Treatment Decisions For Patients Research Articles

Predictive value of technetium-99m sodium pertechnetate thyroid scintigraphy in determining the permanence of congenital hypothyroidism

Objectives: We aim to investigate the predictive value of [99mTc] pertechnetate thyroid scintigraphy in determining the permanence of congenital hypothyroidism (CH). Material and Methods: A retrospective analysis of [99mTc] pertechnetate thyroid scans performed for evaluation of CH at the Nuclear Medicine Unit of a hospital in Hong Kong between January 1, 2008, and December 31, 2018, was conducted. Scintigraphic findings and parameters at diagnosis, including thyroid stimulating hormone (TSH), free thyroxine (fT4), gender, and gestational age, were reviewed. The need for lifelong thyroxine replacement therapy was reviewed. Results: The study included 85 subjects, with 74 (87.1%) presenting with eutopic thyroid and 11 (12.9%) showing thyroid dysgenesis. Patients with scintigraphic evidence of thyroid dysgenesis required permanent thyroid hormone replacement therapy. Among the patients with eutopic thyroid, a higher TSH level was associated with the need for lifelong thyroid hormone replacement therapy (cutoff TSH value 18.72 mIU/L, sensitivity 77.3% and specificity 53.8%). Gender, gestational age, and fT4 did not show significant differences between the transient and permanent CH groups in patients with eutopic thyroid. Conclusion: Scintigraphic findings of thyroid dysgenesis indicate a high prevalence of permanent CH. In patients with eutopic thyroid, higher TSH levels predict the requirement for lifelong thyroid hormone replacement therapy. These results provide insights into the prediction of CH and aid in individualized treatment decisions for patients with CH.

Fluid structure Interaction analysis for rupture risk assessment in patients with middle cerebral artery aneurysms

Accurate rupture risk assessment is essential for optimizing treatment decisions in patients with cerebral aneurysms. While computational fluid dynamics (CFD) has provided critical insights into aneurysmal hemodynamics, most analyses focus on blood flow patterns, neglecting the biomechanical properties of the aneurysm wall. To address this limitation, we applied Fluid-Structure Interaction (FSI) analysis, an integrative approach that simulates the dynamic interplay between hemodynamics and wall mechanics, offering a more comprehensive risk assessment. In this study, we used advanced FSI techniques to investigate the rupture risk of middle cerebral artery bifurcation (MCA) aneurysms, analyzing a cohort of 125 patients treated for a MCA aneurysm at Kepler University Hospital, Linz, Austria. Multivariate analysis identified two significant rupture predictors: High Equivalent Stress Area (HESA; p = 0.049), which quantifies stress distribution relative to the aneurysm surface, and Gaussian curvature (GLN; p = 0.031), which captures geometric complexity. We also introduce the HGD index, a novel composite metric combining HESA, GLN, and Maximum Wall Displacement, designed to enhance predictive accuracy. With a threshold of 0.075, the HGD index exhibited excellent diagnostic performance; in internal validation, 24 of 25 ruptured aneurysms surpassed this threshold, yielding a sensitivity of 0.96. In a 5-fold cross validation the reliability of results was confirmed. Our findings demonstrate that the HGD index provides superior rupture risk stratification compared to conventional single-parameter models, offering a more robust tool for the assessment of complex aneurysmal structures. Further multicenter studies are warranted to refine and validate the HGD index, advancing its potential for clinical application and improving patient outcomes.

Prognostic and Predictive Values of F-18 FDG PET/CT Volumetric Parameters in Small Cell Lung Cancer

Introduction: Volumetric parameters of the 18F-FDG PET/CT can contribute to the treatment decision in high risk patients. In the present study, we aimed to examine the predictive, prognostic, and clinical value of PET/CT by using the two volumetric parameters: metabolic tumor volume (MTV) and total lesion glycolysis (TLG), SUVmax to concurrently evaluate survival data in patients diagnosed with small cell lung cancer (SCLC). Methods: 244 patients with SCLC, who underwent 18F-FDG PET/CT imaging for staging purpose were enrolled. Primary tumor SUVmax, MTV (40-70%) and TLG (40-70%) obtained from PET/CT were documented. Results: All lesions (n=244) showed 18F-FDG uptake, mean SUVmax of 19.74±8.71 [range (min – max) = 3.80 - 58.80]. SUVmax was significantly higher in tumors with diameters > 2 cm compared to those with diameters ≤ 2 cm (p=0.000). The mean survival time was significantly shorter in patients with tumor diameter greater than 2 cm, locoregional LN involvement, distant nodal metastasis, or distant organ metastasis (p=0.019, p

Local excision for T1 rectal cancer: A population-based study of practice patterns and oncological outcomes.

Local excision (LE) for T1 rectal cancer may be recommended in those with low-risk disease, while resection is typically recommended in those with a high risk of luminal recurrence or lymph node metastasis. The aim of this work was to compare survival between resection and LE. This was a population-based retrospective cohort study set in the Canadian province of Ontario. Patients were individuals with T1Nx rectal cancer between 2010 and 2014 and demographics, disease characteristics, treatments and outcomes were determined using linked administrative databases. This study does not include clinical information regarding individual patient treatment decisions. The main outcome measure was overall survival (OS). A total of 719 patients were identified, including 359 with upfront resection, 113 with LE and immediate resection (<90 days) and 247 with LE with definitive intent. The majority of LEs were performed via colonoscopy. Piecemeal excision (42% vs. 49%, p = 0.28) and positive margin (50% vs. 77%, p < 0.01) rates were high in both LE groups, with the highest rate in those with immediate resection. The prevalence of poor differentiation (<5%, p = 0.70) and lymphovascular invasion (LVI) (14%, p = 0.80) was similar across groups. In those with LE with definitive intent, 21% ultimately underwent resection (median 150 days, interquartile range 114-181 days) and 4% received radiation. There was no difference in 5-year OS between groups (resection83.2% vs. LE and immediate resection82.3% vs. definitive LE 83.3%; p = 0.33). Adjusted analyses demonstrated no association between approach and survival [definitive intent LE hazard ratio (HR) 0.97 (95% CI 0.70-1.35), LE and immediate resection HR 0.97 (95% CI 0.60-1.45), upfront resection HR 1 (Ref); p = 0.98]. Differentiation, piecemeal excisions and LVI were not associated with OS in the LE groups. There were no observed differences in survival between those who underwent resection, LE and immediate resection and definitive intent LE. Although, these are observational data, they call into question the reflexive decision to offer radical resection for those with suspected T1 rectal cancer.

Risk factors for mortality in patients receiving extracorporeal membrane oxygenation

Objective Patients on extracorporeal membrane oxygenation (ECMO) are often complex and have a high mortality rate. Currently, risk assessment and treatment decisions for patients receiving ECMO are controversial. Therefore, we sought to identify risk factors for mortality in patients receiving ECMO and provide a reference for patient management. Methods We retrospectively analyzed the clinical data of 199 patients who received ECMO support from December 2013 to April 2023. Univariate and multivariable logistic regression analyses were used to identify risk factors. The cutoff value was determined by receiver operating characteristic (ROC) curve analysis. Results A total of 199 patients were selected for this study, and the mortality rate was 76.38%. More than half of the patients underwent surgery during hospitalization. Multivariable logistic regression analysis revealed that continuous renal replacement therapy (CRRT) implantation (OR = 2.994; 95% CI, 1.405–6.167; p = 0.004) and age (OR = 1.021; 95% CI, 1.002–1.040; p = 0.032) were the independent risk factors for mortality. In the ROC curve analysis, age had the best predictive effect (AUC 0.646, 95% CI 0.559–0.732, p = 0.003) for death when the cutoff value was 48.5 years. Furthermore, in patients receiving combined CRRT and ECMO, lack of congenital heart disease and previous surgical history were the independent risk factors for mortality. Conclusions CRRT implantation and age were independent risk factors for patients with ECMO implantation in a predominantly surgical cohort. In patients receiving a combination of CRRT and ECMO, lack of congenital heart disease and previous surgical history were independent risk factors for mortality.

Genetic diversity and variation in chronic myeloid leukemia patients of Indian origin- Implications for treatment response and prognosis

Chronic myeloid leukemia (CML) is a prevalent blood malignancy characterized by the breakpoint cluster region - abelson tyrosine kinase gene translocation (BCR-ABL1) fusion gene. In India, CML accounts for a significant portion of adult leukemias, with a notable male preponderance and an increasing trend in young adult patients. Most patients present in the chronic phase, and the Sokal/European treatment and outcome study score (EUTOS)/Hasford scoring systems may be used for risk stratification. The advent of imatinib revolutionized CML treatment, making it more accessible, although challenges such as intolerance and treatment failure persist. Cytogenetic analysis is essential for diagnosis and monitoring, with molecular assessments indicating treatment response. Compliance plays a crucial role in achieving optimal outcomes, with non-adherence associated with poorer prognosis. Mutational analysis aids in treatment decisions for patients with suboptimal response to tyrosine kinase inhibitors, revealing resistance patterns. Toxicity profiles resemble Western data, with anemia being the most common hematological toxicity. Despite limitations in resources and late presentations, Indian CML outcomes mirror Western standards, highlighting the importance of standardized cytogenetic testing for improved clinical outcomes.

Clinical performance of endoscopic ultrasound-guided tissue acquisition for perivascular soft-tissue cuffing suspected to be extravascular migratory metastases of pancreatic or bile duct cancer (with video).

This study aimed to investigate the diagnostic performance and safety of endoscopic ultrasound-guided tissue acquisition (EUS-TA) for perivascular soft-tissue cuffing (PSTC). This single-center, retrospective study evaluated patients in whom EUS-TA was performed for PSTC in pancreatic or bile duct cancer lesions between October 2017 and March 2024. PSTC was defined as a perivascular soft-tissue area contiguous with nearby blood vessels from the suspected primary tumor. EUS-TA procedures and outcomes, including technical success, diagnostic performance, adverse events, and comparison with contrast-enhanced computed tomography (CECT), were analyzed. Of 1803 patients, 53 underwent EUS-TA for PSTC. The sensitivity, specificity, and accuracy were 92.1%, 100%, and 92.5%, respectively. The technical success rate was 98.1% (52/53). The adverse event rate was 1.9%. EUS-TA for PSTC was significantly superior to CECT for PSTC in terms of diagnostic accuracy. Furthermore, the diagnostic performance and adverse event rates for EUS-TA for PSTC were comparable to those for TA in solid tumors. Shorter puncture lengths were associated with lower accuracy. EUS-TA for PSTC in pancreatic or bile duct cancer demonstrates high diagnostic accuracy and a low rate of adverse events, showing superior diagnostic performance compared to CECT. These findings suggest that EUS-TA for PSTC can be performed safely and is a clinically beneficial procedure. Despite the technical challenges, EUS-TA for PSTC can influence clinical judgment and should be considered in skilled institutions for future patient treatment decisions. Prospective multicenter studies are warranted to further evaluate its efficacy and safety.

Effectiveness of tofacitinib versus tumor necrosis factor inhibitors and in those receiving tofacitinib as different lines of therapy in patients with rheumatoid arthritis: results from the United States CorEvitas Rheumatoid Arthritis Registry.

To compare effectiveness of tofacitinib versus tumor necrosis factor inhibitors (TNFi), and across tofacitinib lines of therapy, in patients with rheumatoid arthritis (RA), using USCorEvitas RA Registry data. Analysis included patients with RA initiating tofacitinib or TNFi with a 12-month follow-up visit between November 2012-February 2021. Primary (Clinical Disease Activity Index-defined low disease activity [CDAI-LDA: CDAI ≤ 10]) and secondary (clinical/disease activity/patient-reported) effectiveness outcomes were assessed at month 12. Outcomes were stratified by treatment regimen (overall tofacitinib vs overall TNFi/tofacitinib monotherapy vs tofacitinib combination therapy/TNFi monotherapy vs TNFi combination therapy/tofacitinib monotherapy vs TNFi combination therapy/tofacitinib combination therapy vs TNFi combination therapy), or tofacitinib line of therapy (2nd/3rd/ ≥ 4th line). 3,481 eligible patients initiated tofacitinib (n = 805) or TNFi (n = 2,676). Improvements in effectiveness at month 12 were generally similar across treatment regimens; 25.1% and 30.1% of overall tofacitinib and TNFi initiators achieved CDAI-LDA, respectively (oddsratio 1.29 [95% confidence interval (CI) 0.94, 1.76]). Odds ratios (95%CIs) for achieving CDAI-LDA at 12months were 0.70 (0.36, 1.37) for 3rd- versus 2nd-line, and 1.09(0.63,1.88) for3rd- versus ≥ 4th-line tofacitinib initiators. At month 12, mean change from baseline in CDAI was greater among 3rd- versus ≥ 4th-line tofacitinib initiators, and mean Health Assessment Questionnaire and patient-reported pain were greater in 3rd- versus 2nd-line and ≥ 4th- versus 3rd-line tofacitinib initiators. Generally, there were no differences in effectiveness between tofacitinib versus TNFi regimens. Few differences were observed between tofacitinib lines of therapy; sample sizes were small for 2nd/3rd-line initiators. NCT01402661 (ClinicalTrials.gov; July 25, 2011). Key Points • Using data from the US CorEvitas rheumatoid arthritis (RA) Registry, this study compared the effectiveness of tofacitinib versus tumor necrosis factor inhibitors (TNFi) and across tofacitinib lines of therapy. • Effectiveness of tofacitinib was similar to TNFi regimens up to month 12, while differences in some effectiveness outcomes at month 12 were observed with tofacitinib across different lines of therapy. • The findings of this study may inform future treatment decision-making in patients with RA.

Nurse-Led Multicomponent Behavioral Activation Intervention for Patients With Atrial Fibrillation: A Randomized Controlled Trial.

Patients with atrial fibrillation (AF) are often ill-equipped for shared decision-making. This study investigated the effects of a patient empowerment care model on patient-reported health outcomes and treatment decision-making in patients with AF. This randomized controlled trial prospectively randomized patients with AF to receive standard care (n=194) or a 13-week nurse-led multicomponent behavioral activation intervention (n=198). The intervention consisted of risk profile assessments, empowered shared decision-making regarding the use of oral anticoagulants (OACs), empowered AF self-management, and increased access to professional advice. The primary outcome was health-related quality of life measured after the completion of the intervention (T1), while the secondary outcomes were patient-physician decision concordance regarding OAC use, actual OAC use, AF knowledge, medication adherence, anxiety, and depression. The intervention group showed significantly greater improvements in health-related quality of life (β, -6.702 [95% CI, -9.556 to -3.847]; P<0.001), AF knowledge (β, -1.989 [95% CI, -2.342 to -1.635]; P<0.001), and medication adherence (β, 0.340 [95% CI, 0.148-0.532]; P<0.001) at immediate post-intervention compared with the control group, and the improvements were sustained at 6 months for all outcomes. A higher proportion of patients in the intervention group were prescribed an OAC compared with the control group at 6 months (odds ratio, 5.870 [95% CI, 1.957-12.331]; P=0.012). No significant between-group differences were detected for patient-physician decision concordance regarding OAC use, anxiety, or depression at both time points. The nurse-led multicomponent behavioral activation intervention improved patient-reported outcomes and increased OAC prescription among patients with AF.

The IMproving treatment decisions for Patients with AortiC stenosis Through Shared Decision Making (IMPACT SDM) Study: study protocol for a cluster randomized stepped wedge trial

BackgroundThe American College of Cardiology, American Heart Association, and Centers for Medicare and Medicaid Services recommend shared decision-making (SDM) for patients with severe aortic stenosis choosing between transcatheter aortic valve replacement (TAVR) and surgical aortic valve replacement (SAVR). Although tools such as patient decision aids (DAs) and training in SDM have been shown to improve SDM, implementation of SDM and DAs is limited. The IMproving treatment decisions for Patients with AortiC stenosis Through Shared Decision Making (IMPACT SDM) study aims to (1) determine the effectiveness of the interventions (a DA and clinician SDM training) in achieving SDM (primary outcome) and improving the quality of decisions about aortic valve replacement, (2) determine the reach of the DAs and adoption of training, and (3) explore potential mechanisms of effectiveness and implementation at the patient-, clinician-, and clinic-level.MethodsThe study is a hybrid type II effectiveness-implementation study using a cluster randomized batched stepped wedge trial with 8 sites across the USA. Eligible patients will be surveyed before and after visits with the heart valve team; clinicians will be surveyed after visits. Reach of DAs and adoption of training will be tracked. Clinicians will be interviewed regarding barriers and facilitators to implementation.DiscussionThe IMPACT SDM Study seeks to provide evidence of the ability of the interventions to improve SDM and decision quality, and also to shed light on barriers and facilitators to SDM implementation to promote future implementation efforts.Trial registrationClinicalTrials.gov NCT06171737. Registered on December 15, 2023.

Current Trends in Treating Malignant Pleural Effusion: Evidence, Guidelines, and Best Practice Recommendations.

Malignant pleural effusion (MPE) is common in individuals with cancer and typically reflects advanced disease. Most cases are symptomatic, with dyspnea and pain having a severe effect on the patient's quality of life (QOL). The management of MPE aims to relieve symptoms, improve QOL, prevent repeated pleural interventions, and minimize hospital admissions. Common treatments for MPE that provide symptomatic relief include thoracentesis, chemical (talc) pleurodesis, or indwelling pleural catheters (IPCs). Talc pleurodesis and IPCs are the mainstay of treatment but represent very different treatment strategies: talc pleurodesis is an inpatient procedure, whereas IPCs are an ambulatory strategy. Given their similar efficacy, treatment decisions in MPE are often determined by other factors, such as the patient's clinical characteristics, individual treatment goals, and preferences for hospital-based or home-based care. We provide a summary of the evidence for different interventions for treating MPE and compare recommendations from the major American, European, British, and Spanish guidelines regarding when to consider each treatment. We highlight specific challenging treatment scenarios and key clinical considerations that may influence treatment decisions for different patients. There are barriers to accessing and receiving evidence-based care. Patients with symptomatic MPE would benefit from early referral from oncology teams to pleural services. We provide best practice recommendations for optimal referral and coordination of care to ensure that patients receive maximum benefits from their interventions.

Impact of circulating tumor human papillomavirus DNA kinetics on disease outcomes in HPV-associated oropharyngeal cancer.

Circulating tumor tissue modified (TTMV)-HPV DNA has emerged as a promising biomarker in human papillomavirus associated oropharyngeal squamous cell carcinoma (HPV-OPSCC). The objective of this study was to assess ctHPVDNA TTMV clearance kinetics during RT and its relationship with progression in HPV-OPSCC. We identified 80 non-metastatic HPV-OPSCC patients with 366 TTMV samples who underwent prospective plasma TTMV testing before, during and after curative intent RT or CRT between June 2021 and February 2023. Patients with rapid favorable clearance (>95% decline from pre-treatment value) of TTMV were compared to those with suboptimal clearance (<95%). The primary objective was to evaluate the relationship between TTMV clearance during CRT and its impact on progression free survival (PFS). The median follow-up was 14.7 months. Clinical nodal stage was associated with higher TTMV-HPV DNA scores at baseline, with a median score of 128, 778, and 1219 for N0/N1, N2a/b, and N2c/3 patients, respectively. Patients who had persistent TTMV at the end of RT had an inferior PFS compared to those who cleared their TTMV at 2 years (91.7% vs. 71.7%) (log rank, p = .042). Among patients who had complete clearance of their TTMV at 3 months, those who had a negative, equivocal, and incomplete PET response had a 2-year PFS of 94.3%, 77.8%, and 59.3%, respectively (log-rank, p = .029). Our study indicates that persistent TTMV-HPV DNA is associated with worse PFS and may portend unfavorable outcomes. Thus, monitoring TTMV clearance kinetics could be a valuable biomarker for guiding treatment decisions in patients with HPV-OPSCC.

Cost-minimizing thresholds and recurrence rates in surgical evacuation with adjunctive middle meningeal artery embolization versus evacuation alone.

Cost-minimization approaches for the treatment of patients with chronic subdural hematoma (cSDH) are important given the increasing incidence of this pathology, particularly among elderly patients receiving antiplatelet and anticoagulation medications. The use of middle meningeal artery embolization (MMAE) as an adjunct to surgical evacuation has shown promise in reducing surgical recurrence; however, additional costs are involved with this procedure. Using their institutional experience, the authors identified thresholds for cost and the cSDH surgical recurrence rate that could influence treatment decisions in patients requiring surgical evacuation for cSDH. All patients who underwent cSDH evacuation surgery (ES) with concomitant MMAE or ES alone from January 2019 through August 2023 were identified. The authors collected hospital-related costs for the initial admission and any subsequent admissions to address surgical recurrence (rescue surgery [RS]) and conducted cost-minimization analyses. Base-case scenario calculations were supplemented with 1- and 2-way sensitivity analyses to study cost-minimizing variables. Demographic characteristics, comorbidities, and presenting symptoms did not significantly differ between patients who received ES/MMAE (n = 44) and those who received ES (n = 100). ES/MMAE procedures required a mean ± SD 79.3 ± 34.8 minutes whereas ES alone required 54.3 ± 25.9 minutes (p < 0.01), and patients who underwent ES/MMAE had a greater immediate postoperative hemorrhage volume reduction (-62.5% ± 22.1% vs -54.3% ± 21.3%, p = 0.04). No differences in the rates of 30-day complications, readmissions, or mortality were observed (all p > 0.05), but the ES/MMAE cohort had no reoperations after initial surgery whereas 14% in the ES-alone cohort required RS (p < 0.01). The base-case calculations indicated that ES alone minimizes costs more than ES/MMAE when there is no RS. Two-way sensitivity analyses revealed that, given a 14% probability of RS for the ES-alone group and 0% for the ES/MMAE cohort, ES/MMAE becomes cost-minimizing when the costs for ES/MMAE are kept below $21,000. With these same failure rates and cost of ES/MMAE, if ES costs exceed $32,000, ES/MMAE becomes cost-minimizing. Although ES/MMAE is more efficacious for the prevention of surgical recurrence in patients requiring surgical evacuation of cSDH than ES alone, ES alone remains the cost-minimizing option. However, in select situations, as with a low RS rate and low cost for ES/MMAE or a high RS rate and high cost for ES alone, then ES/MMAE also becomes the cost-minimizing option. These thresholds can be used in combination with institutional costs and RS rates to help guide clinical and economic decision-making.

Mutation- and MRD-informed treatment decisions for the transplant-eligible AML patient.

Acute myeloid leukemia (AML) is classified by risk groups according to a number of genetic mutations, which may occur alone or in combination with other mutations and chromosomal abnormalities. Prognosis and appropriate therapy can vary significantly based on a patient's genetic risk group, making mutation-informed decisions crucial to successful management. However, the presence of measurable residual disease (MRD) after induction and consolidation therapy, before hematopoietic cell transplant, and during posttransplant monitoring can be even more significant to patient prognosis than their genetic subtype. Clinicians must select MRD-monitoring methods most appropriate for a patient's genetic profile and a treatment regimen that considers both a patient's primary genetic subgroup and other risk factors, including MRD information. Recent clinical trial data and drug approvals, together with advances in the validation of MRD using next-generation sequencing, require a deeper understanding of the complex AML mutation and MRD matrix, enabling more insightful monitoring and treatment decisions for intensively treated AML patients. Here, we provide an overview on methods and clinical consequences of MRD monitoring in genetic subgroups of patients with AML. As treatment options become more personalized, on-treatment MRD monitoring will become even more important to effective AML care.

Intraoperative Cardiac Arrest in Orthopaedic Surgery: A Case Series of 42 Patients.

Intraoperative cardiac arrest (IOCA) is a rare event during orthopaedic surgery. Although infrequent, it has a notable effect, with mortality as high as 35%. Little is known about the outcomes of IOCA in orthopaedic surgery, and this study aims to fill that knowledge gap to improve patient counseling and treatment decisions. A retrospective review of a single health system over a 20-year period identified 42 patients who experienced IOCA during orthopaedic surgery. Patient characteristics, procedure details, cardiac event specifics, and postoperative complications with an emphasis on morbidity and mortality were collected. Return of spontaneous circulation (ROSC) was achieved in 88% (37 of 42) of patients. In-hospital death following successful resuscitation occurred in 22% (8 of 37) of patients. In those who survived their hospitalization (29 of 42, 69%), 59% (17 of 29) required additional treatment for medical complications acquired secondary to their arrest. IOCA occurred most often during spinal surgery, intramedullary nailing, and cemented endoprosthetic reconstruction, accounting for one-half of cases. Pulmonary embolism was the most common cause of IOCA. In patients requiring case abortion with rapid closure and a delayed return to the operating room for case completion, the infection rate was 40%. The majority of orthopaedic surgery patients achieve ROSC following IOCA. For patients who achieve ROSC, two-thirds had either subsequent in-hospital death or a long-term medical complication secondary to their arrest. These findings suggest that a cautious prognosis is indicated even after a successful resuscitation. IV.

Incorporation of a Comorbidity Index in Treatment Decisions for Elderly AML Patients Can Lead to Better Disease Management-A Single-Center Experience.

Introduction: Acute myeloid leukemia (AML) is a form of cancer originating from precursor cells within the bone marrow. Elderly patients with acute leukemia require a personalized approach, considering age, performance status, and comorbidities, to determine suitability for intensive treatment. Methods: We studied the results of intense chemotherapy in 46 elderly, fit individuals with AML at a cancer center in Romania from January 2017 to December 2023. Results: The study involved a cohort of 46 patients, including 22 men and 24 women. The research indicated that 89.1% of the patients were diagnosed with de novo acute leukemia. Most patients had an ECOG score of 0-1, with one patient scoring ≥2. HCT-CI > 4 was found in 21 patients (45.7%), while CCI > 4 was present in 38 patients (82.6%). After the induction phase, 25 patients (54.3%) achieved complete remission (CR); the relapse rate was 56.8%. Upon completion of the study, nine individuals (19.6%) were still alive. The overall survival duration ranged from 0 to 33 months, with a median survival time of 8 months (CI 5.0-11.0). Conclusions: When considering treatment options for elderly patients, the Eastern Cooperative Oncology Group (ECOG) Performance Status, as well as comorbidity indices such as the Hematopoietic Cell Transplantation-Specific Comorbidity Index (HCT-CI) and the Charlson Comorbidity Index (CCI), have shown promising results in the literature, indicating their relevance in the decision-making process.

A Predictive Model for Graves' Disease Recurrence After Antithyroid Drug Therapy: A Retrospective Multicenter Cohort Study.

Predicting recurrence after antithyroid drug (ATD) cessation is crucial for optimal treatment decision-making in patients with Graves' disease (GD). We aimed to identify factors associated with GD recurrence and to develop a model using routine pretherapeutic clinical parameters to predict GD recurrence risk during the first year following ATD discontinuation. This electronic health records-based observational cohort study analyzed patients with GD treated with ATDs at 3 U.S. academic centers. Demographic, clinical characteristics, and GD recurrence within 1year following ATD discontinuation were assessed. Univariable and multivariable analyses were performed. A predictive model for GD recurrence was developed and visualized as a nomogram. Among the 523 patients included in the study, 211 (40.34%) discontinued treatment. Of these, the 142 (67.29%) that had a follow-up period exceeding 12 months after stopping ATD were used for the development of the predictive model. Among the patients included in the model, the majority were women (n=111, 78.16%), with a mean age of 49.29 years (standard deviation 16.31) and baseline free thyroxine (FT4) levels averaging 3.39ng/dl (standard deviation 2.25). Additionally, 79 of 211 patients (37.44%) experienced recurrence within 1year. Multivariable analysis indicated a 31% increased risk of GD recurrence per additional decade of age (odds ratio 1.31, 95% confidence interval 1.03-1.66, P=.0258), and a 65% increased risk of GD recurrence for every 2.0ng/dL rise in baseline FT4 (odds ratio 1.65, 95% confidence interval 1.08-2.50, P=.0192). The recurrence predictive model's area under the curve was 0.69 in the derivation dataset and 0.65 in cross-validation. This study introduced a practical model that can be used during the initial therapeutic decision-making process. It utilizes easily accessible baseline clinical data to predict the likelihood of GD recurrence after 1year of ATD therapy. Further research is needed to identify other factors affecting risk of recurrence and develop more precise predictive models.

LIBELULE: a randomized phase III study to evaluate the clinical relevance of early liquid biopsy in patients with suspicious metastatic lung cancer.

Genomic profiling is a major component for first-line treatment decisions in patients with non-small cell lung cancer (NSCLC) and the timeliness of biomarker testing is essential to improve time to treatment initiation (TTI) or avoid inappropriate treatment. The phase III LIBELULE trial (NCT03721120) included patients with radiological suspicion of advanced lung cancer. They were randomized (1:1), the control arm receiving diagnostic procedures according to each center's practice and the liquid biopsy arm with additional testing performed at the first visit using the InVisionFirst®-Lung assay. Treatment initiation and type were defined according to ESMO guidelines. Primary endpoint was the time from randomization to initiation of appropriate treatment based on informative genomic and pathological results in the intention-to-treat population. 319 patients were enrolled (LB: 161; control: 158). Median age was 68 years, 28.8% were non-smokers, 18.1% had PS≥2 and 56.7% had adenocarcinoma. In LB arm, 81% of patients had circulating tumor DNA findings. The mean TTI was not significantly reduced (LB: 29.0 days (d); control 34d (p=0.26)). Sensitivity analyses showed a shorter TTI in patients from the LB arm who received systemic treatment (LB: 29.1d; control: 38.8d, p=0.01), in patients with advanced non-squamous NSCLC (LB: 29.5d; control: 40.3d, p=0.01), and in patients with first-line targetable alterations (LB: 21d; control 37.4d) (p=0.004). Time to contributory genomic results was significantly reduced (LB: 17.9d; control 25.6d, p<0.001). Early liquid biopsy testing did not significantly shorten the TTI in unselected patients referred for suspected advanced lung cancer. Nevertheless, it could reduce the TTI in patients eligible for systemic treatment, particularly for those with actionable alterations.

Validation of the Node Reporting and Data System (Node-RADS) for standardized CT evaluation of regional lymph nodes in esophageal squamous cell carcinoma patients.

The accurate identification of positive lymph nodes in esophageal squamous cell carcinoma (ESCC) influences patient risk assessment and treatment decisions, but there is no standardized approach for radiological evaluation. The aim of this study was to verify the diagnostic performance of the new Node Reporting and Data System 1.0 (Node-RADS) in the assessment of lymph node metastasis in patients with ESCC, as verified by final histopathology. Node-RADS is a scoring system composed of different criteria for evaluating lymph node metastasis, with scores ranging from 1 to 5, corresponding to the degree of suspicion of lymph node involvement. In this single-center study, Node-RADS was used to retrospectively evaluate regional lymph nodes in 173 ESCC patients who underwent computed tomography (CT) before radical resection. In addition, the area under the ROC curve (AUC), accuracy, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated for the Node-RADS score and individual criteria. Node-RADS outperformed the individual assessment criteria (AUC: 94.3%, sensitivity: 96.5%, specificity: 92.0%), with scores ≥ 3 indicating the maximum diagnostic effectiveness. The diagnostic efficiency of the highest Node-RADS score surpassed that of the short axis score (AUC: 94.3% vs. 81.9%, p < 0.001). Our results indicated that the best diagnostic cut-off points for the short axis, long axis and short axis/long axis ratio were 9 mm, 11 mm, and 0.74, respectively. Node-RADS has emerged as a practical, repetitive method for the early identification of high-risk metastatic lymph nodes, providing therapeutic guidance and predicting disease prognosis in ESCC patients. Question How does the Node Reporting and Data System 1.0 (Node-RADS) perform in the assessment of lymph node metastasis in patients with esophageal squamous cell carcinoma (ESCC)? Findings The maximum diagnostic efficiency was achieved with a Node-RADS score of ≥ 3. Clinical relevance The Node-RADS has improved diagnostic efficiency for distinguishing lymph node metastasis in patients with ESCC.

Survey on blood glucose and electrolyte levels in patients with acute myocarditis treated at Bach Mai Hospital

Background and Objectives:Myocarditis is a condition characterized by inflammation of the heart muscle tissue due to various causes, with viruses being a common cause. During the progression of the disease, damage to the heart muscle can lead to acute heart failure, dangerous arrhythmias, cardiogenic shock, or even cardiac arrest, which can result in rapid death. Clinical markers such as chest pain, shortness of breath, and arrhythmias, along with diagnostic tools like electrocardiograms and cardiac ultrasounds, play a crucial role in diagnosing and predicting the disease. In addition to monitoring vital signs, tracking blood glucose and electrolyte levels is an important criterion for nurses in managing patients with acute myocarditis. This aids in making appropriate care and treatment decisions for each specific patient. The study aims to investigate blood glucose and electrolyte levels and their relationship with the severity of heart failure and ventricular arrhythmias in patients with acute myocarditis. Methods:A retrospective review was conducted on the records of 119 patients with acute myocarditis treated at Bach Mai Hospital from 2017 to 2021. Biochemical results were included in a regression model to assess their correlation with the occurrence of adverse clinical outcomes during hospitalization. Results:Among the 119 patients (66.4% male; average age 33.93 ± 15.87 years), significant electrolyte disturbances included severe hyponatremia (6.7%), severe hypokalemia (5.8%), hyperkalemia (8.1%), and blood glucose disorders (31.1%). Severe hyponatremia was found to be predictive of ventricular arrhythmias and in-hospital mortality. Severe hypokalemia was also predictive of ventricular arrhythmias and in-hospital mortality. Hyperkalemia was associated with a higher risk of ventricular arrhythmias. Patients with severe conditions requiring intensive care, such as intravenous feeding or intravenous insulin administration, demonstrated a higher risk of in-hospital mortality. Conclusion:Severe electrolyte disturbances, such as severe hyponatremia, severe hypokalemia, and hyperkalemia, have prognostic significance in patients with acute myocarditis.