Surgically-treated Patients Research Articles

Factors associated with vision loss in idiopathic intracranial hypertension patients with severe papilledema.

Our aim was to compare factors associated with poor versus good visual outcomes in idiopathic intracranial hypertension (IIH) patients with severe papilledema at initial presentation. Retrospective review of consecutive IIH patients (1/1/2013-6/10/2023) with severe papilledema (Frisén grade 4-5 and/or atrophy in at least one eye); Patients were divided into "poor visual outcome" (poor visual acuity and constricted visual field in at least one eye) and "good visual outcome" (good visual acuity and only mild visual field changes in both eyes) at >6 months for medically-treated patients and >3 months follow-up for surgically-treated patients. We included 134 IIH patients with severe papilledema (70 had poor and 64 had good visual outcomes). No significant differences existed for age, gender, race, hypertension, haemoglobin, or cerebrospinal fluid opening pressure. The poor-outcome group had significantly greater BMI (mean 39.2 vs 35.1 kg/m2, p = 0.004), and worse initial HVF-MD (-20.04 vs -5.81 dB, p < 0.0001). Poor-outcome patients saw more prior health-care providers (4.7 vs 2.4, p < 0.0001), with delayed neuro-ophthalmology encounters (58.5 vs 15.2 weeks, p = 0.001). 41.4% of poor-outcome patients were initially seen in outside emergency departments (ED) (vs 14.1% of good-outcome patients, p = 0.0005), while only 27.1% were seen by eye-care providers (vs 53.1% of good-outcome patients, p = 0.0027). No poor-outcome patients initially consulted our institution's ED vs 7.8% of good-outcome patients. Although patients with poor visual outcome did not seek medical care later than good outcome patients, they had delayed diagnosis/treatment because of prior outside ED visits andlack of prior eye-care provider evaluations, suggesting that early diagnosis and specialized management of papilledema is essential for patients with symptoms of intracranial hypertension.

A Single Institution Experience in the Management of Localized Neuroendocrine Carcinoma of the Bladder

BackgroundNeuroendocrine carcinoma of the bladder (NEC-bladder) is a rare disease with poor outcomes and variable treatment approaches. Materials and MethodsPatients with localized NEC-bladder treated with surgery or radiation between 2001-2021 were retrospectively identified. Rates of pathologic complete response (pCR) and downstaging were evaluated following NAC in surgically-treated patients. Progression-free survival (PFS) and overall survival (OS) were analyzed with univariable (log-rank) and multivariable (MVA; Cox regression) methods. ResultsSixty-five patients were identified having a median age of 73. The tumor histology distribution was small cell (64.6%) or urothelial with NE differentiation (35.4%). Most patients (69.2%) received NAC. Patients received local therapy by surgery (78.5%) or chemoradiation (21.5%). The majority (62.7%) of surgical patients had ≥ pT2 with 37.3% having nodal involvement (pN+). The pCR and downstaging rates were 21.6% and 35.1%, respectively. At a median follow-up of 60 months (m), the median PFS and OS were 16.4m and 25.9m, respectively. NAC improved PFS (p=0.04) and downstaging improved PFS (p=0.012) and OS (p<0.001). Patients receiving NAC with ypN0 vs. ypN+ had median OS of 69.9m vs 15.3m, respectively (p<0.001). MVA identified receipt of NAC and pN as predictors of PFS; pN was predictive of OS. No differences in PFS or OS were seen between histology of primary tumor. The brain metastasis rate was 10.8% with all patients having small cell histology. ConclusionsOptimized therapy in NEC-bladder includes NAC followed by local consolidation. Ascertainment of ypN0 is associated with long term survival, while pN+ remains associated with poor outcomes.

18F]DOPA PET for lesion definition and contouring using different thresholds in patients with gliomas.

Amino-acid (AA) PET has recently been endorsed by the ESTRO-EANO guidelines for RT-planning in glioblastomas, with recommended lesion-to-brain-ratio thresholds (1.6-1.8) derived from a biopsy-controlled FET-PET study. We aimed to compare target definition at [18F]DOPA-PET between the ESTRO-EANO thresholds and other biological-tumor-volume (BTV) thresholds (derived from the striatum) typically used in [18F]DOPA-PET. A retrospective analysis was conducted on glioma patients scanned with [18F]DOPA-PET/CT at our center between April 2021 and January 2024. 3D BTV was semi-automatically computed using a dedicated workstation (Philips HealthCare) with four thresholds: 1.6xSUV<inf>mean</inf> of background, 1.8xSUV<inf>mean</inf> of background, SUV<inf>mean</inf> and SUV<inf>max</inf> of the contralateral striatum. The delineation accuracy of different thresholds was visually evaluated and a t-test was used to compare the different VOIs volumes (0.05 significance-level). 50 patients were included (36 previously received surgery). Volume definition based on the striatum SUV<inf>max</inf> was significantly smaller compared to other thresholds (2.1 cm3), resulting in inaccurate VOIs at visual inspection in 21/50 patients. No significant differences were highlighted in BTV defined based on 1.6 or 1.8xSUV<inf>mean</inf> of background (15.7 vs. 12.7 cm3; VOIs accurate in 49/50 and 46/50 patients, respectively). BTV based on striatum SUV<inf>mean</inf> was significantly smaller compared to the 1.6xSUV<inf>mean</inf> threshold only in surgically-treated patients (P=0.04), while no significant differences were highlighted compared to the 1.8xSUV<inf>mean</inf> threshold regardless of the patients' group. The ESTRO-EANO FET-PET thresholds proved to be interchangeable in patients scanned with [18F]DOPA-PET, while the use of a threshold based on the contralateral-striatum SUV<inf>mean</inf> provided partially overlapping results prompting further investigation.

Assessment of postoperative therapy de-escalation for early-stage, intermediate-risk cervical cancer

ObjectiveThe objective of this study was to assess the oncologic outcome of surgically-treated patients with early-stage, intermediate-risk cervical cancer according to postoperative therapy modality.MethodsThis retrospective cohort study queried the Japanese...

Management and prognosis of iatrogenic perforations of the cervical oesophagus and hypopharynx.

The study aimed to identify factors affecting the management and prognosis of iatrogenic cervical oesophageal and hypopharyngeal perforations (iCEHPs). We retrospectively analysed 24 patients treated for iCEHP between 2004 and 2021 at a tertiary university medical centre. Data on demographics, clinical features, imaging, management and outcomes were collected. Factors associated with primary management and patient outcome were assessed. The most common management approach was surgical neck exploration (15 patients, 62.5%). Surgical management was used in 93% of uncontained perforations compared to 11% of contained perforations (p < 0.001). Surgically-treated patients had higher levels of C-reactive protein (CRP) than conservatively-treated patients (median, 18.3 vs 4.8 mg/dL; p = 0.001). Delayed diagnosis (≥ 24 hours) was associated with increased mortality (100 vs 5%; p = 0.011). The mortality rate was significantly higher in patients who had a history of neck irradiation than in patients who did not (67 vs 5%; p = 0.032). Early diagnosis of iCEHP improves outcomes. The appropriate management should be carefully selected on the basis of CRP level and imaging findings. Prior neck radiation is a poor prognostic factor.

Surgeon and Care Team Network Measures and Timely Breast Cancer Treatment

Cancer treatment delay is a recognized marker of worse outcomes. Timely treatment may be associated with physician patient-sharing network characteristics, yet this remains understudied. To examine the associations of surgeon and care team patient-sharing network measures with breast cancer treatment delay. This cross-sectional study of Medicare claims in a US population-based setting was conducted from 2017 to 2020. Eligible participants included patients with breast cancer who received surgery and the subset who went on to receive adjuvant therapy. Patient-sharing networks were constructed for treating physicians. Data were analyzed from September 2023 to February 2024. Surgeon linchpin score (a measure of local uniqueness or scarcity) and care density (a measure of physician team familiarity) were assessed. Surgeons were considered linchpins if their linchpin score was in the top 15%. The care density of a patient's physician team was calculated on preoperative teams for surgically-treated patients and postoperative teams for adjuvant therapy-receiving patients. The primary outcomes were surgical and adjuvant delay, which were defined as greater than 60 days between biopsy and surgery and greater than 60 days between surgery and adjuvant therapy, respectively. The study cohort included 56 433 patients (18 004 aged 70-74 years [31.9%]) who were mostly from urban areas (44 931 patients [79.6%]). Among these patients, 8009 (14.2%) experienced surgical delay. Linchpin surgeon status (locally unique surgeon) was not statistically associated with surgical delay; however, patients with high preoperative care density (ie, high team familiarity) had lower odds of surgical delay compared with those with low preoperative care density (odds ratio [OR], 0.58; 95% CI, 0.53-0.63). Of the 29 458 patients who received adjuvant therapy after surgery, 5700 (19.3%) experienced adjuvant delay. Patients with a linchpin surgeon had greater odds of adjuvant delay compared with those with a nonlinchpin surgeon (OR, 1.30; 95% CI, 1.13-1.49). Compared with those with low postoperative care density, there were lower odds of adjuvant delay for patients with high postoperative care density (OR, 0.77; 95% CI, 0.69-0.87) and medium postoperative care density (OR, 0.85; 95% CI, 0.77-0.94). In this cross-sectional study of Medicare claims, network measures capturing physician scarcity and team familiarity were associated with timely treatment. These results may help guide system-level interventions to reduce cancer treatment delays.

Impact of medical therapy for hormone-secreting Pituitary tumors on bone.

Bone health is often impaired in patients with hormone-secreting pituitary tumors. Since medical therapy is central to their care, understanding how its use impacts on this is highly important. This review summarizes a systemmatic review of the literature on the effects of medical therapies for hormone-secreting pituitary tumors on bone. In acromegaly, medical therapy lowers bone turnover marker (BTM) levels, consistent with correction of the high bone turnover of active disease, and overall, areal bone mineral density (aBMD) does not change or increases. Somatostatin-receptor ligand (SRL) and pegvisomant-treated acromegaly patients have persistently reduced volumetric BMD and microarchitectural abnormalities of the peripheral skeleton, deficits that are similar to those in surgically-treated patients. Fracture risk remains elevated in medically-treated acromegaly patients but in conjunction with biochemical control the risk is lessened. Treatment of prolactin-secreting tumors with dopamine agonists is associated with improvements in aBMD, but this does not always fully normalize despite effective medical treatment of the prolactinoma. In one cross-sectional study, prolactinoma patients had lower total volumetric BMD and impaired microarchitecture suggesting that bone microstructure does not fully normalize despite dopamine agonist therapy. Cross-sectional studies show a high rate of VF in patients with prolactin-secreting tumors that is lowered on cabergoline therapy, but still the fracture rate of men and postmenopausal women is higher than that of controls in some studies. Studies on the effects of modern-day medical therapy for Cushing's disease on bone are lacking. More research is needed on the effectsof medical therapies for hormone secreting pituitary tumors on bone health.

The Role of Spinal Cord Compression in Predicting Intraoperative Neurophysiological Monitoring Events in Patients With Kyphotic Deformity: A Magnetic Resonance Imaging-Based Study.

To establish a novel classification system for predicting the risk of intraoperative neurophysiological monitoring (IONM) events in surgically-treated patients with kyphotic deformity. Patients with kyphotic deformity who underwent surgical correction of cervicothoracic, thoracic, or thoracolumbar kyphosis in our center from July 2005 to December 2020 were recruited. We proposed a classification system to describe the morphology of the spinal cord on T2-weighted sagittal magnetic resonance imaging: type A, circular/symmetric cord with visible cerebrospinal fluid (CSF) between the cord and vertebral body; type B, circular/oval/symmetric cord with no visible CSF between the cord and vertebral body; type C, spinal cord that is fattened/deformed by the vertebral body, with no visible CSF between the cord and vertebral body. Furthermore, based on type C, the spinal cord compression ratio (CR) < 50% was defined as the subtype C-, while the spinal cord CR ≥ 50% was defined as the subtype C+. IONM event was documented, and a comparative analysis was made to evaluate the prevalence of IONM events among patients with diverse spinal cord types. A total of 294 patients were reviewed, including 73 in type A; 153 in type B; 53 in subtype C- and 15 in subtype C+. Lower extremity transcranial motor-evoked potentials and/or somatosensory evoked potentials were lost intraoperatively in 41 cases (13.9%), among which 4 patients with type C showed no return of spinal cord monitoring data. The 14 subtype C+ patients (93.3%) had IONM events. Univariate logistic regression analysis showed that patients with a type C spinal cord (subtype C-: odds ratio [OR], 10.390; 95% confidence interval [CI], 2.215-48.735; p = 0.003; subtype C+, OR, 497.000; 95% CI, 42.126- 5,863.611; p < 0.001) are at significantly higher risk of a positive IONM event during deformity correction compared to those with a type A. In further multiple logistic regression analysis, the spinal cord classification (OR, 5.371; 95% CI, 2.966-9.727; p < 0.001) was confirmed as an independent risk factor for IONM events. We presented a new spinal cord classification system based on the relative position of the spinal cord and vertebrae to predict the risk of IONM events in patients with kyphotic deformity. In patients with type C spinal cord, especially those in C+ cases, it is essential to be aware of potential IONM events, and adopt standard operating procedures to facilitate neurological recovery.

LGG-58. A MULTI-CENTER RETROSPECTIVE CASE SERIES OF SURGICAL OUTCOMES FOR INTRAVENTRICULAR JUVENILE PILOCYTIC ASTROCYTOMA

Abstract INTRODUCTION Juvenile pilocytic astrocytoma (JPA) is a common pediatric grade I astrocytoma. Prognosis is excellent with gross total resection (GTR) and 10-year survival rates of up to 95%. However, undesirable outcomes may occur, such as when tumors are in poorly accessible locations. Intraventricularly tumors present a unique surgical challenge due to their midline location in a fluid filled space with any intraparenchymal invasion involving critical neurologic structures. Here we retrospectively describe the clinical features of intraventricular JPA neoplasms from two centers to highlight the challenges in caring for this uncommon presentation. METHODS We retrospectively searched the electronic medical record from 2000-2023 for patients with neurosurgical treatment for intraventricular JPA at two centers. Intraventricular location was verified by a neuroradiologist. Data were collected on demographics, pathology, tumor location, extent of resection, adjuvant therapies, reoccurrence, progression, and neurological deficit. RESULTS We identified 28 surgical treated patients with intraventricular JPA. Females were 15/28 (54%) of patients with a mean age of 11.2±6.4 years. Most tumors presented in the 4th ventricle 15/28 (53.5%), followed by 9/28 (32%) in 3rd ventricle locations, and 4/28 (14%) in lateral ventricles. GTR was achieved in 12/28 patients (43%) and STR in 16/28 patients (57%). Progression/recurrence was noted in 8/28 (29%) and the 5-year PFS was 56% (10/18). Adjuvant treatment was used in 11/28 (39%) patients and repeat surgery was required in 4/28 patients (14%). Chemotherapy in 8/28 (29%) patients and radiation in 4/28 (14%) patients. A pre/post-operative neurological deficit was noted in 10/28 (36%) patients. A BRAF protein fusion was noted in 7 patients and 1 patient demonstrated a v600E mutation (some molecular data not available). Average follow up was 92 months with no deaths. CONCLUSION We observed that intraventricular JPA tumors commonly undergo subtotal resection with frequent progression/recurrence. Subsequently, recurrent surgeries and adjuvant therapies can be necessary.

Epidemiology and Treatment of Patients With Primary Open Angle Glaucoma in Germany: A Health Claims Data Analysis.

Based on a large administrative database of German claims data, our study provides current estimates of the prevalence and incidence of primary open angle glaucoma (POAG) in Germany and describes selected outcomes for prevalent patients with POAG. To estimate the prevalence and incidence of POAG in Germany, to describe the patient population in terms of comorbidity burden, routine care, and overall healthcare resource utilization (HCRU) and associated costs, and to describe treatment patterns over time in patients undergoing relevant laser procedures. Based on anonymized German claims data, we carried out a retrospective, noninterventional study covering calendar years 2016-2021. For the adult German population (≥18y), we estimated a POAG 1-year prevalence of 1.70% and a 1-year incidence of 0.17% in 2018; both increased with age, peaking in 80- to 89-year-olds. Prevalence and incidence were lower in 2020 (1.65% and 0.16%, respectively), the first year of the SARS-CoV-2 pandemic. Most patients solely received topical treatment. Most surgically treated patients underwent laser trabeculoplasty, followed by laser iridotomy, trabeculectomy, and filtration operations with implant. In patients undergoing laser trabeculoplasty, the treatment regimen was nearly unchanged in the second year after, compared with 2 years before the procedure. Multimorbidity was commonly observed; 75.5% of patients had arterial hypertension and 50.0% had disorders of lipoprotein metabolism and other lipidemias, compared with 60.1% and 39.2%, respectively, in an age- and sex-matched control sample. Our study provides insights into epidemiology and routine care of POAG in Germany and HCRU in prevalent patients. There was little change in treatment regimens in patients who underwent laser trabeculoplasty, 2 years after the procedure. Most patients were multimorbid highlighting the need for comprehensive care.

Lumbar parafacetal cyst-spinal segmental instability is the cause and stabilization is the treatment: A clinical report of eight surgically-treated patients.

The authors report the results of "only-fixation" of the affected spinal segment without any decompression of the bones or soft tissue or manipulation of the cyst wall or contents in eight cases having lumbar parafacetal cyst (LPFC). This surgical strategy was based on the concept that LPFCs are secondary to spinal instability, has a protective or adaptive role, and is reversible following stabilization. During the period from January 2018 to January 2023, eight consecutive patients having LPFC were surgically treated. There were 5 males and 3 females, and their ages ranged from 48 to 72 years (average 63 years). Seven patients had a single cyst and one patient had multiple cysts. The patients presented with symptoms classically attributed to lumbar canal stenosis. Apart from the cyst-affected spinal segment, degenerative alterations were observed in adjoining spinal segments in six out of seven patients having a single cyst. All patients underwent "only fixation" of the unstable spinal segments without any kind of bone or soft-tissue resection and without any manipulation or handling of the cyst wall or contents. During the follow-up period that ranged from 12 to 57 months (average 29 months), all patients improved from their symptoms. The recovery was observed in the immediate postoperative period and was lasting. LPFCs are one of the several secondary alterations observed in spinal degeneration. Identification of unstable spinal segments and their fixation constitutes rational treatment of lumbar parafacetal cysts. Direct handling and resection of cysts are unnecessary.

Heath-related quality of life and functional outcomes in patients with congenital or juvenile idiopathic scoliosis after an average follow-up of 25 years: a cohort study

Background ContextCongenital and juvenile scoliosis are both early-onset deformities that develop before the age of 10. Children are treated to prevent curve progression and problems in adulthood such as back pain and a decreased quality of life but literature on long-term outcomes remains scarce. PurposeTo evaluate the health-related quality of life (HRQoL) and potential disability of children with congenital scoliosis (CS) or juvenile idiopathic scoliosis (JIS) after a minimum of 20 years follow-up. Study DesignComparative cohort study. Patient SampleA consecutive cohort of CS and JIS patients were retrospectively identified from a single-center scoliosis database. Patients born between 1968 and 1981 and treated during skeletal growth were eligible for participation. Outcome MeasuresHRQoL (SF-36, SRS-22r, ODI). MethodsThe primary aim was to evaluate the HRQoL of CS and JIS patients using the general SF-36 questionnaire. Both patient cohorts were compared with age-matched national norms. The secondary aim was to analyze the differences between conservatively and surgically treated patients using the scoliosis-specific Scoliosis Research Society-22r questionnaire (SRS-22r) and the Oswestry Disability Index (ODI). T-tests were used for statistical comparison. ResultsIn total, 114 patients (67% of the eligible patients) completed the questionnaire, with a mean follow-up of 25.5±5.5 years after their final clinical follow-up. Twenty-nine patients with CS were included with a mean age of 44.4±3.8 years (79.3% female), and 85 patients with JIS with a mean age of 43.7±4.2 years (89.4% female). Of the SF-36 domains, only the vitality score (60.6±18.0 for CS and 58.1±17.6 for JIS cohort) and mental health score (70.0±18.4 for CS and 72.1±18.1 for JIS cohort) were significantly lower compared with the general population (68.6±19.3 for vitality, and 76.8±17.4 for mental health). These decreased scores were larger than the determined minimum clinically important difference threshold of 4.37. Surgically treated JIS patients had a significantly lower score on the SRS-22r pain domain than their nonsurgically treated peers (3.6±0.9 vs 4.1±0.7l p=.019). Surgically treated CS patients had a significantly higher score on the SRS-22r mental health domain than their nonsurgically treated peers (4.3±0.5 vs 3.5±1.0; p=.023). No significant differences were found in the other domains. ConclusionsExcept for vitality and mental health domains, congenital and juvenile idiopathic scoliosis patients treated during skeletal growth had similar HRQoL on most SF-36 domains in adulthood compared with national norms. Surgical treated JIS patients experienced more pain compared with brace treated patients, while braced CS patients had a significantly lower mental scores compared with surgical treated patients. These long-term outcomes are essential to inform patients and can guide shared decision-making between clinicians and patients.

A decision tree model to help treatment decision-making for severe spontaneous intracerebral hemorrhage.

Surgical treatment demonstrated a reduction in mortality among patients suffering from severe spontaneous intracerebral hemorrhage (SSICH). However, which SSICH patients could benefit from surgical treatment was unclear. This study aimed to establish and validate a decision tree (DT) model to help determine which SSICH patients could benefit from surgical treatment. SSICH patients from a prospective, multicenter cohort study were analyzed retrospectively. The primary outcome was the incidence of neurological poor outcome (modified Rankin scale as 4-6) on the 180th day posthemorrhage. Then, surgically-treated SSICH patients were set as the derivation cohort (from a referring hospital) and validation cohort (from multiple hospitals). A DT model to evaluate the risk of 180-day poor outcome was developed within the derivation cohort and validated within the validation cohort. The performance of clinicians in identifying patients with poor outcome before and after the help of the DT model was compared using the area under curve (AUC). One thousand two hundred sixty SSICH patients were included in this study (middle age as 56, and 984 male patients). Surgically-treated patients had a lower incidence of 180-day poor outcome compared to conservatively-treated patients (147/794 vs. 128/466, P <0.001). Based on 794 surgically-treated patients, multivariate logistic analysis revealed the ischemic cerebro-cardiovascular disease history, renal dysfunction, dual antiplatelet therapy, hematoma volume, and Glasgow coma score at admission as poor outcome factors. The DT model, incorporating these above factors, was highly predictive of 180-day poor outcome within the derivation cohort (AUC, 0.94) and validation cohort (AUC, 0.92). Within 794 surgically-treated patients, the DT improved junior clinicians' performance to identify patients at risk for poor outcomes (AUC from 0.81 to 0.89, P <0.001). This study provided a DT model for predicting the poor outcome of SSICH patients postsurgically, which may serve as a useful tool assisting clinicians in treatment decision-making for SSICH.

Radical hysterectomy case volume and cervical cancer treatment in the era of COVID-19: A multi-site analysis of National Cancer Institute-designated Comprehensive Cancer Centers

ObjectiveTo compare radical hysterectomy case volume, cancer stage, and biopsy-to-treatment time of invasive cervical cancer diagnosed before and after onset of the COVID-19 pandemic. MethodsIn a multi-institution retrospective cohort study conducted at 6 large, geographically diverse National Cancer Institute-designated cancer centers, patients treated for newly diagnosed invasive cervical cancer were classified into 2 temporal cohorts based on date of first gynecologic oncology encounter: (1) Pre-Pandemic: 3/1/2018–2/28/2020; (2) Pandemic & Recovery: 4/1/2020–12/31/2021. The primary outcome was total monthly radical hysterectomy case volume. Secondary outcomes were stage at diagnosis and diagnosis-to-treatment time. Statistical analyses used chi-squared and two sample t-tests. ResultsBetween 3/1/2018–12/31/2021, 561 patients were diagnosed with cervical cancer. The Pre-Pandemic and Pandemic & Recovery cohorts had similar age, race, ethnicity, smoking status, and Body Mass Index (BMI). During Pandemic & Recovery, the mean monthly radical hysterectomy case volume decreased from 7[SD 2.8] to 5[SD 2.0] (p = 0.001), the proportion of patients diagnosed with Stage I disease dropped from 278/561 (49.5%) to 155/381 (40.7%), and diagnosis of stage II-IV disease increased from 281/561 (50.1%) to 224/381 (58.8%). Primary surgical management was less frequent (38.3% Pandemic & Recovery versus 46.7% Pre-Pandemic, p = 0.013) and fewer surgically-treated patients received surgery within 6 weeks of diagnosis (27.4% versus 38.9%; p = 0.025). ConclusionsLower radical hysterectomy case volume, a shift to higher cervical cancer stage, and delay in surgical therapy were observed across the United States following the COVID-19 outbreak. Decreased surgical volume may result from lower detection of early-stage disease or other factors.

Osteochondral Lesions of the Subtalar Joint: Clinical Outcomes in 11 Patients.

The purpose of this retrospective case series was to evaluate clinical outcomes following both conservative treatment and arthroscopic bone marrow stimulation (BMS) for the management of symptomatic subtalar osteochondral lesions (OCLs). All symptomatic subtalar OCLs with a minimum of 12 months follow-up having undergone either a conservative management or arthroscopic procedure were included. Patient-reported outcomes were collected via questionnaires consisting of the Foot and Ankle Outcome Score (FAOS), Numeric Rating Scale (NRS) of pain in rest, during walking, during stair climbing, and during running. In addition, return to sports data, return to work data, reoperations, and complications were collected and assessed. In total, 11 patients across 2 academic institutions were included (3 males, 8 females). The median age was 43 years (interquartile range [IQR]: 32-53). All patients underwent conservative treatment first; in addition, 9 patients underwent subtalar arthroscopic debridement with or without BMS. The median follow-up time was 15 months (IQR: 14-100). In the surgically treated group, the median NRS scores were 2 (IQR: 1-3) during rest, 3 (IQR: 2-4) during walking, 4 (IQR: 4-5) during stair climbing, 5 (IQR: 4-5) during running and the median FAOS score at final follow-up was 74 (IQR: 65-83). In the conservatively treated patients, the median NRS scores were all 0 (IQR: 0-0) and the median FAOS scores were 90 (IQR: 85-94). In the group of surgical treated patients, 4 were able to return to the same level of sports, 2 returned to a lower level of sports. Both conservatively treated patients returned to the sport and the same level of prior participation. All patients except one in the surgical group returned to work. This retrospective case series demonstrated that a high number of patients converted to surgery after initial conservative treatment. In addition, debridement and BMS show good clinical outcomes for the management of symptomatic subtalar OCLs at short-term follow-up. No complications nor secondary surgical procedures were noted in the surgically treated group. The high rate of failure of conservative treatment suggests that surgical intervention for symptomatic subtalar OCLs can be the primary treatment strategy; however, further research is warranted in light of the small number of patients.

Comparison of Bone Healing and Delayed or Nonunion Rates Between Operatively and Non- operatively Treated Displaced Zone 1 Fifth Metatarsal Fractures

Category: Midfoot/Forefoot; Other Introduction/Purpose: Acute fractures of the proximal fifth metatarsal are one of the most common injuries to the foot, occurring in up to 70% of all metatarsal fractures1. Displaced zone 1 fractures of the fifth metatarsal with greater than 2 mm fracture gap or those comprising greater than 30% of the cubometatarsal joint warrant operative treatment with open reduction internal fixation (ORIF)2,7, as satisfactory bone healing and patient-reported outcomes have been reported previously8–13. More recently, a few studies have demonstrated good functional outcomes after conservative treatment of zone 1 fractures with initial displacement greater than 2 mm7,13. Nevertheless, the lack of comparative studies and conflicting available evidence of outcomes warrant further investigation on this topic. Methods: A chart review was conducted to identify patients with displaced zone 1 fractures of the fifth metatarsal. Age at time of injury, gender, smoking and diabetes history, were collected. Degree of fracture displacement were measured (mm) on AP, lateral, and oblique view radiographs obtained at the initial encounter. Non-operatively treated patients were instructed to weightbear as tolerated in a Controlled Ankle Motion (CAM) boot for 6 weeks. Surgically-treated patients were placed in a short-leg splint for 2 weeks, and remained non-weightbearing in a CAM boot until 6 week period. They transitioned to normal shoe wear at the 8 week postoperative period. Chart notes were reviewed to identify the time to complete healing and incidences of delayed or nonunion. Means were compared using a one-way ANOVA or Kruskal Wallis test depending on normality, and categorical variables were compared using Chi-square or Fisher’s exact test. Results: The average time to complete healing was greater in non-operatively treated patients by 3 weeks (17.1 vs. 14.1, p=0.282). 4/37 (10.8%) non-operatively treated patients experienced delayed or non-union whereas 4/38 (13.2%) operatively-treated patients experienced delayed or non-union. This difference was statistically non-significant. The average fracture displacement (mm) on the oblique view was significantly greater in operatively-treated patients (2.68 vs. 5.40, p&lt; 0.001). For patients with fracture gaps greater than 2 mm on the oblique view, non-operatively treated patients took 20.9 weeks whereas operatively- treated patients took 11.8 weeks to reach complete healing (p &lt; 0.01). Conclusion: Patients who were treated non-operatively for displaced zone 1 fractures of the fifth metatarsal took on average 3 weeks longer to reach complete healing than operatively-treated patients. For patients with fracture gap greater than 2 mm on the oblique view, operative treatment was associated with significantly reduced time to complete healing.

Association of patient and tumor characteristics with outcomes in young patients with head and neck squamous cell carcinoma (HNSCC).

e18054 Background: HNSCC is increasingly being diagnosed in a younger population, with a variable prognosis. While studies have evaluated outcomes in young compared to older patients, evaluation of prognostic factors specifically in younger patients, that may help guide treatment decisions, is needed. Therefore, we conducted a retrospective study to investigate the association of patient and tumor characteristics with disease specific survival (DSS) in HNSCC patients ≤45 years old (yo). Methods: Patients treated at the University of Pittsburgh Medical Center from January 1, 2007 to June 30, 2020, that were ≤45 yo at time of diagnosis with HNSCC without distant metastatic disease, were included. Those who received treatments at other institutions and who had no follow-up after index treatments were excluded. Patient demographics, social history, tumor pathology and treatment course were collected. The primary endpoint of DSS was defined as the interval between the time of pathologic diagnosis and the time of cancer-related death. Proportional hazards regression was applied separately for surgically and non-surgically treated patients. A multivariate analysis was conducted for surgically treated patients only. Results: 230 patients were included. Median age was 42, 73% male, 45% oral cavity primary, 35% oropharynx (89% Human papillomavirus positive), 14% larynx, 69% were smokers, and 73% received combined modality therapy. 35% of patients had a recurrence with the majority locoregional only (61%). Median DSS was not reached. The 5 year DSS was 73% (95% CI 67% to 80%). There was no difference in DSS between surgically treated (n = 169) and non-surgically treated (n = 61, p = 0.94) patients. For surgically treated patients, univariate analysis showed significantly worse DSS in those with higher pathologic T and N stages, positive margins, perineural invasion (PNI), extranodal extension (ENE), and negative HPV status. For non-surgically treated patients, only negative HPV status was associated with significantly worse DSS (p = 0.034). In the multivariate analysis for surgical treated patients, which included all significant characteristics from univariate analysis, pathologic T and N stage, positive margins, (HR 4.92, 95% CI 1.98-12.25, p = 0.006) and PNI (HR 2.66, 95% CI 1.17-6.08, p = 0.02) were significantly associated with worse DSS. Conclusions: Pathologic T and N stage, positive margins, and PNI are independently associated with significantly worse DSS in surgically treated HNSCC patients aged ≤45. Compared with classic prognostic factors seen in the overall population with HNSCC, PNI may be a uniquely strong prognostic factor in younger-aged HNSCC patients.

Management of Paget-Schroetter: a Systematic Review and Meta-Analysis

Objective: Effort induced subclavian vein thrombosis, also known as Paget-Schroetter syndrome (PSS) can be treated non-operatively with direct oral anticoagulation (AC), with percutaneous catheter directed thrombolysis (CDT), first rib resection (FRR), or a combination of treatments. Currently, there is no consensus on the optimal management of PSS. The objective of this study was to summarise the current evidence for management of PSS with explicit attention to the clinical outcomes of different management strategies. The main questions to be addressed were: Is surgical management of PSS consisting of CDT followed by FRR superior to non-operative management with AC? Does the use of CDT improve the outcomes of non-operative treated patients? Does the use of CDT improve the outcomes of surgical treated patients with PSS?

Factors Associated with Adverse Outcomes in Cameroonian Patients with Traumatic Brain Injury: A Cross-Sectional Study.

The burden of traumatic brain injury (TBI) disproportionately affects low- and middle-income countries. In Cameroon, the estimated annual incidence rate is 572 cases per 100,000 people. This study investigated factors associated with adverse outcomes in the management of Cameroonian patients with TBI. This cross-sectional study included all patients with TBI treated between January 1 and December 31, 2018, at 2 Cameroonian referral hospitals. Sociodemographic and clinical data were extracted from patient charts and admission registries and analyzed with SPSS v.26. Independent t tests, odds ratios, and cumulative mortality hazard rates were computed. A P-value <0.05 was considered statistically significant. Also, binomial regression analyses were calculated. One hundred seventy-one patients aged 38.63±20.46years old received treatment for TBI. Most patients were male (78.9%), Cameroonian (98.2%), from urban areas (75.4%), and uninsured (88.8%). The average admission length was 11.23±10.71days, during which 27.5% of patients received surgical treatment while 72.5% received non-surgical (conservative) management. From postdischarge day 12 onwards, surgically-treated patients had a greater cumulative mortality hazard rate than conservatively-treated patients. By 28days postdischarge, 66.1% of patients had recovered completely [Glasgow Outcome Scale (GOS)= 5], 23.4% had a disability (GOS=2-4), and 10.5% expired (GOS=1). Complete recovery was associated with the absence of severe TBI (B=-1.42, standard error [SE]=0.52, P= 0.006), disability was associated with increased injury-to-admission delay (B=-1.27, SE=0.48, P= 0.009), and death was associated with severe TBI (B= 3.16, SE=0.73, P < 0.001). We identified factors associated with unfavorable outcomes among Cameroonian patients with TBI. These results can inform triage and referral practices and aid policymakers in developing context-specific prehospital guidelines.

Treatment and Outcome of Osteoporotic Thoracolumbar Vertebral Body Fractures With Deformation of Both Endplates With or Without Posterior Wall Involvement (OF 4): Short-Term Results from the Prospective EOFTT Multicenter Study.

Multicenter prospective cohort study. To analyse therapeutical strategies applied to osteoporotic thoracolumbar OF 4 injuries, to assess related complications and clinical outcome. A multicenter prospective cohort study (EOFTT) including 518 consecutive patients who were treated for an Osteoporotic vertebral compression fracture (OVCF). For the present study, only patients with OF 4 fractures were analysed. Outcome parameters were complications, Visual Analogue Scale, Oswestry Disability Questionnaire, Timed Up & Go test, EQ-5D 5L, and Barthel Index after a minimum follow-up of 6weeks. A total of 152 (29%) patients presented with OF 4 fractures with a mean age of 76years (range 41-97). The most common treatment was short-segment posterior stabilization (51%; hybrid stabilization in 36%). Mean follow up was 208 days (±131days), mean ODI was 30 ± 21. Dorsoventral stabilized patients were younger compared to the other groups (P < .001) and had significant better TuG compared to hybrid stabilization (P = .049). The other clinical outcomes did not differ in the therapy strategies (VAS pain: P = 1.000, ODI: P > .602, Barthel: P > .252, EQ-5D 5L index value: P > .610, VAS-EQ-5D 5L: P = 1.000). The inpatient complication rate was 8% after conservative and 16% after surgical treatment. During follow-up period 14% of conservatively treated patients and 3% of surgical treated patients experienced neurological deficits. Conservative therapy of OF 4 injuries seems to be viable option in patients with only moderate symptoms. Hybrid stabilization was the dominant treatment strategy leading to promising clinical short-term results. Stand-alone cement augmentation seems to be a valid alternative in selected cases.