Single-institution Cohort Study Research Articles

Outcomes of Radial Artery Versus Saphenous Vein as A Second Conduit After Coronary Artery Bypass Grafting

Despite the advantages of multiarterial grafting, saphenous vein (SV) configurations predominate in coronary artery bypass grafting (CABG). In addition, the benefits of radial artery (RA) utilization in multivessel CABG remain unclear. This study aims to compare the clinical outcomes of patients who received RA grafts during CABG with those of patients who received SV grafts. A retrospective, single-institution cohort study was performed in 8,774 adults who underwent isolated CABG surgery with multiple grafts between 2010 and 2022. To balance graft cohorts, propensity score matching (PSM) was performed using a 1:2 (RA/SV) match ratio. Long-term postoperative survival was compared in RA and SV graft groups. Similarly, major adverse cardiac and cerebrovascular event (MACCE) rates were compared in the cohorts, with MACCE comprising death, myocardial infarction (MI), coronary revascularization, and stroke. Kaplan-Meier estimation was performed for both mortality and MACCE. A total of 7,218 patients (82.3%) who underwent multivessel CABG were included in this analysis. Of these patients, 341 (4.7%) received RA grafts, and 6,877 (95.3%) received SV grafts secondary to left internal mammary artery use. PSM yielded a cohort of 335 patients with RA and 670 patients with SV. After matching, groups were well balanced across all baseline variables. No significant differences were observed in either immediate postoperative morbidities or long-term survival. However, Kaplan-Meier estimates of long-term postoperative freedom from MACCE were significantly greater in matched patients with SV (73.3%) than in those with RA (67.4%) (p = 0.044, cluster log-rank), with patients with SV also possessing significantly greater freedom from coronary revascularization and MI. In conclusion, RA and SV secondary conduits for CABG were associated with comparable immediate postoperative complications and long-term survival after PSM. SV grafting was associated with significantly decreased rates of postoperative MACCE, likely owing to lower rates of coronary revascularization and MI than in RA grafting.

D-dimer and sinusoidal obstructive syndrome-novel poor prognostic features of thrombotic microangiopathy in children after hematopoietic cellular therapy in a single institution prospective cohort study.

Transplant-associated thrombotic microangiopathy (TA-TMA) is a common, severe complication of allogeneic hematopoietic cellular therapy (HCT). Even when treated in many studies, morbidity and mortality rates are high. This prospective single-institution cohort study serially enrolled all allogeneic HCT recipients from August 2019-August 2022. Patients were universally screened for TA-TMA and intermediate and high-risk patients were immediately treated with eculizumab. Sub-distribution cox-proportional hazards modelswere used to identify sub-distribution hazard ratios (sHR) for multi-organ dysfunction (MOD) and non-relapse-related mortality (NRM). Of 136 patients, 36 (26%) were diagnosed with TA-TMA and 21/36 (58%) developed MOD, significantly more than those without TA-TMA, (p < .0001). Of those with TA-TMA, 18 (50%) had high-risk TA-TMA (HR-TA-TMA), 11 (31%) had intermediate-risk TA-TMA (IR-TA-TMA), and 8 (22%) had standard risk (SR-TA-TMA). Twenty-six were treated with eculizumab (1/8 SR, 7/11 IR, and 18/18 HR). Elevated D-dimer predicted the development of MOD (sHR 7.6, 95% confidence interval [CI] 1.8-32.3). Children with concurrent sinusoidal obstructive syndrome (SOS) and TA-TMA had an excess risk of MOD of 34% and data supported a biologic interaction. The adjusted NRM risk was significantly higher in the TA-TMA patients (sHR 10.54, 95% CI 3.8-29.2, p < .0001), despite prompt treatment with eculizumab. Significant RF for NRM in TA-TMA patients included SOS (HR 2.89, 95% 1.07-7.80) and elevated D-dimer (HR 3.82, 95% CI 1.14-12.84). An unrelated donor source and random urine protein to creatine ratio ≥2 mg/mg were significantly associated with no response to eculizumab (odds ratio 15, 95% CI 2.0-113.6 and OR 6.5, 95% CI 1.1-38.6 respectively). TA-TMA was independently associated with NRM despite early diagnosis and treatment with eculizumab in this large pediatric transplant cohort. Prognostic implications of D-dimer in TA-TMA merit further investigation as this is a readily accessible biomarker. Concurrent SOS is an exclusion criterion of many ongoing clinical trials, but these data highlight these patients could benefit from novel therapeutic approaches. Multi-institutional clinical trials are needed to understand the impact of TA-TMA-targeted therapies.

Predictive Value of NLR and PLR in Driver-Gene-Negative Advanced Non-Small Cell Lung Cancer Treated with PD-1/PD-L1 Inhibitors: A Single Institutional Cohort Study.

To investigate the predictive value of neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) for the efficacy and prognosis of programmed cell death-1 (PD-1)/programmed cell death-ligand 1 (PD-L1) inhibitors in driver-gene-negative advanced non-small-cell lung cancer (NSCLC). A retrospective analysis of 107 advanced NSCLC patients without gene mutations who received PD-1/PD-L1 inhibitors in our hospital from January 2020 to June 2022 was performed. NLR and PLR were collected before PD-1/PD-L1 inhibitors, the optimal cut-off values of NLR and PLR were determined according to the receiver operating characteristic (ROC) curve, and the effects of NLR and PLR on the efficacy of PD-1/PD-L1 inhibitors in advanced NSCLC patients were analyzed. A total of 107 patients were included in this study. Receiver operating characteristic analysis showed that the optimal cut-off values of NLR and PLR were 3.825, 179, respectively. Kaplan-Meier curve showed that low baseline levels NLR and PLR were associated with an improvement in both progression-free survival (PFS) (P < .001, < .001, respectively) and overall survival (OS) (P = .009, .006, respectively). In first-line treatment and non-first-line treatment, low baseline levels NLR and PLR were associated with an improvement in PFS. In multivariate analysis, low baseline NLR and PLR showed a strong association with both better PFS (P = .011, .027, respectively) and longer OS (P = .042, .039, respectively). Low baseline NLR and PLR levels are significantly associated with better response in advanced NSCLC patients treated with PD-1/PD-L1 inhibitors, which may be indicators to predict the efficacy of immunotherapy in advanced NSCLC with driver-gene-negative.

Idiopathic intracranial hypertension in Omani adults: A tertiary center experience.

To evaluate the clinical profile, risk factors, and ophthalmic diagnostic and monitoring tools in Omani patients with idiopathic intracranial hypertension (IIH) using optical coherence tomography (OCT). A retrospective single institutional cohort study on Omani patients with a fulfilled diagnosis of IIH from January 1, 2014, to January 1, 2020, was conducted. The data obtained from the neuro-ophthalmic clinic contained age of onset of the disease, gender of patients, body mass index (BMI), presence of other associated conditions, and medication use. Our study group comprised 21 patients with IIH with an annual incidence rate of 2.8 per 100,000 population. Female-to-male ratio was 9.5:1 with a mean age of 27.24 ± 7.1. Headaches appeared to be the most prevalent symptom in 21 (100%) patients, followed by transient obscuration of vision in 9 (42.9%) patients and diplopia in 3 (14.3%) patients, and the least common symptom was pulsatile tinnitus in 2 (9.5%) patients. Increased BMI was seen in 19 (90.5%) patients and noted to be the most prevalent predisposing factor among our study group. The use of oral contraceptive pills was documented in 4 (19%) patients and 1 (4.8%) patient was noted to have polycystic ovary syndrome. All patients (100%) had a best-corrected visual acuity of 1.0 in both eyes pre- and postrecovery and 7 (33.3%) patients had an enlarged blind spot on visual field testing. All patients had papilledema on presentation and an average of 14.1 months to resolve to normal clinically and on OCT monitoring. All patients were treated with medications and only 1 (4.8%) continued to have intractable headaches that did not respond to maximum medical therapy and required surgery. The incidence of IIH in the Omani population was found to be less than neighboring countries but comparable worldwide. OCT is considered a useful tool to confirm and document papilledema and more importantly monitor recovery.

The Effect of Transversus Abdominis Plane Block Timing on Milliequivalents of Opioid Use and Immediate Postoperative Pain Scores in Patients Undergoing Minimally Invasive Hysterectomy: A Retrospective Cohort Study

To examine the effect of transversus abdominis plane (TAP) block timing (preoperative or postoperative) on postoperative opioid use (quantified via morphine milligram equivalents; MME) and pain scores in patients undergoing minimally invasive hysterectomy for benign indications. Retrospective, single-institution cohort study SETTING: Academic-affiliated community hospital PATIENTS: A total of 2982 patients were included who underwent a minimally invasive total hysterectomy between January 2018 and December 2022, excluding patients with a malignancy diagnosis, concurrent urogynecological procedure, vaginal hysterectomy, supracervical hysterectomy, or those with baseline narcotic use (opioid use within the 3 months before surgery). Patients were separated into 3 groups: no TAP blocks (n = 1966, 65.9%), preoperative TAP blocks (854, 28.6%), and postoperative TAP blocks (162, 5.4%). Summary statistics and mixed-effects regression methods were used for data analysis. There was a statistically significant lower mean use of opioids (MME 43.2 vs 53.9, p = .002) among patients who received a TAP block (either pre or postoperatively) than those who did not receive a block. However, when comparing preoperative vs postoperative patients with TAP block, there was no statistically significant difference in mean opioid use (MME 43.4 vs 42.1, p = .752). There were no differences in postoperative pain scores between patients with and without a TAP block, however, more opioids were required in patients who did not receive a TAP block to achieve the same pain scores as those who did receive a TAP block. There was a statistically significant shorter time to discharge for TAP versus patients without TAP block(median 5.5 vs 6.3 hours, p ≤ .001) as well as preoperative versus postoperative patients with TAP block (median 5.3 vs 6.2 hours, p = .001). While TAP block use at the time of minimally invasive hysterectomy reduced use of postoperative opioids, the timing of TAP block, either preoperatively or postoperatively, did not significantly affect opioid use. Preoperative compared with postoperative TAP block administration significantly shortened the time to discharge.

The role of obesity in treatment planning for early-stage cervical cancer

ObjectivesOptimal management of obese patients with early-stage cervical cancer is debated despite evidence of non-inferior survival in obese patients undergoing radical hysterectomy with pelvic lymphadenectomy (RH) compared to primary radiation with or without radiosensitizing chemotherapy (RT). Objectives included describing patient factors affecting disposition to RH versus RT; comparing RH outcomes for obese (BMI >30 mg/m2) and non-obese patients; and comparing differences in recurrence free survival (RFS) and overall survival (OS). MethodsThis was a single institution cohort study of all cervical cancer patients who underwent RH or were candidates for RH based on clinical stage. Demographic, clinicopathologic and treatment outcomes were collected and analyzed. ResultsRT patients (n = 39, 15%) had a higher BMI (p = 0.004), older age (p < 0.001), more life-limiting comorbidities (LLC) (p < 0.001), larger tumor size (p = 0.001), and higher clinical stage (p = 0.013) compared to RH patients (n = 221, 85%). On multivariable survival analysis there was no difference in OS based on treatment modality; significant predictors of worse OS were larger tumor size, higher number of LLC and recurrence. Among the RH group, obese patients had a longer operative time (p = 0.01) and more LLC (p = 0.02); there were no differences in demographic or clinicopathologic characteristics, operative outcomes, RFS or OS compared to non-obese patients. ConclusionIn this cohort of RH-eligible cervical cancer patients, BMI was independently associated with disposition to RT. Studies demonstrate that RH is feasible and safe in obese patients with no difference in RFS or OS when compared to non-obese patients. Thus, the decision for disposition to RT should not be based on obesity alone.

Frailty screening for determination of hemodialysis access placement

ObjectiveChoosing the right hemodialysis vascular access for frail patients remains difficult because the patient's preferences and the likelihood of access function and survival must be considered. We hypothesize that patients identified before arteriovenous (AV) access as frail by the PRISMA-7 score may have worse outcomes, indicating that fistula creation may not be the most clinically beneficial option and it would be in the best interest of the patient to receive either AV graft (AVG) placement or dialysis through a percutaneous catheter. Our pilot study aims to determine whether an association exists between patient frailty as defined by PRISMA-7 and newly created AV fistula (AVF) and AVG access outcomes. MethodsThis was a single institutional prospective cohort study of patients undergoing new AVF or AVG intervention from April 2021 to May 2023. Patients were assessed using the PRISMA-7 frailty questionnaire before their AV access surgery. Patients were grouped by frailty score and score groups were examined for trends. Univariable analysis was performed for baseline differences between frail and nonfrail patients. Failure to achieve maturation, postoperative infection, and 180-day mortality difference was also investigated for frail vs nonfrail patients. Univariable analysis was performed for nonmaturation using standard comorbidities, arterial and venous diameters, and frailty. Multivariable binary logistic regression was performed for the outcome of nonmaturation using frailty as one of the variables in conjunction with the univariable risks associated with nonmaturation. ResultsA total of 40 patients undergoing new AV access placement were investigated, among whom 53% were designated as frail (PRISMA-7 score ≥3). When comparing the frail and nonfrail new AV access groups, the access (AVF and AVG combined) failed in 48% (10/21) of the frail patients, but only failed in 5% (1/19) of the nonfrail patients 1 (P = .012). When distinguishing between AV access types, AVF creations followed the overall trend with 60% of AVF access (9/15) sites in frail patients failing to mature when compared with nonfrail patients, who all had fistulas that matured to use (P = .049). Surgical site infection was absent in all frail patients and present in 5% of nonfrail patients (1/19). Both 30-day and 60-day readmission rates were higher in the frail group compared with the nonfrail group. There was 180-day mortality present in 5 of frail patients % (1/21) and absent in nonfrail patients. Multivariable analysis revealed that both frailty (adjusted odd ratio, 10.19; 95% confidence interval, 1.20-82.25); P = .033) and younger age (adjusted odd ratio, 0.953; 95% confidence interval, 0.923-0.983; P = .002) both had a significant association with nonmaturation. Power analysis revealed a power statistic of 0.898 indicating a probability of type 2 error of 10.02% with a P value of .002. Hosmer-Lemeshow goodness of fit for the logistic regression had 75% overall accuracy for the model. ConclusionsPatient frailty is significantly associated with an increased incidence of AV access failure to mature.

Histopathologic regression in patients with primary cutaneous melanoma undergoing sentinel lymph node biopsy is associated with favorable survival and, after metastasis, with improved progression-free survival on immune checkpoint inhibitor therapy: A single-institutional cohort study

Histopathologic regression of cutaneous melanoma is considered a favorable prognostic factor, but its significance in clinical practice remains controversial. To investigate the prognostic importance of regression in patients with primary cutaneous melanoma undergoing sentinel lymph node (SLN) biopsy and to assess its significance in patients progressing to an unresectable stage requiring systemic therapy. We retrospectively reviewed patients with newly diagnosed melanoma undergoing SLN biopsy between 2010 and 2015 and available information on histopathologic regression (n=1179). Survival data and associations of clinical variables with SLN status were assessed. Patients with regressive melanoma showed favorable relapse-free (hazard ratio [HR], 0.52; P=.00013), distant metastasis-free (HR, 0.56; P=.0020), and melanoma-specific survival (HR, 0.35; P=.00053). Regression was associated with negative SLN (odds ratio, 0.48; P=.0077). In patients who progressed to an unresectable stage, regression was associated with favorable progression-free survival under immune checkpoint inhibition (HR, 0.43; P=.031) but not under targeted therapy (HR, 1.14; P=.73) or chemotherapy (HR, 3.65; P=.0095). Retrospective, single-institutional design. Regression of cutaneous melanoma is associated with improved prognosis in patients eligible for SLN biopsy as well as in patients with unresectable disease receiving systemic therapy with immune checkpoint inhibitors.

A paradigm shift in the neoadjuvant treatment of rectal cancer: a single-institution real-world cohort study using the COVID-19 pandemic to compare clinical outcomes between long-course chemoradiotherapy and RAPIDO-style total neoadjuvant therapy

A paradigm shift in the neoadjuvant treatment of rectal cancer: a single-institution real-world cohort study using the COVID-19 pandemic to compare clinical outcomes between long-course chemoradiotherapy and RAPIDO-style total neoadjuvant therapy

Aberrant nuclear β-catenin distribution does not prognosticate recurrences of endometrioid endometrial cancers – A retrospective single-institutional study

ObjectiveAberrant β-catenin distribution has been theorized as a predictive biomarker for recurrence in early stage, low grade endometrioid endometrial cancer. MethodsThis retrospective single-institution cohort study reviewed 410 patients with endometrial cancer from May 2018 to May 2022. Only endometrioid histology was included. Demographic and clinicopathological data were collected from the medical records. Univariate and multivariate logistic regressions, and sensitivity analyses for early stage, low grade and no specific molecular profile (NSMP) tumors were performed. Results297 patients were included for analysis. Most patients were over 60 years old, White, and with a BMI >30 and early stage low grade disease. Aberrant β-catenin distribution was found in 135 patients (45.5%) and wild type membranous β-catenin distribution in 162 (54.5%). While TP53 mutation correlated with endometrial cancer recurrence in this cohort (OR = 4.78), aberrant β-catenin distribution did not correlate in the overall population (OR = 0.75), the early stage low grade cancers (OR = 0.84), or the NSMP group (OR = 1.41) on univariate or multivariate analysis. No correlation between β-catenin distribution and local (OR = 0.61) or distant recurrences (OR = 0.90) was detected. ConclusionsAberrant β-catenin distribution did not significantly correlate with recurrence in endometrioid endometrial cancer, nor in the early stage, low grade and NSMP sub-cohorts.

Improving Discharge Rates to Home With the Help of Mobility Technicians: A Step in the Right Direction.

Background Early ambulation during acute hospitalization has been associated with improved clinical outcomes for patients. Despite the benefits of mobility in the hospital setting, physical therapists and nursing staff are often constrained by time. Mobility technicians (MTs) are individuals with specialized training who have emerged as a potential solution by providing safe ambulation for patients during their hospital stay. Objectives The purpose of this quality improvement project was to investigate the impact of MTs on clinical and financial outcomes for admitted patients at a high-volume tertiary institution. Methods A quality improvement project was implemented at Jersey Shore University Medical Center, Neptune City, from October 2022 to March 2023. The study was a prospective, single-institution cohort study and included patients admitted to two medical floors. Patients were divided into an experimental group that received services from MTs and a control group that did not receive this service but was eligible based on clinical status. The primary endpoint was the proportion of patients discharged to home. Secondary outcomes included the length of stay and financial impact. Results A total of 396 admitted patients were included, with 222 patients in the MT group and 174 in the non-MT group. Patients in the MT group were discharged home more frequently, at a rate of 79.7% compared to 66.1% for patients in the non-MT group (p = 0.002). MTs contributed to an average 2.4-day reduction in the length of hospital stay (7.8 days vs. 10.2 days, p = 0.007). The MT intervention led to an estimated net savings of $148,500 during the six-month study period. Additionally, 2.9 daily hospital beds were created. Conclusion Implementing an MT program significantly increased the discharge-to-home rates and decreased hospital length of stay. Preliminary analysis suggests that this intervention is cost-effective and can assist institutions in managing increased hospital capacity strain through the creation of additional hospital beds.

Surgical treatment of tertiary hyperparathyroidism: does one fit for all?

Tertiary hyperparathyroidism (3HPT) is defined as a condition of excessive autonomous excretion of intact parathyroid hormone (iPTH) with persistent hypercalcemia (>10.5 mg/dL) that lasts for more than 12 months after a successful kidney transplantation, in the context of a long course secondary hyperparathyroidism (2HPT). The chronic high levels of iPTH cause a worsening of graft function, accompanied by systemic symptoms of hypercalcemia. The only curative therapy is parathyroidectomy (PTX). It remains unclear whether total parathyroidectomy with autotransplantation (TPTX-AT) or subtotal parathyroidectomy (SPTX) lead to better outcomes. The aim of this retrospective, single-institution cohort study is to evaluate the rate of persistent or recurrent disease and postoperative calcium/iPTH disturbances in patients treated with TPTX-AT or SPTX for 3HPT. A single-center retrospective analysis of 3HPT patients submitted to TPTX-AT or SPTX between 2007-2020 with at least 24 months follow-up was conducted. The outcome parameters included persistence/recurrence of disease, incidence of transitory hypocalcemia, and temporary/permanent hypoparathyroidism. A cohort of 52 patients was analyzed and divided in two groups: 38 (73%) were submitted for TPTX-AT, and 14 patients (27%) were submitted for SPTX. The TPTX-AT population showed lower plasmatic calcium concentrations compared with the SPTX group during the entire follow-up period (p<0.001). There were eight cases (21%) of transitory hypocalcemia in the TPTX-AT group and none in the SPTX group, with p=0.065. Two cases (5%) of temporary hypoparathyroidism occurred in the TPTX-AT group and none in the SPTX group, with p= 0.530. There were no cases of permanent hypoparathyroidism and no cases of persistent disease. No statistical difference was assessed for the recurrence of 3HPT between the TPTX-AT group and the SPTX group (N=1, 3% vs N=1, 7%) (p=0.470). No significative difference was registered between the TPTX-AT and SPTX groups in terms of persistence/recurrence of disease, incidence of transitory hypocalcemia, and temporary/permanent hypoparathyroidism. Mean calcium levels iPTH values were statistically lower among the TPTX-AT group compared with the SPTX group while remaining always in the range of normality.

Pediatric arterial thrombosis: A single-institution cohort study of patient characteristics and thrombosis outcomes.

Arterial thrombosis (AT) is an increasingly recognized complication in pediatrics. Consensus clinical practice guidelines suggest immediate removal of the indwelling arterial catheter and a short course (5-7 days) of anticoagulation. The optimal duration and modality of antithrombotic therapy in children are yet to be determined. Describe treatment patterns and outcomes in pediatric patients with AT and explore predictors for complete thrombus resolution or long-term complications. Single-institution retrospective study. Patients were identified by ICD-9 and ICD-10 codes for the diagnosis of AT or reports of AT on ultrasound from January 1, 2012, to October 1, 2022. Descriptive and logistic regression analyses were used. 101 patients were included. The median age was 2.2 months. The most common underlying diagnoses were congenital heart disease (39.6%) and infection (22.8%). A majority of patients had symptomatic thrombosis in an extremity, and 78% were catheter-associated. 81% of patients received anticoagulation with a median duration of 35 days. Out of the 70 patients who were treated with anticoagulation alone and had a follow-up imaging, 70% had complete resolution after 90 days of anticoagulation. No clear predictors of complete resolution were identified. Eighteen patients had long-term sequelae secondary to arterial insufficiency. Those with infection-associated AT were more likely to have long-term complications. The major and clinically relevant non-major bleeding rate was 11%. Duration of anticoagulation was widely variable, and 70% of patients achieved complete resolution by 90 days of anticoagulation. A significant proportion of patients developed long-term sequelae secondary to arterial insufficiency. Sepsis/infection at the time of diagnosis with AT was more likely to be associated with long-term complications.

Discussion to: AATS 2023: Empiric flap coverage for the pneumonectomy stump: How protective is it? A single-institution cohort study

Discussion to: AATS 2023: Empiric flap coverage for the pneumonectomy stump: How protective is it? A single-institution cohort study

Stereotactic Body Radiation Therapy and High-Dose Rate Brachytherapy Boost in Combination with Intensity Modulated Radiation Therapy for Localized Prostate Cancer: A Single-Institution Cohort Study

The use of dose-escalated external beam radiation (EBRT) and brachytherapy (BT) boost with ADT has emerged as an option with superior biochemical control compared to dose-escalated EBRT alone. BT is traditionally delivered using low-dose rate techniques, but more recently high-dose rate (HDR) BT has also emerged as a boost option for these patients with promise of low toxicity rates. SBRT is a favorable modality for monotherapy for low and intermediate risk group patients, however its safety and efficacy as a boost in combination with EBRT is less well understood. The aim of this study is to compare SBRT boost, HDR boost and LDR boost for localized prostate cancer. A single-institution retrospective chart review was performed of men receiving EBRT delivered using intensity modulated RT and either SBRT boost (650cGy x 3), HDR-BT boost (1500cGy x 1), or LDR boost with I-125 (110Gy). Of patients treated w/ SBRT boost, 39 (80%) were treated with an SIB to the MRI-detectable lesion(s) to 700cGy x 3. Treatment characteristics for each strategy were reviewed and on-treatment toxicity outcomes for each of the cohorts were compared using Chi-square tests. From 2017-2022, 49 patients were treated with EBRT+SBRT boost, 44 patients received EBRT+ HDR-BT boost, and 46 patients received EBRT+ LDR-BT boost. The average age of patients included in the study was 71.2 years (median age 69.55 years, range 51.42-83.70 years) with average baseline PSA of 11 (median 7.6, range 3.3-64). In addition, 55% of the patients had high-risk/very high-risk disease, 39% had unfavorable intermediate disease and 6% had favorable intermediate disease. 139 patients received androgen deprivation therapy (93%). There were no differences in these baseline demographics and clinical or treatment factors between SBRT, HDR and LDR boost (p>0.05). The median dose/fx of EBRT was 4500cGy/25 fx (range 4500-5040cGy/23-28 fractions). At the end of treatment, 69% of the patients had 0-1 change in nocturia. There is an increase in nocturia episodes of 2-3 from baseline in 27% of the patients, while 4% had an increase in nocturia episodes of 4 or more from baseline with no difference between the SBRT, HDR and LDR boost. At baseline 36 patients (26%) reported urinary frequency symptoms, increasing to 80 patients (58%) by end of treatment with no difference between the SBRT, HDR and LDR boost. Similarly, there was a trend to increased use of urinary modifiers at end of treatment in patients treated with EBRT+HDR boost compared to EBRT+SBRT and EBRT+ LDR boost (89% vs. 71% v 72% respectively). There was no significant difference in acute urinary toxicity and nocturia between SBRT, HDR and LDR boost (p>0.05).

Use of Postoperative PET/CT in Altering Management in Adjuvant Head and Neck Radiation Therapy

Routine clinical practice does not include postoperative positron emission tomography (PET)/CT prior to postoperative radiation therapy (PORT) for head and neck cancer. Besides logistical challenges in obtaining postoperative PET/CT within six weeks after surgery, interpreting PET/CT findings in the postoperative setting can also be difficult. However, given the potential for residual or rapidly recurrent disease, postoperative PET/CT may help identify the need for additional diagnostic evaluation or alter adjuvant therapy. There are limited data evaluating the utility of postoperative PET/CT prior to PORT for head and neck cancer. We sought to evaluate the use and clinical relevance of postoperative PET/CT prior to PORT. In this retrospective, single-institution cohort study, we identified patients with head and neck cancer between 2013 and 2020 who received a postoperative PET/CT prior to PORT. We extracted electronic medical record data supplemented with manual chart review to collect patient and disease-related information. We measured the rates of additional diagnostic workup and treatment alterations as a result of postoperative PET/CT findings. The cohort included 29 patients who received a postoperative PET/CT prior to PORT. The mean age at diagnosis was 60.8 years (standard deviation: 15.0 years) and 20 (69.0%) were male. Regarding primary site, 10 (34.5%) were oropharynx, 7 (24.1%) were salivary gland, and 6 (20.7%) were oral cavity. The mean time from surgery to postoperative PET was 40.9 days (standard deviation: 27.7 days), and the mean time from postoperative PET/CT to start of PORT was 22.4 days (standard deviation: 20.3 days). A total of 9 (31.0%) patients experienced a change in management as a result of the PET/CT findings. Six (66.7%) patients received a biopsy. All 9 patients had a change in their radiation treatment plan, either dose escalation, target change, or in one case, converting to palliative dosing. Six (66.7%) patients were recommended addition of chemotherapy as a result of additional workup, with 4 (44.4%) of those patients ultimately receiving chemotherapy. Three (33.3%) patients underwent re-resection prior to PORT. In patients with head and neck cancer who received postoperative PET/CT prior to PORT, a meaningful proportion underwent additional diagnostic evaluation and/or experienced an alteration in adjuvant therapy as a result of the imaging findings. Interestingly, all patients with abnormal postoperative PET findings had changes in their radiation treatment plan, including at least boosting gross disease for patients in whom re-resection or chemotherapy was not pursued. Future work will seek to expand this cohort through 2022 when postoperative PET/CT became more routine at our institution and include oncologic outcomes. Additional studies are needed to identify appropriate candidates for postoperative PET/CT and determine the clinical impact of postoperative PET/CT.

Laparoscopic Right Hemicolectomy for Inflammatory Bowel Disease: Is Intracorporeal Anastomosis Feasible? A Retrospective Cohort Comparison Study.

Background: Inflammatory bowel disease (IBD) affects all ages and backgrounds, and many individuals require surgical intervention during their disease course. The adoption of laparoscopic techniques in this patient population has been slow, including intracorporeal anastomosis (ICA). The aim of our study was to determine if ICA was feasible and safe in patients with IBD undergoing laparoscopic right hemicolectomy (LRHC). Methods: This is a retrospective, single institution cohort study of elective and emergent cases of LRHC at a single academic center. Patients included underwent LRHC or ileocolic resection for IBD. Exclusion criteria: conversion to laparotomy, resection without anastomosis, or unconfirmed diagnosis of IBD. Main outcomes studied were anastomotic leak rate, surgical site infection (SSI), postoperative length of stay, 30-day readmission/reoperation, and operative time. Secondary outcomes were incisional hernia rates and rates of disease recurrence. Results: A total of 70 patients were included, 12 underwent ICA and 58 extracorporeal anastomosis. Anastomotic leak rate (intracorporeal 8.3% [n = 1], extracorporeal 8.6% [n = 5], P = .97), and SSI rates (intracorporeal 0%, extracorporeal 6.9% [n = 4], P = .36) were similar. Mean postoperative length of stay, rates of 30-day readmission/reoperation and diagnosis of hernia at 1 year were not significantly different. Rates of IBD recurrence and location of recurrence at 1 year were similar. However, operative time was significantly longer in those undergoing ICA (intracorporeal 187 minutes versus extracorporeal 139 minutes, P = < .05). Conclusions: ICA is a safe option in patients with IBD undergoing LRHC.

The impact of antibiotic and proton pump inhibitor use at the time of adjuvant platinum-based chemotherapy on survival in patients with endometrial cancer

ObjectiveWe sought to assess the impact of antibiotic (ABX) and proton-pump inhibitor (PPI) use on progression-free (PFS) and overall survival (OS) in patients treated with adjuvant platinum-based chemotherapy (PC) for endometrial cancer (EC). MethodsA retrospective, single-institution cohort study of EC patients treated with ≥four cycles of adjuvant PC following surgical staging from 2014 to 2020. Demographics and clinicopathologic features, including ABX and PPI use, were compared using χ2 and Fisher's exact tests. Univariate and multivariable analyses were performed, and survival outcomes were compared using the log-rank test. ResultsOf 325 patients, 95 (29%) received ABX, and 80 (24.6%) received PPI. ABX were associated with decreased 3-year PFS (49.9% vs. 66%; p = 0.0237) but not 3-year OS (68.9% vs. 79.9%; p = 0.0649). ABX targeting gram-positive bacteria were associated with decreased 3-year PFS (21.2% vs. 66.0% vs. 55.4%; p = 0.0038) and 3-year OS (36.5% vs. 79.9% vs. 75.6%; p = 0.0014) compared to no ABX and other ABX, respectively. PPI use was associated with decreased 3-year PFS (46.9% vs. 66.0%; p = 0.0001) and 3-year OS (60.7% vs. 81.9%; p = 0.0041) compared to no PPI. On multivariable regression analysis controlling for confounders including stage, histology, grade, radiation, and co-morbidities, PPI use was independently associated with worse PFS (HR 1.96, 95% CI 1.25–3.08; p = 0.0041) and OS (HR 2.06, 95% CI 1.01–4.18, p = 0.04). ConclusionIn this retrospective cohort study, we demonstrate that PPI use is independently associated with worse PFS and OS in patients with EC treated with PC. ABX use was associated with worse PFS on univariate analysis only. There is an unmet need to understand how PPI, ABX, and, potentially, the microbiome impact the effectiveness of chemotherapy in EC patients.

Methotrexate for refractory adult atopic dermatitis leads to alterations in cutaneous IL-31 and IL-31RA expression

BackgroundMethotrexate (MTX) is an alternative treatment for patients with moderate/severe atopic dermatitis (AD). ObjectiveThe authors evaluated the effect of MTX on the cutaneous expression of cytokines and chemokines that are involved in the inflammatory response in adult AD patients who received treatment with methotrexate for 24 weeks. MethodsThe authors conducted a prospective single-institution cohort study with 12 adults with moderate/severe AD who received oral MTX (15 mg/wk for 24 wks) and 10 non-atopic matched controls. The comparison was made of skin biopsies of lesional and non-lesional skin, pre- and post MTX treatment. The authors analyzed mean epidermal thickness and expression of IL-31, IL-31RA, OSMR, TSLP, Ki67, IL-4 mRNA, IL-6, IL-10, TNF-α, IFN-γ, TARC, and CCL-22. ResultsThere was a reduction in mean epidermal thickness (p = 0.021), an increase in IL-31RA expression (immunohistochemistry) in the epidermis (p = 0.016) and a decrease in IL-31 gene expression (p = 0.019) on lesional AD skin post-MTX treatment. No significant changes in the cutaneous expression of the other evaluated markers were identified. Study limitationsSmall sample size and limited length of follow-up. ConclusionsTreatment with MTX in adults with moderate/severe AD reduced epidermal hyperplasia and changed the cutaneous expression of inflammatory cytokines and receptors that are mainly related to pruritus, including IL-31 and IL-31RA. Trial registrationClinicalTrials.gov Identifier: NCT03327116.

HPV Vaccination in Immunosuppressed Patients with Established Skin Warts and Non-Melanoma Skin Cancer: A Single-Institutional Cohort Study.

cSCC (cutaneous squamous cell carcinoma) and its precursors are a major cause of morbidity, especially in immunosuppressed patients, and are frequently associated with human papillomavirus (HPV) infections. The purpose of this study is to investigate the therapeutic potential of alpha-HPV vaccination for immunosuppressed patients with established cSCC and its precursors. In this retrospective study, all patients who received Gardasil-9®, a nonavalent HPV vaccine, as secondary prophylaxis were examined. Dermatologic interventions in both the pre- and post-vaccination periods were analyzed with zero-inflated Poisson regression and a proportional intensity model for repeated events with consideration of the clinically relevant cofactors. The hazard ratio for major dermatologic interventions was 0.27 (CI 0.14-0.51, p < 0.001) between pre- and post-Gardasil-9® intervention. Gardasil-9® vaccination showed good efficacy in reducing major dermatologic interventions even after correction of relevant cofactors and national COVID-19 caseloads during the observational period. Alpha-HPV vaccination may potentially cause a significant decrease in dermatologic interventions and overall mortality as well as healthcare costs in immunosuppressed patients with high skin tumor burden.