Standard Adjunct Research Articles

Intercostal Nerve Cryoablation in Minimally Invasive Repair of Pectus Excavatum: National Trends, Outcomes, and Predictors of Utilization

PurposeIntercostal nerve cryoablation during minimally invasive repair of pectus excavatum (MIRPE) is an effective pain control technique. Some insurers may not reimburse for cryoablation in this context, contending that it’s an experimental procedure. This study aimed to describe national trends in cryoablation use and evaluate outcomes and predictors of its use. MethodsThe Pediatric Health Information System database was queried for pectus excavatum patients aged 9–21 who underwent MIRPE between 2016 and 2023. Concurrent cryoablation use was identified using billing/supply codes. Temporal trends in cryoablation utilization were described and quantified using linear regression. Demographics, resource utilization, and outcomes were compared for patients based on cryoablation utilization using chi-square and Kruskal–Wallis tests. Predictors of cryoablation use were evaluated with logistic regression. ResultsThis analysis included 2068 patients (mean age 15 ± 1.8 years; 86 % male). Cryoablation utilization increased from 33 % to 61 % from 2016 to 2023, with a strong positive trend (R2 = 0.73). Cryoablation patients had fewer surgical complications (8 % vs 12 %, p = 0.004), shorter LOS (2.0 ± 1.3 vs. 2.8 ± 1.6 days, p < 0.001), fewer total mean opiate days billed (1.4 ± 1.1 vs. 1.6 ± 1.4 days, p < 0.0001) and higher total costs ($24,045 ± $9696 vs. $20,751 ± $9,237, p < 0.001). High-volume centers (odds ratio (OR) 1.9, 95 % confidence interval (CI) 1.2–3.0) and commercial HMO insurance (OR 2.7, 95 % CI 1.9–3.8) were predictors of cryoablation use. ConclusionCryoablation during MIRPE has increased nationally since 2016; now being performed in nearly two-thirds of all cases. Cryoablation should be considered a standard adjunct to MIRPE rather than an experimental technique. Level of evidence2.

PP79 Use Of Vagus Nerve Stimulation Therapy In Treatment-Resistant Depression

IntroductionMajor depressive disorder (MDD) severely limits a person’s psychosocial functioning and reduces quality of life. According to world statistics, about 3.8 percent of the population, or about 280 million people, suffer from depression. Approximately one-third of patients with MDD have treatment-resistant depression (TRD). Meanwhile, Vagus Nerve Stimulation (VNS) therapy was approved by the US Food and Drug Administration and received CE marking in Europe for the treatment of chronic or recurrent depression in the early 2000s. The aim of this analysis is to determine the impact of VNS use in the treatment of TRD.MethodsA comprehensive literature search was performed in MEDLINE/PubMed and Google Scholar databases in order to estimate the clinical effectiveness of neurostimulator implantation for treatment of TRD. The main assessment methods were the Hamilton Rating Scale for Depression, the Montgomery-Asberg Depression Rating Scale and the Beck Depression Inventory.ResultsIn total, 6 systematic reviews with meta-analyses on the effectiveness of VNS in TRD were studied. The identified meta-analyses did not report any statistically significant differences in treatment outcomes favoring VNS compared to placebo and treatment as usual (TAU). However, the results of two studies demonstrate its positive clinical effect in the form of additional treatment to the TAU with longer follow-up period. An improvement in the clinical response is observed on average after 12 months as a decrease of about 50 percent in the initial estimates of depression.ConclusionsDespite the lack of clinical evidence of the benefits of treating depression, VNS therapy should be used as a standard adjunct treatment to antidepressants or other treatments for people with TRD. Many studies tend to suggest that the efficacy and safety of VNC in depression is still unclear, and additional further research is still needed to establish clinically significant effects.

A Pragmatic, Single-Center, Prospective, Randomized Controlled Trial of Adjunct Hemoglobin-Mediated Granulox Topical Oxygen Therapy Twice Weekly for Foot Ulcers.

Achieving timely healing of foot ulcers can help avoid complications such as infection and amputation; topical oxygen therapy has shown promise in achieving this. We evaluated the clinical effectiveness of Granulox, a hemoglobin spray device designed to deliver oxygen to the surface of wounds, for the healing of foot ulcers. We conducted a single-center, prospective, randomized controlled trial comparing standard of care (once-weekly podiatric medical clinic visits) versus standard care plus adjunct Granulox therapy twice weekly in adults with foot ulcers. After a 2-week screening phase, patients in whom the index wound had healed by less than 50% were randomized 1:1. Outcome measures were collated during the trial phase at 6 and 12 weeks. Of 79 patients enrolled, 38 were randomized. After 12 weeks, the median percentage wound size reduction compared with the size of the ulcer at the start of the trial phase was 100% for the control arm and 48% for the Granulox arm (P = .21, Mann-Whitney U test). In the former, eight of 14 foot ulcers had healed; in the latter, four of 15 (P = .14, Fisher exact test). In the control arm, two amputations and one withdrawal occurred, whereas in the Granulox arm, one unrelated death and five withdrawals were recorded. We could not replicate the favorable healing associated with use of Granulox as published by others. Differences in wound chronicity and frequency of Granulox application might have influenced differences in study results. Granulox might perform best when used as an adjunct for treatment of chronic wounds at least 8 weeks old.

Burns Depth Assessment Using Deep Learning Features

PurposeBurns depth evaluation is a lifesaving task and very challenging that requires objective techniques to accomplish. While the visual assessment is the most commonly used by surgeons, its accuracy reliability ranges between 60 and 80% and subjective that lacks any standard guideline. Currently, the only standard adjunct to clinical evaluation of burn depth is Laser Doppler Imaging (LDI) which measures microcirculation within the dermal tissue, providing the burns potential healing time which correspond to the depth of the injury achieving up to 100% accuracy. However, the use of LDI is limited due to many factors including high affordability and diagnostic costs, its accuracy is affected by movement which makes it difficult to assess paediatric patients, high level of human expertise is required to operate the device, and 100% accuracy possible after 72 h. These shortfalls necessitate the need for objective and affordable technique.MethodIn this study, we leverage the use of deep transfer learning technique using two pretrained models ResNet50 and VGG16 for the extraction of image patterns (ResFeat50 and VggFeat16) from a a burn dataset of 2080 RGB images which composed of healthy skin, first degree, second degree and third-degree burns evenly distributed. We then use One-versus-One Support Vector Machines (SVM) for multi-class prediction and was trained using 10-folds cross validation to achieve optimum trade-off between bias and variance.ResultsThe proposed approach yields maximum prediction accuracy of 95.43% using ResFeat50 and 85.67% using VggFeat16. The average recall, precision and F1-score are 95.50%, 95.50%, 95.50% and 85.75%, 86.25%, 85.75% for both ResFeat50 and VggFeat16 respectively.ConclusionThe proposed pipeline achieved a state-of-the-art prediction accuracy and interestingly indicates that decision can be made in less than a minute whether the injury requires surgical intervention such as skin grafting or not.

Abstract PO-042: Would dermoscopic photographs help triage teledermatology consults in the COVID-19 era?

Abstract Background: The coronavirus pandemic led to a rapid transition to telemedicine across medical specialties. Dermatologists can utilize digital images to remotely manage skin diseases, including determining the urgency with which patients need to be seen in person. Accurately triaging urgent cases can be impacted by imaging modality. Dermoscopy is the examination of the skin with polarized light, which for some providers can increase their diagnostic accuracy and confidence in managing potential skin cancers. It has been increasingly viewed as a standard adjunct for examining skin lesions. Dermoscopic photographs have been shown to improve providers' abilities to correctly diagnose telemedicine consults. However, this has only been studied with a limited subset of skin neoplasms and is limited to a workflow involving a photographer with a dermatoscopic imaging capability. In the pandemic, the ability of patients to access dermoscopy is exceedingly limited. This study aims to assess the impact of dermoscopy on decision-making by dermatologists, including confidence, diagnostic accuracy, and triaging urgency. Our premise is that if dermoscopy is impactful, innovative means to increase accessibility to dermoscopy would be valuable for cancer management during COVID. Methods: Twenty sets of clinical and dermoscopic photographs were selected as representative of commonly seen skin pathologies in our teledermatology consults. Study participants were first shown a clinical photograph and asked to determine their diagnoses, management decisions, level of urgency, and confidence in their triage decisions. The responses were scaled ranging from non-neoplastic to malignant, 0-100% confidence, and non-urgent (1) to emergent (3), respectively. They were then asked to answer the same questions after viewing the associated dermoscopic image. Results: Twenty-six physicians participated in the study: 16 dermatology attendings and 10 residents. The majority reported using dermoscopy in ≥25% of their clinical practice. Fifty-nine percent rated themselves as "somewhat confident" in their dermoscopic abilities. Providers correctly diagnosed 45.3% of study cases using clinical images alone. This increased to 53.6% after viewing the associated dermoscopic images (p=0.02). The greatest increase was for malignant neoplasms (31% vs. 54%, p=0.0007). Dermoscopy significantly reduced triage urgency scores for both non-neoplastic (mean 1.6 vs. 1.2, p&amp;lt;0.001) and benign neoplastic (mean 1.43 vs. 1.35, p=0.01) pathologies. Dermoscopy significantly increased urgency scores for malignant neoplasms (mean 1.47 vs. 1.64, p=0.01). There was a 7.6% increase in providers' confidence in their management decisions with dermoscopy (p&amp;lt;0.0001). Conclusions: Dermoscopic photographs improve providers’ abilities to correctly diagnose and prioritize skin lesions. In the COVID-19 era, innovative means to make dermoscopy available to patients at risk for skin cancer would be valuable. Citation Format: Myles R. McCrary, Tova Rogers, Howa Yeung, Loren Krueger, Suephy C. Chen. Would dermoscopic photographs help triage teledermatology consults in the COVID-19 era? [abstract]. In: Proceedings of the AACR Virtual Meeting: COVID-19 and Cancer; 2020 Jul 20-22. Philadelphia (PA): AACR; Clin Cancer Res 2020;26(18_Suppl):Abstract nr PO-042.

Mitomycin C modulates tumor microenvironment and enhances radiosensitivity in rectal cancer

Background: Neoadjuvant chemoradiation is the standard of care for locally advanced rectal cancer, however, pathological complete response (pCR) rate remains unsatisfactory. Tumor hypoxia in rectal cancer might be one factor of radioresistance. Mitomycin C (MMC), a hypoxia-activated prodrug (HAP), enhances radiosensitivity and is the standard adjunct to radiotherapy (RT) in anal cancer. Our study evaluated the effect of MMC and RT on rectal cancer and its tumor microenvironment (TME). Methods: In vitro hypoxia was induced by 1% O2 culture for CT26 rectal adenocarcinoma cells and HIF-1α expression was validated with Western blotting. Clonogenicity and MTT assays were used for radiation and drug survival. In syngeneic CT26 model, tumors were treated as follows: control, MMC (2 mg/kg/day), RT (2 Gy × 2 fractions), and combination with MMC 2 h prior to RT. Tumor volume, body weight, and white blood cell count were monitored for 1 month. Immune cells in TME were analyzed using flow cytometry. Results: MMC inhibited cell viability and enhanced radioresponse in CT 26 cells with delayed repair of DNA double strand break (P Ifnb1 was augmented by RT and upregulated with addition of MMC. In vivo treatment using MMC plus RT suppressed tumor growth with durable effect in comparison to MMC or RT alone (P Conclusions: The combination of MMC and RT may have synergistic therapeutic effect accompanied by modulation of TME towards favorable anti-tumor immunity.

Impact of Referring Hospital Imaging on Mortality at a Level I Trauma Center

BackgroundComputed tomography (CT) has become a standard adjunct in the evaluation of patients with trauma. However, utility of imaging at the referring hospital remains controversial. We study the effect of CT scans at referring hospitals on in-hospital mortality at a receiving trauma center. Materials and methodsA retrospective cohort study was performed with adult patients with severe trauma transferred to a level I trauma center from regional nontrauma hospitals between 2012 and 2017. Baseline characteristics were compared with Student's t-test and Pearson's chi-squared testing. The primary endpoint was in-hospital mortality. Cox regression, controlling for transfer time, was used to evaluate the effect of imaging on mortality. ResultsThree thousand four hundred and fifteen adult patients with trauma were included: 1135 (33.2%) received a pretransfer CT scan, whereas 2280 (66.8%) did not. Patients who received a pretransfer CT scan were more likely to be older, female, white, have a higher Charlson Comorbidity Index, less severely injured, have a blunt mechanism, and be transferred by ground. There was no difference in distance (58.3 miles versus 57.0 miles, P = 0.34), but transfer times were significantly increased for those who received pretransfer scans (288 versus 213 min, P < 0.005). The adjusted model controlling for multiple variables has a hazard ratio of 0.533 (95% confidence interval 0.42-0.68, P < 0.005). ConclusionsThere is a survival advantage for patients who receive pretransfer CT scans despite having significantly longer transport times. We suggest that this decreased mortality associated with pretransfer imaging may reflect improving trends in referring physician transfer decisions.

Assessment of dyspneic patients in the emergency department using point-of-care lung and cardiac ultrasonography-a prospective observational study.

Lung ultrasonography is increasingly used in the emergency department (ED) as a standard adjunct in the evaluation of the breathless patient. The study objective was to ascertain the diagnostic accuracy of lung and cardiac ultrasound in undifferentiated dyspneic ED patients. We conducted this prospective observational study on patients presenting with dyspnea in the ED of a tertiary hospital. The sonographers who performed lung and cardiac ultrasound according to a locally-designed protocol were blinded to clinical and radiologic results. Ultrasonographic findings were subsequently compared with the final adjudicated diagnoses. Between February and August 2015, 231 patients were recruited. There was male predominance (63.2%) with a mean age of 67.8 years. Overall, lung ultrasonography yielded correct diagnoses in 68.3% of patients. Our protocol had likelihood ratios of 3.63 [95% confidence interval (CI): 2.44-5.40], 3.73 (95% CI: 2.50-5.57) and 6.31 (95% CI: 3.72-10.72) for positive findings; and 0.42 (95% CI: 0.29-0.63), 0.35 (95% CI: 0.25-0.50), and 0.40 (95% CI: 0.28-0.56) for negative findings in the diagnoses of pneumonia, pulmonary edema, and chronic obstructive pulmonary disease or asthma, respectively. Addition of bedside echocardiography was able to differentiate cardiogenic from nephrogenic pulmonary edema in 70% of patients. Lung ultrasonography, when complemented with other tools of investigation, aids evaluation, allows for earlier treatment and more accurate disposition of undifferentiated dyspneic patients in the ED. The addition of cardiac ultrasound was not able to reliably differentiate the causes of pulmonary edema.

A comparative evaluation of spectrophotometric intracutaneous analysis and laser doppler imaging in the assessment of adult and paediatric burn injuries

Clinical assessment of mid-dermal burns can be challenging. Currently, laser Doppler imaging (LDI) is the gold standard adjunct in the assessment of burn injuries. Although LDI has demonstrated reliable accuracy, it poses various limitations in routine use including cost and ease of use. In comparison, spectrophotometric intracutaneous analysis (SIA) is a relatively cheaper technique, which can be carried out using a modified digital camera that enables easy image acquisition. We aim to compare the accuracy of the two modalities in the assessment of mid-dermal burn injuries. We recruited 29 patients with mid-dermal burns presenting within 2 to 5 days post burn. Forty-five burn regions of interest were identified, and the patients underwent imaging using both the modalities. Subsequent clinical outcome was followed up and showed that treatment remained unaffected by participation. Two clinicians then independently predicted the healing potential of each burn region retrospectively as per images from either modality. McNemar's test indicated that there is no significant difference between the accuracy of the two modalities (p = 0.61). The results suggest that the accuracy of SIA is comparable to that of LDI. Our experience with SIA indicates its potential as a cost-effective and user-friendly adjunct in decision-making.

Glide Path Enlargement of Mandibular Molar Canals by Using K-files, the ProGlider File, and G-Files: A Comparative Study of the Preparation Times

IntroductionThe preparation of a glide path before the introduction of rotary nickel-titanium instruments is a standard adjunct to ensure increased safety during root canal preparation. The aim of this study was to compare the mean preparation time of manual instrumentation with K-files, G-Files, and the ProGlider instrument to prepare a glide path in curved root canals. MethodsThe mesial canals of 90 mandibular molars (with curvature angles between 25° and 35°) were selected. The specimens were randomly divided into 3 groups with 30 canals each, and canal preparations were performed by an endodontist who used #10-15-20 stainless steel manual K-files (group KF), #10 stainless steel manual K-file followed by #12-17 G-File instruments (group GF), and #10 stainless steel manual K-file followed by #16 ProGlider instrument (group PG). The total time it took to prepare the glide paths was recorded with an electronic stopwatch. New instruments were used for each canal. ResultsGlide path enlargement with the PG group (27.9 ± 8.6 seconds) and GF group (41.9 ± 20.1 seconds) was shown to be statistically significantly faster than stainless steel KF group (74.9 ± 24.1 seconds) by using analysis of variance (P < .05). There was no statistically significant difference observed between the mean preparation times of the PG and GF groups (P < .05). ConclusionsGlide path preparation times with the rotary instrument groups were significantly faster than with stainless steel manual K-files.

Short-term outcome of cardiac resynchronization therapy – a comparison between newly implanted and chronically right ventricle-paced patients

BackgroundCardiac resynchronization therapy (CRT) is considered as a standard adjunct therapy in symptomatic patients with congestive heart failure (CHF) who have a prolonged QRS. There is an increasing number of patients who do not receive de novo CRT devices but are upgraded from right ventricular (RV) pacing to biventricular stimulation. We wanted to evaluate the benefit of CRT in patients with chronic RV pacing in comparison to previously non-paced heart failure patients. MethodsOne hundred and sixty-five patients who had their device newly implanted (group I) and 116 who were upgraded from previously implanted RV pacing systems (group II) at Mayo Clinic Hospital were retrospectively analyzed. Clinical and echocardiographic response to CRT was evaluated. Mean follow-up time was 290±250days. ResultsBaseline characteristics did not differ between the two groups of patients. Clinical response rate was identical in Groups I and II (65 vs. 65%, respectively; P=0.98) and echocardiographic response rate was similar in both groups of patients (64 vs. 62%; P=0.80). Post-implant QRS increased in group I and was reduced in group II (5 (27.4) vs. −20.0 (33.9) ms; P<0.001). NYHA class improvement (−0.7 (0.6) vs. −0.7 (0.6), P=0.81), LV ejection fraction increase (9.2 (12.9) vs. 8.2 (9.9)%; P=0.55) and LV end-systolic volume reduction (−34.5 (50.7) vs. −25.7 (47.4)%; P=0.28) were comparable in both groups. ConclusionsChronically RV-paced patients who receive CRT have similar short-term benefits when compared with patients with new CRT implantations.

In-flight ultrasound identification of pneumothorax.

Ultrasound is a standard adjunct to the initial evaluation of injured patients in the emergency department. We sought to evaluate the ability of prehospital, in-flight thoracic ultrasound to identify pneumothorax. Non-physician aeromedical providers were trained to perform and interpret thoracic ultrasound. All adult trauma patients and adult medical patients requiring endotracheal intubation underwent both in-flight and emergency department ultrasound evaluations. Findings were documented independently and reviewed to ensure quality and accuracy. Results were compared to chest X-ray and computed tomography (CT). One hundred forty-nine patients (136 trauma/13 medical) met inclusion criteria. Mean age was 44.4 (18-94) years; 69 % were male. Mean injury severity score was 17.68 (1-75), and mean chest injury score was 2.93 (0-6) in the injured group. Twenty pneumothoraces and one mainstem intubation were identified. Sixteen pneumothoraces were correctly identified in the field. A mainstem intubation was misinterpreted. When compared to chest CT (n = 116), prehospital ultrasound had a sensitivity of 68 % (95 % confidence interval (CI) 46-85 %), a specificity of 96 % (95 % CI 90-98 %), and an overall accuracy of 91 % (95 % CI 85-95 %). In comparison, emergency department (ED) ultrasound had a sensitivity of 84 % (95 % CI 62-94 %), specificity of 98 % (95 % CI 93-99 %), and an accuracy of 96 % (95 % CI 90-98 %). The unique characteristics of the aeromedical environment render the auditory element of a reliable physical exam impractical. Thoracic ultrasonography should be utilized to augment the diagnostic capabilities of prehospital aeromedical providers.

OP3-11 INGUINAL LYMPHADENECTOMY IN PENILE CANCER: RESULTS FROM THE NATIONAL CANCER DATABASE

You have accessJournal of UrologyOutstanding Posters: Oncology1 Apr 2014OP3-11 INGUINAL LYMPHADENECTOMY IN PENILE CANCER: RESULTS FROM THE NATIONAL CANCER DATABASE Samuel Kaffenberger, Harras Zaid, Cary Stimson, Zach Reardon, Daniel Barocas, Matthew Resnick, and Sam Chang Samuel KaffenbergerSamuel Kaffenberger More articles by this author , Harras ZaidHarras Zaid More articles by this author , Cary StimsonCary Stimson More articles by this author , Zach ReardonZach Reardon More articles by this author , Daniel BarocasDaniel Barocas More articles by this author , Matthew ResnickMatthew Resnick More articles by this author , and Sam ChangSam Chang More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2014.02.2332AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Inguinal Lymphadenectomy (ILND) for clinical stage T2 or greater penile cancer provides both therapeutic and diagnostic benefit and is an important part of the treatment algorithm for patients without evidence of distant metastases. We sought to assess the rate of performance of ILND in appropriate patients with penile cancer across the country and assess for factors which may influence performance of ILND. METHODS We analyzed patients with clinical stage T2 or greater penile cancer who had no evidence of metastatic disease and were either N0 or N1 diagnosed between 1998 and 2010 from the National Cancer Data Base (NCDB) cancer registry. The NCDB captures approximately 70% of all cancer diagnoses from 1400 accredited hospitals in the US. We examined the relationship between clinical and socioeconomic variables and the use of ILND. Inclusion criteria were stage cT2-4/cN0 or cN1/cM0, histology−proven squamous cell carcinoma, and complete ILND data. We performed both univariate chi−squared and t-test analyses and multivariate logistic regression analysis to identify independent predictors of performance of ILND. RESULTS 231 of 1165 (19.8%) patients had ILND during the study period. The median number of nodes in the ILND cohort was 17, interquartile range 11 to 26. Age, grade, distance from hospital and year of diagnosis were associated with performance of ILND. CONCLUSIONS Most patients (80.2%) with pathologic characteristics consistent with the need for ILND did not undergo ILND. Several access-related patient characteristics predict which patients are less likely to receive this standard adjunct. However, the reasons behind the low performance rate of ILND across multiple socioeconomic strata are unclear at this time. © 2014FiguresReferencesRelatedDetails Volume 191Issue 4SApril 2014Page: e855 Advertisement Copyright & Permissions© 2014MetricsAuthor Information Samuel Kaffenberger More articles by this author Harras Zaid More articles by this author Cary Stimson More articles by this author Zach Reardon More articles by this author Daniel Barocas More articles by this author Matthew Resnick More articles by this author Sam Chang More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Intraoperative Imaging and Assessment of Cerebral Blood Flow in Cerebrovascular Surgery: Hybrid Operating Rooms, Intraoperative Angiography and Magnetic Resonance Imaging, Doppler Ultrasound, Cerebral Blood Flow Probes, Endoscopic Assistance, Indocyanine Green Videography, and Laser Speckle Contrast Imaging

ntraoperative imaging has become a beneficial and standard adjunct in cerebrovascular microsurgery. Intraoperative vasI cular evaluation may avoid parent vessel compromise or occlusion and devastating postoperative results. Detection of these complications with postoperative imaging is often too late to preclude infarction. Additionally, intraoperative evaluation may obviate the need for future surgery for clip repositioning or failure of complete aneurysm, arteriovenous malformation (AVM), or arteriovenous fistula (AVF) obliteration. Common intraoperative modalities used alone or in combination include cerebral angiography, intraoperative magnetic resonance imaging (MRI) or computed tomography (CT), Doppler ultrasound, cerebral blood flow (CBF) probe, endoscopic assistance, indocyanine green (ICG) videography, and laser speckle flow imaging (LSFI). Hybrid operative suites with biplane angiography and intraoperative MRI or CT have improved access to these imagingmodalities and intraoperative assessment. Improvements in imaging and technology have led to many means to improve visualization through both extravascular and intravascular techniques aswell as assess blood velocity and calculate CBF. Intraoperative quantification of vascular dynamics also can help in surgical assessment and planning and may help in the prediction of postoperative complications. Although it is time-consuming to use

Current role of neoadjuvant and adjuvant systemic therapy for high-risk localized prostate cancer.

Although most men are diagnosed with readily curable localized prostate cancer, those with high-risk features face a significant mortality risk. Androgen deprivation therapy (ADT) is a standard adjunct to radiotherapy for high-risk prostate cancer, but its role around prostatectomy has not been as clearly defined, and concerns over cardiovascular toxicity have led to decreasing use. The use of chemotherapy for localized disease remains experimental. We review the most recently published trials of neoadjuvant or adjuvant systemic therapy for prostate cancer. The optimal duration of ADT with higher dose modern radiation techniques is under active investigation, but current data support the use of longer duration as standard. Prostate-specific antigen (PSA) and MRI changes may be useful in future studies optimizing duration of neoadjuvant ADT. Two years of combined ADT after prostatectomy is associated with a lower risk of disease recurrence and better prostate cancer specific mortality than predicted. Persistence of intraprostatic androgens during neoadjuvant ADT may contribute to resistance. Androgen deprivation added to definitive radiation or surgery improves outcomes for high-risk prostate cancer, although the role of chemotherapy remains undefined. Molecular classification is needed to improve risk stratification.

Mo1561 Comparative Effectiveness of Water Exchange vs Air Insuffaltion and Water Immersion vs Air Insufflation in Colonoscopy: a Meta-Analysis

Mo1561 Comparative Effectiveness of Water Exchange vs Air Insuffaltion and Water Immersion vs Air Insufflation in Colonoscopy: a Meta-Analysis

Bone Graft and Bone Graft Substitutes in Spine Surgery: Current Concepts and Controversies

Iliac crest bone graft has long been the standard adjunct used in spine fusion surgery. This graft provides osteogenic, osteoinductive, and osteoconductive elements that aid in creation of a fusion mass. However, morbidity associated with bone graft harvest has led surgeons to seek other potential adjuncts, including bone morphogenetic proteins, demineralized bone matrix, and graft expanders such as synthetic bone graft and allograft. Knowledge of fusion biology is required to understand the benefits and limitations of these agents, which promote fusion via one of four mechanisms: osteogenesis, osteoinduction, osteoconduction, and osteopromotion. Although bone morphogenetic proteins have shown a clear ability to aid in bone formation and successful fusion, recent concern regarding their safety has tempered enthusiasm regarding their use.

Zotarolimus-eluting stent-induced hypersensitivity pneumonitis

Zotarolimus-eluting stent-induced hypersensitivity pneumonitis

Abstract 18625: Preemptive Continuous Renal Replacement Therapy in Pediatric Cardiac Patients Requiring Extracorporeal Support is Associated with Increased Mortality

Objective: Acute kidney injury (AKI) is a common co-morbidity for children placed on ECMO because of primary cardiac disease; AKI can impact both length of ECMO support and adversely affect clinical outcomes. Continuous veno-venous hemofiltration (CVVH) is thought to optimize fluid status and lessen inflammatory response during pediatric ECMO support, leading some centers to use it as a standard adjunct to ECMO support. However, published data are derived primarily from the children without primary cardiac disease. Therefore, we reviewed our experience for pediatric cardiac patients receiving CVVH while on ECMO support. Methods: A retrospective analysis of the Children's Healthcare of Atlanta CICU ECMO database from 2002-2011 was performed. In order to limit the bias that CVVH would be instituted only after evidence of end-organ injury, we considered “pre-emptive CVVH” to be CVVH instituted with 48 hours of ECMO initiation. Multivariate logistic regression was undertaken to adjust for covariates. Results: Of 153 total cardiac ECMO patients, 59 (39%) received CVVH at the discretion of the attending physician. The time from ECMO initiation to CVVH initiation was 1.7 ± 2.9 days (median 1 day). Pre- and post-ECMO serum creatinine levels were similar between patients on ECMO who received CVVH with those that did not receive CVVH. However, peak serum creatinine was 1.1 ± 0.4 mg/dL (median 1.0 mg/dL) in the CVVH group and 0.9 ± 0.4 mg/dL (median 0.8 mg/dL) in the non CVVH group (p=0.003). Patients on ECMO who received CVVH had a higher mortality (p&lt;0.0001), were less likely to have had ECPR (p=0.004), and had a longer duration on ECMO (p&lt;0.0001). In multivariate analysis subjects receiving CVVH support within 48 hours of ECMO cannulation were three times more likely to die during their hospitalization (OR 3.02; 95% CI 1.32-6.9, p=0.009) even after adjusting for other risk factors such as ECPR, indication (post-operative support), and pre-ECMO serum creatinine. Conclusion: Preemptive CVVH support in pediatric cardiac patients requiring ECMO support is associated with increased in-hospital mortality. A strategy of pre-emptive CVVH in the cardiac ECMO population does not appear justified.

Effect of Early Door to Balloon Time on Treatment with Adjunctive Therapy and Resultant Procedural Success in STEMI

Objectives: We studied whether earlier door-to-balloon (DTB) times affected use of standard adjunct medications (Rx), and the effect of differential Rx on PCI success. Background: Striving for earlier DTB times in STEMI is important, but rushing may negatively impact pt management. We studied whether earlier DTB times negatively affected use of standard adjunct Rx, pre-PCI chest x-ray (CXR), and the effect on PCI success. Methods: 227 pts diagnosed with STEMI were taken directly for angiography. Rx use between 3 grps were compared: Grp A=DTB>90 (n=156), Grp B=DTB<90 (n=71), Grp C =DTB<60 (n=12). Differential Rx patterns were evaluated for effect on PCI success. Optimal PCI result was defined as post-PCI TIMI 3 flow and stenosis <50% in the infarct vessel. Results: Fewer pts received all Rx pre-PCI in Grp B than in Grp A, 1.4% vs. 9.6% (p=0.02), including B-blk, 53.5% vs. 67.3% (p=0.01) heparin infusion (GTT), 19.7% vs. 46.8% (p 66min) of heparin pretreatment had more optimal PCI result (65.0%), vs. Q1 (0-30min) (41.0%) (p=0.02). Pts receiving heparin GTT had optimal results 66.2% vs. 50.0% (p=0.02), and higher TIMI 3 flow (69.8% vs. 53.2%, p=0.02). In this cohort, there was no significant difference in mortality based on DTB group, though use of B-blk and IIb/IIIa medications improved mortality and cardiac mortality, respectively. Conclusion: In this cohort, earlier DTB times led to less complete adjunctive Rx and omission of diagnostic steps. Shorter pretreatment with heparin, and omission of heparin GTT, predicted less favorable procedural outcomes.