The risk analysis index is an independent predictor of outcomes after lung cancer resection.

BACKGROUND: The Risk Analysis Index (RAI) is a frailty assessment tool based on an accumulation of deficits model. We mapped RAI to data from the Society of Thoracic Surgeons (STS) Database to determine whether RAI correlates with postoperative outcomes following lung cancer resection. METHODOLOGY/PRINCIPAL FINDINGS: This was a national database retrospective observational study based on data from the STS Database. Study patients underwent surgery 2018 to 2020. RAI was divided into four increasing risk categories. The associations between RAI and each of postoperative complications and administrative outcomes were examined using logistic regression models. We also compared the performance of RAI to established risk indices (American Society of Anesthesiology (ASA) and Charlson Comorbidity Index (CCI)) using areas under the Receiver Operating Characteristic (ROC) curves (AUC). Results: Of 29,420 candidate patients identified in the STS Database, RAI could be calculated for 22,848 (78%). Almost all outcome categories exhibited a progressive increase in marginal probability as RAI increased. On multivariable analyses, RAI was significantly associated with an incremental pattern with almost all outcomes. ROC analyses for RAI demonstrated "good" AUC values for mortality (0.785; 0.748) and discharge location (0.791), but only "fair" values for all other outcome categories (0.618 to 0.690). RAI performed similarly to ASA and CCI in terms of AUC score categories. CONCLUSIONS/SIGNIFICANCE: RAI is associated with clinical and administrative outcomes following lung cancer resection. However, its overall accuracy as a surgical risk predictor is only moderate and similar to ASA and CCI. We do not recommend routine use of RAI for assessment of individual patient risk for major lung resection.

T-cell inflammation is prognostic of survival in patients with high-risk neuroblastoma enriched for an adrenergic signature.

Purpose: T-cell inflammation (TCI) has been shown to be a prognostic marker in neuroblastoma, a tumor comprised of cells that can exist in two epigenetic states, adrenergic (ADRN) and mesenchymal (MES). We hypothesized that elucidating unique and overlapping aspects of these biologic features could serve as novel biomarkers. Patients and Methods: We detected lineage-specific, single-stranded super-enhancers defining ADRN and MES specific genes. Publicly available neuroblastoma RNA-seq data from GSE49711 (Cohort 1) and TARGET (Cohort 2) were assigned MES, ADRN, and TCI scores. Tumors were characterized as MES (top 33%) or ADRN (bottom 33%), and TCI (top 67% TCI score) or non-inflamed (bottom 33% TCI score). Overall survival (OS) was assessed using the Kaplan-Meier method, and differences were assessed by the log-rank test. Results: We identified 159 MES genes and 373 ADRN genes. TCI scores were correlated with MES scores (R=0.56, p<0.001 and R=0.38, p<0.001) and anticorrelated with MYCN -amplification (R=-0.29, p<0.001 and -0.18, p=0.03) in both cohorts. Among Cohort 1 patients with high-risk, ADRN tumors (n=59), those with TCI tumors (n=22) had superior OS to those with non-inflammed tumors (n=37) (p=0.01), though this comparison did not reach significance in Cohort 2. TCI status was not associated with survival in patients with high-risk MES tumors in either cohort. Conclusions: High inflammation scores were correlated with improved survival in some high-risk patients with, ADRN but not MES neuroblastoma. These findings have implications for approaches to treating high-risk neuroblastoma.

Persistence of Racial and Ethnic Disparities in Risk and Survival for Patients with Neuroblastoma over Two Decades.

BACKGROUND: Racial/ethnic survival disparities in neuroblastoma were first reported more than a decade ago. We sought to investigate if these disparities have persisted with current era therapy. METHODS: Two patient cohorts were identified in the International Neuroblastoma Risk Group Data Commons (INRGdc) (Cohort 1: diagnosed 2001-2009, n=4359; Cohort 2: diagnosed 2010-2019, n=4891). Chi-squared tests were used to assess the relationship between race/ethnicity and clinical and biologic features. Survival was estimated by the Kaplan-Meier method. Cox proportional hazards regression analyses were performed to investigate the association between racial/ethnic groups and prognostic markers. RESULTS: Significantly higher 5-year event-free survival (EFS) and overall survival (OS) were observed for Cohort 2 compared to Cohort 1 (P<0.001 and P<0.001, respectively). Compared to White patients, Black patients in both cohorts had a higher proportion of high-risk disease (Cohort 1: P<0.001; Cohort 2: P<0.001) and worse EFS (Cohort 1: P<0.001; Cohort 2 P<0.001) and OS (Cohort 1: P<0.001; Cohort 2: P<0.001). In Cohort 1, Native Americans also had a higher proportion of high-risk disease (P=0.03) and inferior EFS/OS. No significant survival disparities were observed for low- or intermediate-risk patients in either cohort or high-risk patients in Cohort 1. Hispanic patients with high-risk disease in Cohort 2 had significantly inferior OS (P=0.047). Significantly worse OS, but not EFS, (P=0.006 and P=0.02, respectively) was also observed among Black and Hispanic patients assigned to receive post-Consolidation dinutuximab on clinical trials (n=885). CONCLUSION: Racial/ethnic survival disparities have persisted over time and were observed among high-risk patients assigned to receive post-Consolidation dinutuximab.

Frailty Is Associated With Adverse Postoperative Outcomes After Lung Cancer Resection.

Introduction: Frailty is an important predictor of outcomes after noncardiac surgery. The 5-factor Modified Frailty Index (mFI-5) is a recently developed frailty metric that has not been adequately evaluated in relation to surgical therapy for lung cancer. We evaluated whether the mFI-5 is predictive of clinical and administrative outcomes after anatomical lung resection for cancer. Methods: Data in the Society of Thoracic Surgeons Database were used to evaluate the relationship of mFI-5 to outcomes of patients undergoing elective anatomical lung resection for cancer from 2015 to 2018 using logistic regression analyses. Results were compared with validated risk predictors, including the American Society of Anesthesiologists Physical Status Classification and the Charlson Comorbidity Index. Results: The mFI-5 score could be calculated for 36,587 patients. On univariate analyses, mFI-5 was significantly associated with all clinical and administrative outcomes in an incremental pattern (p < 0.0001 for each). On multivariate analyses, mFI-5 was significantly associated in an incremental pattern with 13 of 15 postoperative complication and administrative outcome categories; the exceptions were cardiovascular complications and 30-day mortality. The overall performance of the frailty metric mFI-5 was similar to that of the American Society of Anesthesiologists and the Charlson Comorbidity Index. Conclusions: The mFI-5 is independently predictive of almost all outcomes after lung resection for cancer. It can be calculated from data typically collected for thoracic surgical patients. Assessment of surgical candidates using mFI-5 may be useful in risk prediction and may identify patients who would benefit from mitigation of increased surgical risk related to frailty.

Recent Changes in Characteristics of Applicants and Matriculants to Thoracic Surgery Fellowships.

The match rate for traditional thoracic surgery fellowships decreased from 97.5% in 2012 to 59.1% in 2021, reflecting an increase in applications. We queried whether characteristics of applicants and matriculants to traditional thoracic surgery fellowships changed during this time period. Applicant data from the 2008 through 2018 application cycles were extracted from the Electronic Residency Application System (ERAS) and Graduate Medical Education (GME) Track Resident Survey and stratified by period of application (2008-2014 vs 2015-2018). Characteristics of applicants and matriculants were analyzed. There were 697 applicant records in the early period and 530 in the recent period (application rate 99.6/year vs 132.5/year; P = 0.0005), and 607 matriculant records in the early period and 383 in the recent period (matriculation rate 87% vs 72%; P < 0.0001). There was no difference in representation of university-affiliated versus community-based general surgery residency programs among applicants comparing the periods. Higher proportions of applicants and matriculants in the early period trained in general surgery programs affiliated with a comprehensive cancer center or a thoracic surgery fellowship. Applicants and matriculants of the recent period had higher median numbers of journal publications and had higher impact factor journal publications. The increase in applicants for thoracic surgery training is primarily from general surgery trainees in residency programs not affiliated with a comprehensive cancer center or a thoracic surgery fellowship. The increased interest in thoracic surgery training was accompanied by overall enhanced scholarship production among the applicants and matriculants regardless of their residency characteristics.

Oncology Training Needs Assessment Among Health Care Professionals in Nigeria.

PURPOSE: This study investigated the status of training and preparedness for oncology practice and research and degree of interprofessional collaboration among health care professionals in the six geopolitical regions of Nigeria. METHODS: A convergent parallel mixed methods design was used. Three hundred seventeen respondents completed a three-part, online questionnaire. Self-rated competencies in oncology research (26 items), oncology practice (16 items), and interprofessional collaboration (nine items) were assessed with a one- to five-point Likert scale. Six key informant and 24 in-depth interviews were conducted. Descriptive statistics, analysis of variance, and pairwise t-test were used to analyze the quantitative data, whereas thematic analysis was used for the qualitative data. RESULTS: Respondents were mostly female (65.6%) with a mean age of 40.5 ± 8.3 years. Respondents include 178 nurses (56.2%), 93 medical doctors (29.3%), and 46 pharmacists (14.5%). Self-assessed competencies in oncology practice differed significantly across the three groups of health care professionals (F = 4.789, P = .009). However, there was no significant difference across professions for competency in oncology research (F = 1.256, P = .286) and interprofessional collaboration (F = 1.120, P = .327). The majority of respondents (267, 82.4%) felt that educational opportunities in oncology-associated research in the country are inadequate and that this has implications for practice. Key training gaps reported include poor preparedness in data analysis and bioinformatics (138, 43.5%), writing clinical trials (119, 37.5%), and writing grant/research proposals (105, 33.1%). Challenges contributing to gaps in cancer research include few trained oncology specialists, low funding for research, and inadequate interprofessional collaboration. CONCLUSION: This study highlights gaps in oncology training and practice and an urgent need for interventions to enhance interprofessional training to improve quality of cancer care in Nigeria. These would accelerate progress toward strengthening the health care system and reducing global disparities in cancer outcomes.

Evaluation of the fibrosis-4 index for detection of advanced fibrosis among individuals at risk for intestinal failure-associated liver disease.

BACKGROUND: Intestinal failure-associated liver disease (IFALD) refers to the spectrum of liver injury secondary to IF and parenteral nutrition use. Our aim was to evaluate the use of noninvasive indices of liver fibrosis to detect advanced fibrosis among individuals at risk for IFALD. METHODS: We performed a secondary analysis of a retrospective study, including all liver biopsies performed on individuals undergoing intestinal transplantation (ITx) between January 2000 and May 2014. To determine the clinical utility of detecting advanced fibrosis, receiver operating characteristic curves were developed. Comparison between the area under the curves was performed by DeLong test. RESULTS: Fifty-three patients had a liver biopsy performed at the time of ITx; 13 of 53 (24.5%) patients had advanced fibrosis. The fibrosis-4 (FIB-4) index positively correlated to the stage of fibrosis on liver biopsy (r = 0.426, P = .002). When compared against the FIB-4 index, the aspartate aminotransferase to platelet ratio index had a significantly decreased ability to correctly identify the presence of advanced fibrosis (P = .019). When determining the cutoff value with 90% specificity for the detection of advanced fibrosis, a FIB-4 index of ≥4.4 had a sensitivity of 0.462 and a positive predictive value of 0.6. CONCLUSION: In this retrospective cohort study, we found a positive correlation between the FIB-4 index and the liver fibrosis stage as characterized by the Brunt classification. This evaluation of the FIB-4 index against liver biopsies supports the use of the FIB-4 index in the detection of liver fibrosis in IF.

The Influence of the In-person Residency Interview: A Prospective Study.

BACKGROUND: This prospective study investigated whether in-person interviews affected interviewer assessments of anesthesiology residency applicants at an academic medical center, and which applicant characteristics influenced interview performance. METHODS: Eighteen faculty members involved in residency recruitment between November 2019 and January 2020 documented preinterview (after full application review) and postinterview scores of the applicants on a scale of 1 to 5. Faculty also reported the relative contributions of specific interview characteristics (personality, physical appearance, professional demeanor, discussion regarding academic/scholarly activity, and level of interest in the specialty) to their postinterview assessments. Mixed-effects models were used to assess whether interviews changed faculty assessment of applicants, and what the relative contributions of applicant characteristics were to faculty assessments. RESULTS: A total of 696 interviews were conducted with 232 applicants. The postinterview scores differed significantly from the preinterview scores (estimated mean difference, 0.09 ± 0.02; P < 0.0001). The characteristics most affecting postinterview scores were positive impressions of applicants' personalities (marginal mean change in postinterview score, 0.259; 95% confidence interval, 0.221-0.297) and negative impressions of applicants' professional demeanor (marginal mean change, -0.257; 95% confidence interval, -0.350 to -0.164). CONCLUSIONS: In-person interviews significantly affected residency applicants' scores. Personality and professional demeanor influenced scores more than did other characteristics examined. Further studies are needed to clarify the relevance of in-person interviews to the assessment of residency applicants.

Association Between Participation in Clinical Trials and Overall Survival Among Children With Intermediate- or High-risk Neuroblastoma.

Importance: Participants in clinical trials may experience benefits associated with new therapeutic strategies as well as tight adherence to best supportive care practices. Objectives: To investigate whether participation in a clinical trial is associated with improved survival among children with neuroblastoma and investigate potential recruitment bias of patients in clinical trials. Design, Setting, and Participants: This cohort study included pediatric patients with intermediate- or high-risk neuroblastoma in North American studies who were included in the International Neuroblastoma Risk Group Data Commons and who received a diagnosis between January 1, 1991, and March 1, 2020. Exposure: Enrollment in a clinical trial. Main Outcomes and Measures: Event-free survival and overall survival (OS) of patients with intermediate- or high-risk neuroblastoma enrolled in an up-front Children's Oncology Group (COG) clinical trial vs a biology study alone were analyzed using log-rank tests and Cox proportional hazards regression models. The racial/ethnic composition and the demographic characteristics of the patients in both groups were compared. Results: The cohort included 3058 children with intermediate-risk neuroblastoma (1533 boys [50.1%]; mean [SD] age, 10.7 [14.7] months) and 6029 children with high-risk neuroblastoma (3493 boys [57.9%]; mean [SD] age, 45.8 [37.4] months) who were enrolled in a Children's Oncology Group or legacy group neuroblastoma biology study between 1991 and 2020. A total of 1513 patients with intermediate-risk neuroblastoma (49.5%) and 2473 patients with high-risk neuroblastoma (41.0%) were also enrolled in a clinical trial, for a cohort total of 3986 of 9087 children (43.9%) enrolled in a clinical trial. The prevalence of prognostic markers for the clinical trial and non-clinical trial cohorts differed, although representation of patients from racial/ethnic minority groups was similar in both cohorts. Among patients with intermediate-risk neuroblastoma, OS was higher among those who participated in a clinical trial compared with those enrolled only in a biology study (OS, 95% [95% CI, 94%-96%] vs 91% [95% CI, 89%-94%]; P = .01). Among patients with high-risk neuroblastoma, participation in a clinical trial was not associated with OS (OS, 38% [95% CI, 35%-41%] in the clinical trial group vs 41% [95% CI, 38%-44%] in the biology study group; P = .23). Conclusions and Relevance: Approximately 44% of patients in this large cohort of patients with neuroblastoma were enrolled in up-front clinical trials. Compared with children not enrolled in clinical trials, a higher prevalence of favorable prognostic markers was identified among patients with intermediate-risk neuroblastoma enrolled in clinical trials, and unfavorable features were more prevalent among patients with high-risk neuroblastoma enrolled in clinical trials. No evidence of recruitment bias according to race/ethnicity was observed. Participation in a clinical trial was not associated with OS in this cohort, likely reflecting the common practice of treating nontrial participants with therapeutic and supportive care regimens used in a previous therapeutic trial.

Toxicity of the recombinant human hyaluronidase ALT-BC4 on embryonic development.

Cumulus-oocyte complexes (COCs), which contain immature oocytes, are matured in vitro for in vitro embryo production. Oocyte and cumulus cells are then separated using hyaluronidase. To date, there have only been a few reported cases of the toxic effects of hyaluronidase on porcine oocytes. The aim of this study was to compare the effects of bovine testis-derived hyaluronidase and recombinant human hyaluronidase on oocyte denudation and quality. Porcine COCs were matured for 44 h and denuded using different hyaluronidase concentrations and exposure times. Then, oocytes were activated by electrical parthenogenesis. In experiment 1, COCs were denuded using bovine-derived, ovine-derived (Hirax), and human recombinant (ALT-BC4) hyaluronidases for 10 and 20 min. In experiment 2, bovine-derived and human recombinant (ALT-BC4 and ICSI Cumulase®) hyaluronidases were used to denude the COCs for 2 and 20 min. In both experiments the oocytes were all completely denuded, and there was no degeneration. Rate of embryo development was significantly increased in group treated ALT-BC4 for 2 min and not significantly different in other treatment groups. In general it slightly decreased with longer exposure times. These results have confirmed that different sources of hyaluronidase do not have detrimental effects on the quality of porcine oocytes and suggest that the human recombinant hyaluronidase ALT-BC4 is suitable for oocyte denudation with an increased blastocyst rate.

Recommendations and outcomes from a geriatric assessment guided multidisciplinary clinic prior to autologous stem cell transplant in older patients.

BACKGROUND: Autologous hematopoietic stem cell transplant (autoHCT) is a mainstay of treatment for multiple myeloma and non-Hodgkin lymphoma but is underutilized in older adults. We investigated the association of vulnerabilities identified by a geriatric assessment (GA)-guided multidisciplinary clinic (MDC) on the receipt of autoHCT and evaluated its ability to predict outcomes in older autoHCT candidates. METHODS: Patients 50+ years received GA-informed optimization recommendations: 'decline' if unlikely to realize benefits of autoHCT, 'defer' if optimization necessary before autoHCT, and 'proceed' if autoHCT could proceed without delay. We compared characteristics and outcomes of autoHCT recipients (n = 62) to non-autoHCT patients (n = 29) and evaluated GA deficits on outcomes. RESULTS: 91 patients were evaluated; the MDC recommendation was 'decline' for 5 (6%), 'defer' for 25 (27%), and 'proceed' for 61 (67%). AutoHCT recipients had fewer GA-rated impairments relative to non-autoHCT patients, as did patients with a 'proceed' recommendation relative to 'defer'. Among autoHCT recipients, 1-year and 3-year non-relapse morality (NRM) was 0% and 5%, and there was no difference in length of hospitalization, readmission rate, or mortality after transplant by MDC recommendation. Frail grip strength and poor performance status were associated with inferior post-autoHCT progression-free survival and overall survival. CONCLUSIONS: Patients pursuing autoHCT after MDC-directed optimization achieved excellent outcomes, including patients deferred but ultimately receiving autoHCT. GA-identified functional deficits, especially frail grip strength, may improve risk stratification in older autoHCT candidates. Employing a GA earlier in the disease trajectory to inform early referral to an MDC may increase autoHCT safety and utilization in older patients.

Implementing a multilevel intervention to accelerate colorectal cancer screening and follow-up in federally qualified health centers using a stepped wedge design: a study protocol.

BACKGROUND: Screening for colorectal cancer (CRC) not only detects disease early when treatment is more effective but also prevents cancer by finding and removing precancerous polyps. Because many of our nation's most disadvantaged and vulnerable individuals obtain health care at federally qualified health centers, these centers play a significant role in increasing CRC screening among the most vulnerable populations. Furthermore, the full benefits of cancer screenings must include timely and appropriate follow-up of abnormal results. Thus, the purpose of this study is to implement a multilevel intervention to increase rates of CRC screening, follow-up, and referral-to-care in federally qualified health centers, as well as simultaneously to observe and to gather information on the implementation process to improve the adoption, implementation, and sustainment of the intervention. The multilevel intervention will target three different levels of influences: organization, provider, and individual. It will have multiple components, including provider and staff education, provider reminder, provider assessment and feedback, patient reminder, and patient navigation. METHODS: This study is a multilevel, three-phase, stepped wedge cluster randomized trial with four clusters of clinics from four different FQHC systems. In the first phase, there will be a 3-month waiting period during which no intervention components will be implemented. After the 3-month waiting period, we will randomize two clusters to cross from the control to the intervention and the remaining two clusters to follow 3 months later. All clusters will stay at the same phase for 9 months, followed by a 3-month transition period, and then cross over to the next phase. DISCUSSION: There is a pressing need to reduce disparities in CRC outcomes, especially among racial/ethnic minority populations and among populations who live in poverty. Single-level interventions are often insufficient to lead to sustainable changes. Multilevel interventions, which target two or more levels of changes, are needed to address multilevel contextual influences simultaneously. Multilevel interventions with multiple components will affect not only the desired outcomes but also each other. How to take advantage of multilevel interventions and how to implement such interventions and evaluate their effectiveness are the ultimate goals of this study. TRIAL REGISTRATION: This protocol is registered at clinicaltrials.gov ( NCT04514341 ) on 14 August 2020.

Geriatric assessment in older alloHCT recipients: association of functional and cognitive impairment with outcomes.

Use of allogeneic hematopoietic cell transplantation (alloHCT) is increasing in older patients with hematologic malignancies. Studies suggest that geriatric assessment (GA), incorporating functional measures such as instrumental activities of daily living (IADL), delineates subtle age-related impairments that enhance risk-stratification. The objective of this multi-institutional retrospective study was to evaluate the prognostic utility of GA metrics collected pre-alloHCT. Eligibility criteria included age ≥50 and pre-alloHCT GA inclusive of at least IADL. Beyond IADL, additional geriatric metrics were collected where available and included Medical Outcomes Study Physical Health score (MOS-PH), Timed Up and Go (TUG), and cognition by Blessed Orientation Memory Concentration (BOMC). Three hundred thirty subjects were included, with a median age of 63 (range 50 to 77). Impairments were frequent: 36% had at least 1 IADL impairment; 14% had TUG ≥13.5 seconds; and 17% had cognitive impairment (BOMC ≥ 7). Median MOS-PH score was 80. IADL and age were not significantly associated with nonrelapse mortality (NRM) or overall survival (OS). In multivariate analysis, only impaired cognition and Hematopoietic Cell Transplant-Comorbidity Index score ≥3 showed an independent association with 1-year NRM (subdistribution hazard ratio [SHR], 2.36; P = .01; and SHR, 2.19; P = .009, respectively). Cognitive impairment independently conferred inferior 1-year OS (hazard ratio, 1.94; P = .01). In a preplanned subgroup analysis in 224 patients aged ≥60 years, cognitive impairment remained the sole GA metric predictive of NRM (2-year NRM: SHR, 2.72; P = .007). These data suggest that cognitive impairment elevates risk of post-alloHCT NRM in older patients.

Black recipients of oocyte donation experience lower live birth rates compared with White recipients.

RESEARCH QUESTION: Is minority race associated with worse oocyte donation outcomes? DESIGN: Retrospective analysis of 926 oocyte recipients who underwent a donor cycle with fresh embryo transfer at a single fertility centre between January 2009 and June 2015. Race was self-reported. To adjust for repeat donors within the sample, mixed models were used to analyse donor parameters and recipient outcomes. The recipient outcome models were adjusted for age, body mass index and primary infertility diagnosis. RESULTS: The study consisted of 767 (82.8%) White, 41 (4.4%) Black, 63 (6.8%) Asian and 55 (5.9%) Hispanic women. Compared with White recipients, the adjusted odds ratio (aOR) for clinical pregnancy was 0.39 (95% confidence interval [CI] 0.19-0.79) for Black, 0.55 (95% CI 0.31-0.98) for Hispanic and 0.88 (95% CI 0.51-1.53) for Asian recipients. The aOR for live birth was 0.47 (95% CI 0.23-0.98) for Black, 0.58 (95% CI 0.32-1.06) for Hispanic and 0.62 (95% 0.35-1.09) for Asian recipients. A subgroup analysis restricted to cycles with racially concordant donors and recipients showed that the odds of clinical pregnancy and live birth were further reduced among Black recipients, with aOR of 0.28 (95% CI 0.09-0.81) and 0.30 (95% CI 0.09-0.98), respectively. CONCLUSIONS: Black and Hispanic oocyte donation recipients experience lower clinical pregnancy rates and Black recipients experience lower live birth rates compared with White recipients. Racially discordant donor oocyte cycles involving donors and recipients of different races present an opportunity to further investigate the cause of disparity.

Smooth muscle tumors of the gastrointestinal tract: an analysis of prognostic features in 407 cases.

Smooth muscle tumors represent the second most common mural mesenchymal neoplasm in the gastrointestinal tract, but established criteria for prognostic assessment of these tumors are lacking. A large cohort of surgically resected intramural gastrointestinal smooth muscle tumors from 31 institutions was analyzed to identify potential prognostic features. Pathologic features were assessed by expert gastrointestinal and/or soft tissue pathologists at each center. Immunohistochemical confirmation was required. A total of 407 cases from the esophagus (n = 97, 24%), stomach (n = 180, 44%), small bowel (n = 74, 18%), and colorectum (n = 56, 14%) were identified. Patients ranged in age from 19 to 92 years (mean 55 years), with a slight female predominance (57%). Mean tumor size was 5.4 cm, with the largest tumor measuring 29 cm. Disease progression following surgery, defined as local recurrence, metastasis, or disease-related death, occurred in 56 patients (14%). Colorectal tumors were most likely to progress, followed by small bowel and gastric tumors. None of the esophageal tumors in this series progressed. Receiver operator characteristic analysis identified optimal cutoffs of 9.8 cm and 3 mitoses/5 mm2 for discriminating between progressive and non-progressive tumors. Histologic features strongly associated with progression by univariate analysis included moderate-to-severe atypia, high cellularity, abnormal differentiation (defined as differentiation not closely resembling that of normal smooth muscle), tumor necrosis, mucosal ulceration, lamina propria involvement, and serosal involvement (P < 0.0001 for all features). Age, sex, and margin status were not significantly associated with progression (P = 0.23, 0.82, and 0.07, respectively). A risk assessment table was created based on tumor site, size, and mitotic count, and Kaplan-Meier plots of progression-free survival for each subgroup revealed progression-based tiers. Based on our findings, it appears that nonesophageal gastrointestinal smooth muscle tumors measuring >10 cm and/or showing ≥3 mitoses/5 mm2 may behave aggressively, and therefore close clinical follow-up is recommended in these cases.

Dose escalation prophylactic donor lymphocyte infusion after T-cell depleted matched related donor allogeneic hematopoietic cell transplantation is feasible and results in higher donor chimerism, faster immune re-constitution, and prolonged progression-free survival.

Prophylactic donor lymphocyte infusion (pDLI) is a potential intervention to prolong remission for patients receiving allogeneic hematopoietic stem cell transplantation (allo-SCT), however, the optimal timing and dose are unknown. We conducted a prospective trial exploring the feasibility of early withdrawal of immunosuppression (WOI) at day 60 followed by dose escalation of pDLI after alemtuzumab-based, T-cell depleted conditioning for patients with high-risk hematologic malignancies. pDLI were administered at day 75 to day 90 and again in 4-8 week intervals with receipt of up to 5 pDLI infusions. Fourty-six patients with matched-related donors (MRD) and 29 patients with matched-unrelated donors (MUD) were considered. Twenty-eight MRD patients were able to undergo WOI, 26 patients (93%) received at least 1 DLI, 16 patients (57%) received 3+, and 7 patients (25%) received 5 pDLI. Only 7 MUD patients were able to undergo WOI, 4 (57%) received at least 1 pDLI, 1 patient (14%) received 3 DLI, and no patients received all 5. Median PFS for patients on the study was 366 days. The estimated 2-year PFS and OS rates for all patients were 41% (95% CI, 32-54%) and 51% (95% CI, 41-63%) compared with 57% (95% CI, 41-77%) and 67% (95% CI, 52-86%) for patients who received at least one pDLI. In addition, MRD patients receiving pDLI had faster immune re-constitution and improved donor chimerism. Our trial proposes a novel dosage and treatment schedule for pDLI that is tolerable for patients who have received MRD allo-SCT and leads to improved outcomes.

A Morphomic Index Is an Independent Predictor of Survival After Lung Cancer Resection.

BACKGROUND: Sarcopenia, visceral fat volume, and bone density have been associated with lung cancer survival. We developed a morphomic index based on computed tomographic measurements of these components, and assessed its relationship to survival after lung cancer resection. METHODS: Patients who underwent lung cancer resection from 1995 to 2014 were evaluated. A morphomic index (range of 0 to 3) was developed as the sum of the scores for three body components-dorsal muscle area, vertebral trabecular bone density, and visceral fat area-measured at vertebral levels T10 to T12, with a point assigned to each component when in the lowest tercile. The relationship of the morphomic index to overall survival was assessed by the log rank test. Overall survival was assessed using Cox proportional hazards models adjusted for relevant covariates. RESULTS: We included 944 patients (451 women; 48%). The mean age was 66.4 ± 10.3 years. Median follow-up was 4.5 years. Median survival was associated with the morphomic index scores on univariate analysis (P < .001). Morphomic index scores of 2 (P = .026) and 3 (P = .004) referenced to score 0 or 1 were independent predictors of survival on Cox regression analysis. CONCLUSIONS: A morphomic index is an independent predictor of survival after lung cancer resection. The index may help in calibrating patient expectations and in shared decision making regarding lung cancer surgery.

Results from a multidisciplinary clinic guided by geriatric assessment before stem cell transplantation in older adults.

Limitations found on geriatric assessment (GA) track with worse outcomes after hematopoietic cell transplantation (HCT). We report on a multidisciplinary team clinic (MDC), consisting of a cancer-specific GA and a multidisciplinary team of providers, to assess candidacy and create an individualized optimization plan for allogeneic HCT candidates aged ≥60 years and autologous HCT and adoptive T-cell therapy candidates aged ≥70 years. Among the 247 patients evaluated in the MDC, allogeneic HCT candidates comprised the majority (60%), followed by autologous HCT (37%) with occasional older cellular therapy candidates (3%). Almost all patients meeting program-required minimum ages for MDC optimization at our institution were assessed (98%). Relative to historical control subjects undergoing GA alone, allogeneic HCT patients aged ≥60 years who underwent MDC appraisal had similar frequencies of high-risk disease, reduced intensity regimens, and high comorbidity but fewer GA-graded functional impairments. The MDC cohort experienced fewer inpatient deaths, shorter length of stay, and fewer discharges to nursing facilities compared with control subjects. Improvements in early mortality were observed over time; 1-year overall survival improved from 43% in the pre-MDC era to 70% in the recent MDC era, and 1-year nonrelapse mortality decreased from 43% to 18%. The 31 autologous HCT recipients aged ≥70 years optimized by the MDC achieved 0% nonrelapse mortality and 97% overall survival at 1 year. A GA-guided MDC for older HCT candidates is feasible and seems to reduce transplant-associated morbidity and mortality. An MDC should encourage broader and safer utilization of transplantation in older patients.

Provider and Staff Morale, Job Satisfaction, and Burnout over a 4-Year Medical Home Intervention.

BACKGROUND: The patient-centered medical home (PCMH) is a widely adopted primary care model. However, it is unclear whether changes in provider and staff perceptions of clinic PCMH capability are associated with changes in provider and staff morale, job satisfaction, and burnout in safety net clinics. OBJECTIVE: To determine how provider and staff PCMH ratings changed under a multi-year PCMH transformation initiative and assess whether changes in provider and staff PCMH ratings were associated with changes in morale, job satisfaction, and burnout. DESIGN: Comparison of baseline (2010) and post-intervention (2013-2014) surveys. SETTING: Sixty clinics in five states. PARTICIPANTS: Five hundred thirty-six (78.2%) providers and staff at baseline and 589 (78.3%) post-intervention. INTERVENTION: Collaborative learning sessions and on-site coaching to implement PCMH over 4 years. MEASUREMENTS: Provider and staff PCMH ratings on 0 (worst) to 100 (best) scales; percent of providers and staff reporting good or better morale, job satisfaction, and freedom from burnout. RESULTS: Almost half of safety net clinics improved PCMH capabilities from the perspective of providers (28 out of 59, 47%) and staff (25 out of 59, 42%). Over the same period, clinics saw a decrease in the percentage of providers reporting high job satisfaction (- 12.3% points, p = .009) and freedom from burnout (- 10.4% points, p = .006). Worsened satisfaction was concentrated among clinics that had decreased PCMH rating, with those clinics seeing far fewer providers report high job satisfaction (- 38.1% points, p < 0.001). LIMITATIONS: Control clinics were not used. Individual-level longitudinal survey administration was not feasible. CONCLUSION: If clinics pursue PCMH transformation and providers do not perceive improvement, they may risk significantly worsened job satisfaction. Clinics should be aware of this potential risk of PCMH transformation and ensure that providers are aware of PCMH improvements.