III occurred within 30-days. The 3-month continence rate was 82%. The docking-free design of hinotori™ confers a spacious extracorporeal working environment but requires careful setup of pivot points to avoid instrument friction, which may impact precision. To our knowledge, our institution represents the first centre outside Japan to adopt a complete platform switch from the da Vinci® system to the hinotori™ platform for RARP. Our initial experience suggests that the hinotori™ robotic surgical system is feasible and safe in the short-term perioperative setting. Key technical considerations and workflow adaptations identified in our early experience may serve as a practical reference for other institutions considering a transition from the da Vinci® system to hinotori™. Studies with longer follow-up and learning curves are warranted to further evaluate clinical outcomes and effectiveness.

The cognitive outcome of patients with sagittal synostosis (SS) has been studied previously; however, patients with developmental or behavioral problems have often been excluded, resulting in an incomplete picture. In this retrospective study, the authors evaluate the cognitive profile of patients with both SS and developmental or behavioral problems, as well as its relationship with the type and timing of the surgery performed. All patients born between 2000 and 2018 at a single institution who had a diagnosis of SS and underwent surgery were included in the study. Patients were treated with one of the following surgical techniques: spring-assisted correction, extended strip craniotomy, or frontobiparietal remodeling. Subsequently, if parents had concerns about their child's developmental or behavioral functioning, the child underwent psychological or psychiatric diagnostic assessment. The Wechsler Preschool and Primary Scale of Intelligence or the Wechsler Intelligence Scale for Children were used to evaluate cognitive profiles. Full Scale IQ (FSIQ), Verbal IQ (VIQ), Performance IQ (PIQ), and index scales were used to measure cognitive profiles. Among the 534 patients with SS who presented to the outpatient clinic after surgery, 99 (18.5%) had parents who expressed concerns about their child's developmental or behavioral functioning. Seventy-eight patients (14.6%) underwent psychological or psychiatric assessment. The mean FSIQ, VIQ, and PIQ scores were 96.29 ± 13.66, 98.21 ± 14.51, and 96.10 ± 12.98, respectively; both the mean FSIQ and PIQ were lower than the norm (p = 0.02). Patients with SS had lower Visual Spatial Index scores than the norm (91.82 ± 16.80, p = 0.005). The type and timing of surgery were not related to the cognitive profile of patients with SS. Results were adjusted for sex, age at surgery, and parental education level. Of the 534 patients with SS, 99 had parents who voiced concerns about their child's development or behavior. The intellectual ability of patients with both SS and developmental or behavioral issues was slightly lower than the norm. Surgical technique and timing did not affect the cognitive profile.

A modified FAST (Focused Assessment with Sonography for Trauma) examination is increasingly being used in obstetrics as a rapid and low-cost tool to assess postoperative patients with possible intra-abdominal bleeding. The purpose of this study was to evaluate whether a modified FAST examination reliably detects, or excludes, intra-abdominal free fluid in postcesarean delivery obstetric patients when compared with gold-standard imaging, such as computed tomography or magnetic resonance imaging, or intraoperative findings on abdominal re-exploration. This was a retrospective cohort study of patients who underwent cesarean delivery at a single institution between 2015 and 2020. The primary outcome was presence or absence of abdominal free fluid detected by modified FAST examination that was confirmed on formal imaging or abdominal re-exploration. Positive and negative predictive values, sensitivity, and specificity were calculated for modified FAST examination compared with gold-standard imaging or intraoperative findings on abdominal re-exploration. Of the 35 patients with true-positive results, 16 (45.7%) had formal imaging only, 16 (45.7%) had abdominal re-exploration only, and three (8.6%) had both formal imaging and abdominal re-exploration. Our analysis indicates that a modified FAST examination is a valid test for identifying intra-abdominal free fluid after cesarean delivery and supports its use in clinical decision making in obstetrics.

Lumbosacral transitional vertebrae (LSTV) are very common congenital spinal anomalies that consist of sacralization of the lowest lumbar vertebra or lumbarization of the uppermost sacral vertebra. They are a main cause of wrong-level surgery. This study aimed to explore morphological characteristics which can help to rapidly identify LSTV on lumbar spine radiography and computed tomography. Retrospective, case-control study. (1) Anterior superior angle (ASA) of the last presacral vertebra (PSV)-the angle between the anterior edge and superior endplate of the last PSV on a mid-sagittal lumbar CT view; (2) Posterior angle (PA) of the last PSV and the first sacral vertebra-the angle between the posterior edge of the last PSV and the posterior edge of the uppermost sacral-type segment on a mid-sagittal lumbar CT view; (3) Location of the iliac crest line (ICL) on AP whole-spine image-it was defined based on its location with respect to the transverse processes of the vertebra above the last PSV. An ICL higher than the inferior edges of the transverse process of the vertebra above the last PSV was defined as high ICL. Data of all patients, who underwent lumbar computed tomography (CT) and whole-spine radiography for lumbar spinal stenosis or lumbar disc herniation, at a single institution from 2017 to 2023, were analyzed from the local database. Data of 909 patients were grouped according to lumbosacral anatomy as follows: lumbarization of the first sacral vertebra (LZ), sacralization of the fifth lumbar vertebra (SZ), and normal spine (control). The anterior superior angle (ASA) of the last PSV, posterior angle (PA) of the last PSV and the first sacral vertebra, and location of the iliac crest line (ICL) on AP whole-spine imaging were measured. Receiver operating characteristic (ROC) curve analysis was performed to assess the diagnostic performance of the measurements (ASA; PA; ICL; ASA and PA; ASA, PA, and ICL). Inter- and intra-observer reliabilities of each measurement were assessed using the intraclass correlation coefficient (ICC). LSTV were present in 105 patients (11.6%): LZ in 76 (8.4%) and SZ in 29 (3.2%). ASA of the last PSV (85.7° ± 4.1° vs. 90.6° ± 2.9°; P < 0.001) and PA of the last PSV and the first sacral vertebra (19.7° ± 14.2° vs. 36.9° ± 9.1°; P < 0.001) were significantly lower in the LZ group than the control group. The prevalence of a high ICL was significantly higher in the LZ group than the control group (36.8% vs. 0.9%; P < 0.001). Mean ASA and PA and prevalence of high ICL were 90.1° ± 2.6°, 32.6° ± 11.4°, and 6.9%, respectively, in the SZ group; corresponding values in the control group were 90.6° ± 2.9°, 36.9° ± 9.1°, and 0.9%, respectively. The differences were not significant. Among the 37 patients with a high ICL, 30 (81.1%) also had an LZ. Twenty-three of the 24 patients (95.8%) with both a high ICL and PA < 20° had an LZ. ASA, PA, and ICL combined demonstrated excellent or good performance in differentiating patients in the LZ group from those in the control group (area under the ROC curve = 0.91; 95% confidence interval, 0.85-0.96) and from those in the SZ group (area under the ROC curve = 0.84; 95% confidence interval, 0.76-0.92). Lumbarization can be identified on lumbar spine imaging using a rapid method. When the ICL is high and both the ASA and PA are small on lumbar imaging, whole-spine radiography is recommended to definitively identify if lumbarization is present.

The Application of Flowable Gelatin without Thrombin in Total Joint Arthroplasty: A Propensity Score-Matched Comparative Study.

To present a case series of eight patients with noninfectious chronic uveitis treated at a single institution with one of two JAK inhibitors (Jakinibs), upadacitinib or tofacitinib. A retrospective chart review of patients seen by the uveitis service from 2015 to 2022 treated with upadacitinib and/or tofacitinib was performed. All patients included had previously failed alternative immunomodulatory therapy (IMT), had consistent ophthalmic evaluations for at least 6 months, and stayed on the Jakinib for at least 3 months. Eight patients were included. Demographic information was collected. Flares were classified clinically through visual acuity, symptoms, examination, and imaging. Side effects of the Jakinibs were recorded. The median length of Jakinib therapy duration was 29.5 months (range 6 months-43 months). Five patients were initiated on a Jakinib due to poor control of their ocular inflammatory diseases. Four of these patients achieved control with tofacitinib with or without additional steroid use; one patient achieved control with upadacitinib with one mild flare that resolved with systemic steroid use. Three patients started a Jakinib due to poor systemic disease control. Two of those remained flare-free of uveitis in the following year. The third patient had a flare that resolved with topical and oral therapy. Gastrointestinal upset was the most common side effect of tofacitinib. Upadacitinib had no reported side effects. Jakinibs may have a role in treatment of refractory noninfectious uveitis after failing conventional IMT. Both Jakinibs were well tolerated with a low incidence of side effects.

We aimed to investigate a potential association between hypofractionated radiotherapy (HFRT) vs. conventional radiotherapy (CRT) and development of pseudoprogression in patients over the age of 65 treated for glioblastoma (GBM). Seventy-nine patients with glioblastoma (29 who received HFRT and 50 who received CRT) were included in this retrospective cohort study from a single institution. Demographic, clinical, and radiation information, including development of pseudoprogression and standard prognostic factors like Karnofsky Performance Status (KPS) and extent of surgical resection, were collected. Radiation regimen alone was not associated with development of pseudoprogression. Patients who had lower KPS at the time of diagnosis and received HFRT had lower rates of pseudoprogression. There was no association between radiation regimen, pseudoprogression, and any other clinical factors. Older patients with glioblastoma who receive HFRT are not more likely to develop pseudoprogression than those who receive CRT. Patients with lower functional status receiving HFRT may be less likely to mount an inflammatory response leading to pseudoprogression. Prospective investigation is warranted to validate these results and evaluate other factors leading to treatment complications in older patients with glioblastoma in order to optimize outcomes and minimize toxicity.

Though anti-histone H3.3G34W antibody is highly sensitive to giant cell tumours of bone, a subset of tumours which are negative on immunohistochemistry harbours variant H3F3A mutations. In this study, the diagnostic utility of anti-histone H3.3G34V and R immunohistochemistry was assessed along with H3F3A gene mutation analysis by Sanger sequencing. This study also attempted to establish an algorithmic approach to analysis of H3.3G34W immunohistochemically negative tumours. Immunohistochemistry was performed using anti-histone H3.3G34R and anti-histone H3.3G34V antibodies in 35 anti-histone H3.3G34W IHC negative tumours. Simultaneously, all the tumours were subjected to Sanger sequencing to detect mutations in H3F3A gene. Of the 35 tumours tested, 14 showed positive staining for H3.3G34V and one for H3.3G34R immunohistochemistry. Gene mutation analysis by sequencing detected 3 additional cases of H3.3G34W mutation not detected by immunohistochemistry. Of the 14 tumours with H3.3G34V immunohistochemical expression, 11 showed corresponding H3.3G35V mutation on sequencing and a single tumour with H3.3G34R expression showed corresponding H3.3G35R mutation. In addition, sequencing detected 5 cases of H3.3G35L mutation which were negative on immunohistochemistry. Combining immunohistochemistry and sequencing results for the overall 309 GCTBs diagnosed during the study period, the most frequent H3F3A gene mutation was H3.3G34W/H3.3G35W (277/309, 89.6%). Other variants included H3.3G34V/H3.3G35V (14/309,4.5%), H3.3G34L/H3.3G35L (5/309,1.6%), and H3.3G34R/H3.3G35R (1/309,0.3%), while 3.9% (12/309) had the wild-type gene. Immunohistochemistry with H3.3 G34W, H3.3 G34R and G34V can be used as a surrogate for detection of corresponding H3F3A gene mutations. These antibodies should be used as first-line tests for confirming the diagnosis with sequencing being restricted only to tumors negative on immunohistochemistry.

Background The Controlled Nutritional Status (CONUT) metric has demonstrated effectiveness as a prognostic indicator for acute and chronic diseases in addition to other wasting conditions. However, its association with sarcopenia in elderly hospitalized patients remains insufficiently explored. Our study objectives included the assessment of the potential of CONUT score to predict sarcopenia onset. Methods Our study was a single center retrospective cohort study. Patients from the Department of Geriatrics of the First People’s Hospital of Kunshan were recruited for this study. Multiple indicators related to nutrition and sarcopenia, including CONUT, Prognostic Nutritional Index (PNI), triglyceride–total cholesterol–body weight index (TCBI), Geriatric Nutritional Risk Index (GNRI), and handgrip strength (HGS). Spearman’s and Pearson’s correlation were calculated to assess the associations between nutritional indices and sarcopenia-related indicators. The demographic characteristics, physical examination findings and laboratory parameters were included in univariate logistic regression. Based on the results of univariate logistic regression and theoretical analysis, variables were selected for multivariate logistic regression in order to identify risk factors for sarcopenia. Results A total of 236 elderly hospitalized patients were included. Malnutrition was prevalent in patients with sarcopenia. The optimal CONUT cut-off values were defined as &amp;gt;4 for males and &amp;gt;3 for females, dividing patients into high CONUT ( n = 140, 59.32%) and low CONUT ( n = 96, 40.58%) groups. Patients in the high CONUT group had lower levels of albumin, prealbumin, hemoglobin, and total lymphocyte count. Multivariate logistic regression analysis showed that a high CONUT score was an independent risk factor for sarcopenia ( OR:1.814, 95% CI: 1.019–3.255, p = 0.044 ). Male sex and low iron level were also demonstrated to be associated with sarcopenia. Conclusion CONUT score is an independent risk factor for sarcopenia and may serve as a practical indicator for sarcopenia risk screening in elderly hospitalized patients.

Background/Objectives: Oral squamous cell carcinoma (OSCC) carries a risk of late metastasis not only in advanced stages but also in early stages. In this study, we built and tested radiomics-based machine learning (ML) models for predicting the risk of metastasis from early OSCC on 18F-FDG positron emission tomography (PET). Methods: Patients diagnosed with T1 or T2 squamous cell carcinoma who underwent a preoperative 18F-FDG PET-CT examination at a single institution between 2016 and December 2022 were included in this retrospective study. The presence or absence of late cervical lymph node metastasis was confirmed for all patients. Among the radiomics features extracted from the images, we selected those that were useful for predicting late metastasis and used them to create ML models. We then verified the prediction accuracy of the models. Results: A total of 109 subjects were included, of which 31 had late lymph node metastasis and 78 were without metastasis. The most accurate ML model created using radiomics features selected from the subject cases had an area under the curve of 0.977 and accuracy of 87.5%. Conclusions: We confirmed that ML models using radiomics features extracted from PET images can be useful for predicting late metastasis in patients with early-stage OSCC.

Formal dangling protocols are often used after lower extremity free flap reconstruction to acclimate flaps to gravitational stress. However, their clinical benefit remains uncertain. This study evaluates how inclusion or omission of structured inpatient dangling affects flap outcomes. A retrospective review was conducted of 82 patients who underwent lower extremity free flap reconstruction at a single institution (2015-2024). Patients were grouped based on use of a formal dangling protocol (≥3 consecutive supervised sessions beginning after postoperative day 5) versus no protocol (ad libitum dangling beginning day 3). Outcomes included flap survival, complications, 30-day unplanned reoperation, time to ambulation, and length of stay. Statistical analysis included chi-squared, t-tests, and multivariable regression models. Fifty-three patients adhered to a dangle protocol; 29 did not follow a protocol. Demographics, comorbidities, flap type, and defect characteristics were similar between groups. Flap survival (96.2% vs. 96.6%, p = 0.94), partial necrosis (9.4% vs. 10.3%, p = 0.89), and reoperation rates (3.4% vs. 7.5%, p = 0.46) were comparable. On multivariable analysis, dangle protocol use was not associated with reduced complication risk (OR = 0.95, p = 0.93) but was associated with a 3.0-day longer median hospital stay (p < 0.01). The application of a formal dangling protocol did not affect flap survival but was independently associated with prolonged hospitalization. These findings challenge the necessity of structured regimens and support more patient-tailored postoperative strategies that may accelerate recovery without compromising surgical outcomes.

European studies have demonstrated acute uncomplicated sigmoid diverticulitis can be managed without antibiotics in select patients. However, routine use of antibiotics remains prevalent for this disease in the United States. This study aimed to evaluate the effectiveness of a quality improvement initiative implemented to reduce antibiotic use in patients with acute uncomplicated sigmoid diverticulitis discharged from the emergency department. Retrospective study comparing pre-intervention and post-intervention periods. A single academic institution in an urban setting. From June 2022 to June 2024, 189 patients presented to the emergency department with imaging-confirmed acute uncomplicated sigmoid diverticulitis: 81 patients in the pre-intervention group and 108 patients in the post-intervention group. In the post-intervention group, 66 patients received antibiotics while 42 did not. In June 2023, a diverticulitis clinical pathway was implemented in the electronic health record, accompanied by educational intervention for emergency department providers. Antibiotic prescribing and clinical outcomes. The post-intervention group demonstrated a significant reduction in use of antibiotic use, including oral antibiotics (p < 0.001). There was no difference in the use of intravenous antibiotics. No differences were seen in the subsequent antibiotic usage, return visits to emergency department, hospitalization, drainage procedures, or emergency surgery within 90 days between the two groups. In the post-intervention group, no differences were noted in diverticulitis-related return to emergency department, hospitalization, drainage procedures, or emergency surgery within 90 days between patients who received antibiotics and those who did not. Retrospective, single-center study. Prior to this study, guidelines recommending the omission of antibiotics in acute uncomplicated sigmoid diverticulitis were poorly adopted in our emergency department. The introduction of the electronic health record-based diverticulitis pathway and provider education were associated with reduction in antibiotics use for acute uncomplicated sigmoid diverticulitis without compromising patient outcomes. See Video Abstract.

The challenge in modern Islamic boarding school education lies in the suboptimal integration of non-formal dormitory-based education (riāyah) with formal academic instruction (tarbīyah), which may hinder holistic student development. This study examines the interrelationships among problem-solving skills, mental resilience, and intellectual growth as factors that foster effective synergy between tarbīyah and riāyah at the Zam-Zam Muhammadiyah Islamic Boarding School in Banyumas, Indonesia. Employing a quantitative methodology, data were collected through purposive sampling of Year XII Socioscience students using surveys and interviews, with descriptive and correlational analyses conducted via SPSS. Findings reveal significant positive correlations between the variables; however, the majority of students perceive the current integration practices as insufficient. The discussion emphasises the imperative for curricular innovation, enhanced pedagogical strategies, and comprehensive activity evaluations to optimise both academic proficiency and religious comprehension. This integrative model, despite its limitations—including a restricted sample size and the focus on a single institution—demonstrates potential in equipping students to navigate personal and societal challenges. The study advocates for ongoing educational innovation and expanded research across diverse boarding school contexts to maximise student outcomes.

Background/Objectives: Older adults with breast cancer may suffer from over- and undertreatment if intensity of therapy does not align with their physiologic age. We sought to evaluate the association between physiologic age, chronologic age, and treatment patterns in women ≥ 70 years with non-metastatic breast cancer. Methods: Patients ≥ 70 diagnosed with non-metastatic breast cancer 10/2021–3/2024 who had received surgical therapy and frailty (Geriatric-8) and life expectancy (Schonberg index) screening at our institution were identified from our institutional database. Descriptive analyses were run using chi-square tests of proportion. In the largest subgroup (patients with hormone receptor-positive (HR+)/human epidermal growth factor receptor 2-negative (HER2)-disease), multivariate logistic regression adjusting for patient- and disease-level characteristics was used to assess the relationship between life expectancy &lt; 10 years and the omission of sentinel lymph node biopsy (SLNB) and radiation therapy (RT). Results: Of 272 patients, 104 (38.2%) screened positive for frailty and 64 (23.5%) had a life expectancy of &lt;10 years. On bivariate analysis, a higher proportion of frail patients (44 (42.3%) had a life expectancy &lt; 10 years, while 20 (11.9%) robust patients had a life expectancy &lt; 10 years (p &lt; 0.001). Most patients (226, 83.1%) had HR+/HER-2 negative disease; 10 (3.7%) had HER2+ disease; and 33 (12.1%) had triple-negative breast cancer (TNBC) (p &lt; 0.001). Life expectancy was not significantly associated with omission of SLNB (life expectancy &lt; 10 years: reference; life expectancy ≥ 10 years: OR 0.81 95% CI [0.20–3.28]) or RT (life expectancy &lt; 10 years: reference; life expectancy ≥ 10 years: OR 1.14, 95% CI 0.44–2.93]) in patients with stage I–II HR+/HER-2− disease on adjusted analysis. Conclusions: While patients at risk for frailty and limited life expectancy are relatively common in our population, these measures may not significantly influence patient and clinician treatment decision making. Future efforts to tailor therapy by measures of physiologic age are needed.

Background: Although percutaneous ablation is currently the mainstay of ventricular arrhythmia (VA) management, surgical cardiac sympathetic denervation (CSD) as well as surgical epicardial ablation (SEA) complement the comprehensive management of refractory VA. Hypothesis: Surgical/hybrid interventions can safely and effectively treat refractory VA across the full spectrum of VA etiologies and complexities. Methods: We retrospectively identified 19 patients with refractory VA who underwent CSD and/or SEA, in the form of radiofrequency ablation or intramyocardial direct alcohol injection using thoracoscopy or thoracotomy at a single institution between 2007 and 2024. Patient demographics were collected and correlated with post-operative ventricular tachycardia (VT)-free survival. Results: 19 male patients underwent a surgical/hybrid intervention with a median age 63, 74% non-ischemic VA etiology, average of 2 failed anti-arrhythmic drugs (AAD), average of 2 endocardial and 1 epicardial VT ablations prior to surgery. 13 patients underwent CSD, 4 SEA and 2 both. Three patients were excluded from quantitative analyses due to incomplete data. At one-year post-operative analysis, 75% of patients were free from VT and 81% free from reintervention (Figure 1A). All VT recurrences were seen in CSD-only patients, with all but one occurring within 60 days post-CSD and one late recurrence on day 243. VT-free survival did not differ in patients stratified by VA etiology (non-ischemic vs ischemic, 27% vs 20%, p = 0.612, 1B), number of failed AAD (0-1 vs ≥2, 22% vs 29%, p = 0.89, 1C) or number of prior ablations (0-1 vs ≥2, 10% vs 50%, p = 0.096, 1D). Seattle Heart Failure Model (SHFM) score (mean 0.26 ±0.72) or PAINESD score (mean 8 ±7) did not predict VT-free survival (R 2 = 0.01, p = 0.68 and R 2 = 0.07, p = 0.33 respectively). Conclusions: CSD and SEA are extremely effective in treating refractory VA. CSD might require up to 60 days to take full effect but provides excellent long-term outcomes. Indicators of disease severity did not correlate with clinical success and high-risk patients identified by SHFM and PAINESD scores still benefited from surgical hybrid intervention. This suggests that most patients suffering from refractory VA can benefit from CSD and SEA.

Background: Anthracycline use is limited by cardiotoxicity resulting in heart failure (HF). The spatial ventricular gradient (SVG) is a vectorcardiographic (VCG) measurement of myocardial electrical heterogeneity that is associated with adverse outcomes including sudden death and incident HF. Objective: Determine if serial assessment of SVG direction is associated with anthracycline-associated HF. Methods: Retrospective analysis of adult cancer patients treated with anthracyclines in 1992-2019 at a single institution. Patients with prior HF were excluded. Standard 12-lead ECGs obtained within 6 months before and up to 5 years after anthracycline initiation were analyzed. VCGs were constructed, and SVG vector coordinates were obtained by integrating under the X, Y, and Z QRST complexes. Multivariable competing-risks regression was performed with SVG azimuth (the angle of the SVG in the transverse plane) included as a time-varying covariate with sine/cosine transformation to account for the circular nature of SVG azimuth, incident HF as the main outcome, and death as a competing outcome. Results: Among 889 patients (51% male, mean age at drug initiation 58±15 yrs), 70% had hematologic malignancies, 12% breast cancer, and 18% other malignancies. Incident HF developed in 97 patients (11%), and 305 patients (34%) died within 5 yrs of treatment. In unadjusted analyses, time-updated SVG azimuth was associated with incident HF (joint p=0.003). After adjustment for known risk factors for anthracycline-associated HF, including age, sex, hypertension, CAD, diabetes, cumulative doxorubicin equivalent dose, heart rate and QRS duration, SVG azimuth remained significantly associated with incident HF (joint p=0.045) with adjusted sub-distribution hazard ratios (SHRs) ranging from 0.47 to 2.13 across the circular spectrum (4.5-fold SHR variation). The Figure shows how SHRs for incident HF varied significantly by SVG azimuth. Notably, the anterior/leftward orientation, (see Figure green area) was associated with a reduced risk of HF with SHRs ~0.5-0.6, while the posterior/rightward orientation, (see Figure red area) was associated with a ~2-fold increased risk for incident HF. Conclusion: SVG azimuth is independently associated with increased risk of anthracycline-associated HF. Measuring how SVG azimuth changes during anthracycline treatment may enhance early identification of patients at risk for HF and inform preventive cardioprotective strategies during cancer therapy.

Introduction: Catheter ablation is a commonly performed invasive procedure for management of atrial fibrillation (AF), and offers favorable cardiovascular outcomes and improved quality of life in patients with AF. However, it is associated with procedural complications. Reported complication rates vary in literature, ranging from 1-8% overall, and limited data exists regarding temporal trends of complication rates. Furthermore, as ablation technology has evolved, it is important to understand how these innovations influence the safety profile. Research Question: To determine the trend of AF catheter ablation complication rates over ten years within a single institution. Methods: All patients undergoing left atrial catheter ablation for AF at Johns Hopkins Hospital from January 1 st , 2015, to December 31 st , 2024, were prospectively enrolled in a comprehensive database. Data including demographics, disease characteristics, procedural data, and 90-day complications were collected via the electronic health record (Epic). Major complications were defined as vascular complications requiring transfusion or surgery, pericardial effusion or tamponade requiring drainage, thromboembolic stroke, sepsis, shock, severe respiratory compromise requiring hospitalization, atrio-esophageal fistula, or death. Results: A total of 2,453 procedures were included. Ablation procedures were grouped into three time periods: 2015-2018 (N=641), 2019-2021 (N=750), and 2022-2024 (N=1062). A total of 87 procedures (3.55%) were associated with complications, including 34 major complications (1.38%) and 53 minor complications (2.16%). Figure 1 shows trends in total, major, and minor complications over time, with a noted significant decrease in major complications (p=0.037). Complication rates were also analyzed by ablation catheter type, as shown in Figure 2. The total complication rate for pulsed field ablation was 2.26% (5/221) compared to an overall complication rate of 3.55%, although this difference was not statistically significant. Conclusion: Major complications from catheter ablation for AF significantly decreased over time within our single-institution cohort. This may be attributed to increasing operator and institutional experience, and incorporation of newer technologies and safety techniques. No statistically significant difference was observed between ablation catheter types. However, this may have been limited by sample size and statistical power, and warrants future investigation.