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BACKGROUND: Even though cytoreductive nephrectomy (CN) was once the standard of care for patients with advanced renal cell carcinoma (RCC), its role in treatment has not been well analyzed or defined in the era of immunotherapy (IO). MATERIALS AND METHODS: This study analyzed pathological outcomes in patients with advanced or metastatic RCC who received IO prior to CN. This was a multi-institutional, retrospective study of patients with advanced or metastatic RCC. Patients were required to receive IO monotherapy or combination therapy prior to radical or partial CN. The primary endpoint assessed surgical pathologic outcomes, including American Joint Committee on Cancer (AJCC) staging and frequency of downstaging, at the time of surgery. Pathologic outcomes were correlated to clinical variables using a Wald-chi squared test from Cox regression in a multi-variable analysis. Secondary outcomes included objective response rate (ORR) defined by response evaluation criteria in solid tumors (RECIST) version 1.1 and progression-free survival (PFS), which were estimated using the Kaplan-Meier method with reported 95% CIs. RESULTS: Fifty-two patients from 9 sites were included. Most patients were male (65%), 81% had clear cell histology, 11% had sarcomatoid differentiation. Overall, 44% of patients experienced pathologic downstaging, and 13% had a complete pathologic response. The ORR immediately prior to nephrectomy was stable disease in 29% of patients, partial response in 63%, progressive disease in 4%, and 4% unknown. Median follow-up for the entire cohort was 25.3 months and median PFS was 3.5 years (95% CI, 2.1-4.9). CONCLUSIONS: IO-based interventions prior to CN in patients with advanced or metastatic RCC demonstrates efficacy, with a small fraction of patients showing a complete response. Additional prospective studies are warranted to investigate the role of CN in the modern IO-era.
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OBJECTIVE: The optimal surgical management of Chiari malformation type I (CM-I) remains controversial and heterogeneous. The authors sought to investigate patient-specific, technical, and perioperative features that may affect the incidence of CSF-related complications including pseudomeningocele and CSF leak at their institution. METHODS: The authors performed a single-center, retrospective review of all adult patients with CM-I who underwent posterior fossa decompression. Patient demographics, operative details, and perioperative factors were collected via electronic medical record review. The authors performed Fisher's exact test and independent Student t-tests for categorical and continuous variables, respectively. Univariate regression analysis was performed to determine odds ratios. A multivariable regression analysis was performed for those factors with p < 0.10 or large effect sizes (OR ≥ 2.0 or ≤ 0.50) by univariate analysis. The STROBE guidelines for observational studies were followed. RESULTS: A total of 59 adult patients were included. Most patients were female (78.0%), and the mean body mass index was 32.2 (± 9.0). Almost one-third (30.5%) of patients had a syrinx on preoperative imaging. All patients underwent expansile duraplasty, of which 47 (79.7%) were from autologous pericranium. Arachnoid opening for fourth ventricular inspection was performed in 26 (44.1%) cases. CSF-related complications were identified in 18 (30.5%) of cases. Thirteen (22.0%) patients required readmission and 11 (18.6%) required intervention such as wound revision (n = 5), wound revision with CSF diversion (n = 4), CSF diversion alone (n = 1), or blood patch (n = 1). Three (5.1%) patients required permanent CSF diversion. Male sex (OR 3.495), diabetes mellitus (OR 0.249), tobacco use (OR 2.53), body mass index more than 30 (OR 2.45), preoperative syrinx (OR 1.733), autologous duraplasty (OR 0.331), and postoperative steroids (OR 2.825) were included in the multivariable analysis. No factors achieved significance by univariate or multivariable analysis (all p > 0.05). CONCLUSIONS: The authors report a single-center, retrospective experience of posterior fossa decompression for 59 adults with CM-I. No perioperative or technical features were found to affect the CSF-related complication rate. More standardized practices within centers are necessary to better delineate the true risk factors and potential protective factors against CSF-related complications.
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Malformación de Arnold-Chiari , Rinorrea de Líquido Cefalorraquídeo , Adulto , Humanos , Femenino , Masculino , Incidencia , Estudios Retrospectivos , Pérdida de Líquido Cefalorraquídeo , DescompresiónRESUMEN
BACKGROUND: Brain tumors are the most common solid tumors and the leading cause of cancer-related deaths in children. Incidence in the USA has been on the rise for the last 2 decades. While therapeutic advances in diagnosis and treatment have improved survival and quality of life in many children, prognosis remains poor and current treatments have significant long-term sequelae. SUMMARY: There is a substantial need for the development of new therapeutic approaches, and since the introduction of immunotherapy by immune checkpoint inhibitors, there has been an exponential increase in clinical trials to adopt these and other immunotherapy approaches in children with brain tumors. In this review, we summarize the current immunotherapy landscape for various pediatric brain tumor types including choroid plexus tumors, embryonal tumors (medulloblastoma, AT/RT, PNETs), ependymoma, germ cell tumors, gliomas, glioneuronal and neuronal tumors, and mesenchymal tumors. We discuss the latest clinical trials and noteworthy preclinical studies to treat these pediatric brain tumors using checkpoint inhibitors, cellular therapies (CAR-T, NK, T cell), oncolytic virotherapy, radioimmunotherapy, tumor vaccines, immunomodulators, and other targeted therapies. KEY MESSAGES: The current landscape for immunotherapy in pediatric brain tumors is still emerging, but results in certain tumors have been promising. In the age of targeted therapy, genetic tumor profiling, and many ongoing clinical trials, immunotherapy will likely become an increasingly effective tool in the neuro-oncologist armamentarium.
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Neoplasias Encefálicas , Neoplasias Cerebelosas , Humanos , Niño , Calidad de Vida , Neoplasias Encefálicas/terapia , Neoplasias Encefálicas/patología , Inmunoterapia/métodos , Encéfalo/patologíaRESUMEN
Objectives: To determine if the fear of developing Alzheimer's disease (FDAD) construct, in combination with similar psychoemotional factors, could help elucidate the nature of older adults' subjective memory complaints (SMCs) and subsequent objective memory performance.Methods: One hundred ninety-three healthy older adults (aged 65-93) were administered clinician and self-report measures of depression, worry, anxiety, illness attitudes, and memory, and each rated their concern with developing AD.Results: Self-reported FDAD was not associated with objective memory performance (p > .05). FDAD, trait anxiety, general anxiety, and general and illness-related worry were independently associated with subjective memory report (ps < .05). The relationship between FDAD and subjective memory report was mediated by measures of general trait and state anxiety, but not general worry or illness-specific worry.Conclusions: FDAD was not associated with objective memory functioning, suggesting AD concerns were not reflective of memory pathology. The mediating effect of anxiety on the relationship between FDAD and subjective memory report suggests that assessment of anxiety, beyond AD fear, may help identify older adults at risk for developing negative perceptions of memory and related distress.
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Enfermedad de Alzheimer/psicología , Ansiedad/psicología , Cognición/fisiología , Miedo , Trastornos de la Memoria/psicología , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Masculino , Memoria , Pruebas Neuropsicológicas , Escalas de Valoración Psiquiátrica , Autoinforme , Encuestas y CuestionariosRESUMEN
Objectives: This article examines the convergent validity and clinical utility of the 34-item short form of the Lichtenberg Financial Decision Rating Scale (LFDRS-SF). A briefer scale can lead to enhanced and efficient use of a person-centered approach to the assessment of financial decision-making.Methods: Using data on 200 community-dwelling older adults from Lichtenberg and colleagues (2017a), convergent validity was examined with cognitive and financial management measures using a correlational and regression approach. Receiver operating curve analyses for predicting decision-making ability classification and suspected financial exploitation classification were used to evaluate clinical utility.Results: The LFDRS-SF total risk score was significantly correlated with both cognitive and financial management measures, and the regression analysis predicted 9% of the LFDRS-SF measure. These results demonstrate not only convergent validity, but also the conceptual and empirical uniqueness of financial decision-making.Conclusions: The LFDRS-SF is a valid tool to assess real-world financial decision-making abilities.Clinical Implications: The LFDRS-SF offers an efficient way to assess financial decision-making. Training on the tool and automatic scoring and recommendations for next steps can be found at https://olderadultnestegg.com.
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Abuso de Ancianos/economía , Administración Financiera/estadística & datos numéricos , Competencia Mental/psicología , Psicometría/métodos , Anciano , Toma de Decisiones/fisiología , Abuso de Ancianos/etnología , Abuso de Ancianos/estadística & datos numéricos , Femenino , Humanos , Vida Independiente/psicología , Masculino , Persona de Mediana Edad , Pruebas Neuropsicológicas/normas , Valor Predictivo de las PruebasRESUMEN
Objectives: This work examines the clinical utility of the scoring system for the Lichtenberg Financial Decision-making Rating Scale (LFDRS) and its usefulness for decision making capacity and financial exploitation. Objective 1 was to examine the clinical utility of a person centered, empirically supported, financial decision making scale. Objective 2 was to determine whether the risk-scoring system created for this rating scale is sufficiently accurate for the use of cutoff scores in cases of decisional capacity and cases of suspected financial exploitation. Objective 3 was to examine whether cognitive decline and decisional impairment predicted suspected financial exploitation.Methods: Two hundred independently living, non-demented community-dwelling older adults comprised the sample. Participants completed the rating scale and other cognitive measures.Results: Receiver operating characteristic curves were in the good to excellent range for decisional capacity scoring, and in the fair to good range for financial exploitation.Conclusions: Analyses supported the conceptual link between decision making deficits and risk for exploitation, and supported the use of the risk-scoring system in a community-based population.Clinical Implications: This study adds to the empirical evidence supporting the use of the rating scale as a clinical tool assessing risk for financial decisional impairment and/or financial exploitation.
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Disfunción Cognitiva/economía , Toma de Decisiones/fisiología , Abuso de Ancianos/economía , Competencia Mental/psicología , Anciano , Anciano de 80 o más Años , Disfunción Cognitiva/etnología , Disfunción Cognitiva/psicología , Abuso de Ancianos/etnología , Abuso de Ancianos/psicología , Femenino , Administración Financiera/ética , Administración Financiera/estadística & datos numéricos , Humanos , Vida Independiente/psicología , Vida Independiente/estadística & datos numéricos , Masculino , Persona de Mediana Edad , Valor Predictivo de las Pruebas , Psicometría , Proyectos de Investigación/estadística & datos numéricos , Medición de Riesgo , Sensibilidad y EspecificidadRESUMEN
Adult Protective Services (APS) professionals are often called on to assess decision-making capacity when investigating financial exploitation. Previous research found that in consecutive APS cases, a decision-making screening scale (LFDSS) also detected financial exploitation. The purpose of this study was to apply the clinical cutoff scores derived from the previous study to a new sample of APS cases. Using a sample of 105 participants, from APS workers across 5 counties this study investigated the clinical utility of the LFDSS to detect financial exploitation based on ratings by APS professionals using the scale. Results demonstrate that the LFDSS has excellent internal consistency and clinical utility properties. This paper provides support for use of the LFDSS as a reliable and valid instrument. Instructions for use of the LFDSS are included in the article, along with information about online support tools.
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Abuso de Ancianos/diagnóstico , Administración Financiera , Evaluación Geriátrica/métodos , Competencia Mental , Anciano , Toma de Decisiones , Femenino , Humanos , Masculino , Trabajadores SocialesRESUMEN
Background and Objective: Despite the growth of financial exploitation research in the past decade, almost none has focused on older urban adults, and especially urban African Americans. The Success After Financial Exploitation (SAFE) program provides individual financial coaching to older urban adults. Methods: We use community education, delivered separately to older adults and to the professionals who serve them, to raise awareness about financial exploitation (FE) and to motivate referrals for financial coaching. This paper describes the program and methodology, and uses case examples and preliminary research to investigate the intersection of FE and physical and mental health functioning. Results: SAFE participants were able to repair their credit scores, reduce new financial burdens, and even recover monies they had lost due to FE. Case examples illustrate how financial scams and identity theft impacts urban older adults. Participants were assessed prior to the provision of services, and SAFE participants performed poorer on executive functioning tasks than participants in the control group. They also reported more physical health problems and anxiety and depressive symptoms. SAFE participants also had significantly higher risk scores on a financial decision-making scale. Conclusion: Study findings advance our understanding of the impacts of FE on cognitive functioning, mental health, and financial decision-making. Clinical Implications: Clinicians need to be more attuned to the financial health of their older clients, who, if they are struggling with financial exploitation, may also be suffering from problems with cognitive functioning and physical and mental health.
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Envejecimiento/psicología , Negro o Afroamericano/psicología , Abuso de Ancianos/economía , Geriatras/ética , Salud Mental/economía , Anciano , Ansiedad/psicología , Concienciación , Estudios de Casos y Controles , Cognición/fisiología , Toma de Decisiones/fisiología , Depresión/psicología , Función Ejecutiva , Femenino , Humanos , Masculino , Persona de Mediana EdadRESUMEN
OBJECTIVES: The objectives of this study were threefold: (1) to empirically test the conceptual model proposed by the Lichtenberg Financial Decision-making Rating Scale (LFDRS); (2) to examine the psychometric properties of the LFDRS contextual factors in financial decision-making by investigating both the reliability and convergent validity of the subscales and total scale, and (3) extending previous work on the scale through the collection of normative data on financial decision-making. METHODS: A convenience sample of 200 independent function and community dwelling older adults underwent cognitive and financial management testing and were interviewed using the LFDRS. Confirmatory factor analysis, internal consistency measures, and hierarchical regression were used in a sample of 200 community-dwelling older adults, all of whom were making or had recently made a significant financial decision. RESULTS: Results confirmed the scale's reliability and supported the conceptual model. Convergent validity analyses indicate that as hypothesized, cognition is a significant predictor of risk scores. Financial management scores, however, were not predictive of decision-making risk scores. CONCLUSIONS: The psychometric properties of the LFDRS support the scale's use as it was proposed. CLINICAL IMPLICATIONS: The LFDRS instructions and scale are provided for clinicians to use in financial capacity assessments.
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Toma de Decisiones , Administración Financiera , Trastornos Neurocognitivos/psicología , Anciano , Anciano de 80 o más Años , Investigación Empírica , Análisis Factorial , Femenino , Humanos , Vida Independiente , Masculino , Persona de Mediana Edad , PsicometríaRESUMEN
Neuroimaging and lesion studies have implicated specific prefrontal cortex locations in subjective memory awareness. Based on this evidence, a rostrocaudal organization has been proposed whereby increasingly anterior prefrontal regions are increasingly involved in memory awareness. We used theta-burst transcranial magnetic stimulation (TBS) to temporarily modulate dorsolateral versus frontopolar prefrontal cortex to test for distinct causal roles in memory awareness. In three sessions, participants received TBS bilaterally to frontopolar cortex, dorsolateral prefrontal cortex, or a control location prior to performing an associative-recognition task involving judgments of memory awareness. Objective memory performance (i.e., accuracy) did not differ based on stimulation location. In contrast, frontopolar stimulation significantly influenced several measures of memory awareness. During study, judgments of learning were more accurate such that lower ratings were given to items that were subsequently forgotten selectively following frontopolar TBS. Confidence ratings during test were also higher for correct trials following frontopolar TBS. Finally, trial-by-trial correspondence between overt performance and subjective awareness during study demonstrated a linear increase across control, dorsolateral, and frontopolar TBS locations, supporting a rostrocaudal hierarchy of prefrontal contributions to memory awareness. These findings indicate that frontopolar cortex contributes causally to memory awareness, which was improved selectively by anatomically targeted TBS.
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Aprendizaje por Asociación/fisiología , Lóbulo Frontal/fisiología , Reconocimiento en Psicología/fisiología , Estimulación Magnética Transcraneal/métodos , Adulto , Concienciación/fisiología , Femenino , Lóbulo Frontal/anatomía & histología , Humanos , Juicio/fisiología , Aprendizaje/fisiología , Imagen por Resonancia Magnética , Masculino , Persona de Mediana Edad , Pruebas Neuropsicológicas , Adulto JovenRESUMEN
OBJECTIVES: To assess the relationship between patient smoking status and fracture-related infection (FRI) characteristics including patient symptoms at FRI presentation, bacterial species of FRI, and rates of fracture union. DESIGN: Retrospective cohort study. SETTING: Urban level 1 trauma center. PATIENT SELECTION CRITERIA: All patients undergoing reoperation for FRI from January 2013 to April 2021 were identified through manual review of an institutional database. OUTCOME MEASURES AND COMPARISONS: Data including patient demographics, fracture characteristics, infection presentation, and hospital course were collected through review of the electronic medical record. Patients were grouped based on current smoker versus nonsmoker status. Hospital course and postoperative outcomes of these groups were then compared. Risk factors of methicillin-resistant Staphylococcus aureus (MRSA) infection, Staphylococcus epidermidis infection, and sinus tract development were evaluated using multivariable logistic regression. RESULTS: A total of 301 patients, comprising 155 smokers (51%) and 146 nonsmokers (49%), undergoing FRI reoperation were included. Compared with nonsmokers, smokers were more likely male (69% vs. 56%, P = 0.024), were younger at the time of FRI reoperation (41.7 vs. 49.5 years, P < 0.001), and had lower mean body mass index (27.2 vs. 32.0, P < 0.001). Smokers also had lower prevalence of diabetes mellitus (13% vs. 25%, P = 0.008) and had higher Charlson Comorbidity Index 10-year estimated survival (93% vs. 81%, P < 0.001). Smokers had a lower proportion of S. epidermidis infections (11% vs. 20%, P = 0.037), higher risk of nonunion after index fracture surgery (74% vs. 61%, P = 0.018), and higher risk of sinus tracts at FRI presentation (38% vs. 23%, P = 0.004). On multivariable analysis, smoking was not found to be associated with increased odds of MRSA infection. CONCLUSIONS: Among patients who develop a FRI, smokers seemed to have better baseline health regarding age, body mass index, diabetes mellitus, and Charlson Comorbidity Index 10-year estimated survival compared with nonsmokers. Smoking status was not significantly associated with odds of MRSA infection. However, smoking status was associated with increased risk of sinus tract development and nonunion and lower rates of S. epidermidis infection at the time of FRI reoperation. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Diabetes Mellitus , Fracturas Óseas , Staphylococcus aureus Resistente a Meticilina , Infecciones Estafilocócicas , Humanos , Masculino , Estudios Retrospectivos , Fumar/efectos adversos , Infecciones Estafilocócicas/microbiología , HospitalesRESUMEN
OBJECTIVES: To analyze demographics, comorbidities, fracture characteristics, presenting characteristics, microbiology, and treatment course of patients with fracture-related infections (FRIs) to determine risk factors leading to amputation. DESIGN: Retrospective cohort. SETTING: Single Level I Trauma Center (2013-2020). PATIENT SELECTION CRITERIA: Adults with lower extremity (femur and tibia) FRIs were identified through a review of an institutional database. Inclusion criteria were operatively managed fracture of the femur or tibia with an FRI and adequate documentation present in the electronic medical record. This included patients whose primary injury was managed at this institution and who were referred to this institution after the onset of FRI as long as all characteristics and risk factors assessed in the analysis were documented. Exclusion criteria were infected chronic osteomyelitis from a non-fracture-related pathology and a follow-up of less than 6 months. OUTCOME MEASURES AND COMPARISONS: Risk factors (demographics, comorbidities, and surgical, injury, and perioperative characteristics) leading to amputation in patients with FRIs were evaluated. RESULTS: A total of 196 patients were included in this study. The average age of the study group was 44±16 years. Most patients were men (63%) and White (71%). The overall amputation rate was 9.2%. There were significantly higher rates of chronic kidney disease (CKD; P = 0.039), open fractures (P = 0.034), transfusion required during open reduction internal fixation (P = 0.033), Gram-negative infections (P = 0.048), and FRI-related operations (P = 0.001) in the amputation cohort. On multivariate, patients with CKD were 28.8 times more likely to undergo amputation (aOR = 28.8 [2.27 to 366, P = 0.010). A subanalysis of 79 patients with either a methicillin-sensitive Staphylococcus aureus or methicillin-resistant S. aureus (MRSA) infection showed that patients with MRSA were significantly more likely to undergo amputation compared with patients with methicillin-sensitive Staphylococcus aureus (P = 0.031). MRSA was present in all cases of amputation in the Staphylococcal subanalysis. CONCLUSIONS: Findings from this study highlight CKD as a risk factor of amputation in the tibia and femur with fracture-related infection. In addition, MRSA was present in all cases of Staphylococcal amputation. Identifying patients and infection patterns that carry a higher risk of amputation can assist surgeons in minimizing the burden on these individuals. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Amputación Quirúrgica , Fracturas del Fémur , Fracturas de la Tibia , Humanos , Masculino , Femenino , Estudios Retrospectivos , Amputación Quirúrgica/estadística & datos numéricos , Adulto , Persona de Mediana Edad , Fracturas de la Tibia/cirugía , Fracturas de la Tibia/complicaciones , Factores de Riesgo , Fracturas del Fémur/cirugía , Fracturas del Fémur/complicaciones , Osteomielitis/epidemiología , Osteomielitis/cirugía , Infección de la Herida Quirúrgica/epidemiología , Extremidad Inferior/cirugía , Extremidad Inferior/lesionesRESUMEN
BACKGROUND: Postoperative pseudomeningocele (PMC) and cerebrospinal fluid (CSF) leak are common complications following posterior fossa and posterolateral skull base surgeries. We sought to 1) determine the rate of CSF-related complications and 2) develop a perioperative model and risk score to identify the highest risk patients for these events. METHODS: We performed a retrospective cohort of 450 patients undergoing posterior fossa and posterolateral skull base procedures from 2016 to 2020. Logistic regressions were performed for predictor selection for 3 prespecified models: 1) a priori variables, 2) predictors selected by large effect sizes, and 3) predictors with P ≤ 0.100 on univariable analysis. A final model was created by elimination of nonsignificant predictors, and the integer-based postoperative CSF-related complications (POCC) clinical risk score was derived. Internal validation was done using 10-fold cross-validation and bootstrapping with uniform shrinkage. RESULTS: A total of 115 patients (25.6%) developed PMC and/or CSF leakage. Age >55 years (odds ratio [OR], 0.560; 95% confidence interval [CI], 0.328-0.954), body mass index >30 kg/m2 (OR, 1.88; 95% CI, 1.14-3.10), and postoperative CSF diversion (OR, 2.85; 95% CI, 1.64-5.00) were associated with CSF leak and PMC. Model 2 was the most predictive (cross-validated area under the receiver operating characteristic curve, 0.690). The final risk score was devised using age, body mass index class, dural repair technique, use of bone substitute, and duration of postoperative CSF diversion. The POCC score performed well (cross-validated area under the receiver operating characteristic curve, 0.761) and was highly specific (96.1%). CONCLUSIONS: We created the first generalizable and predictive risk score to identify patients at risk of CSF-related complications. The POCC score could improve surveillance, inform doctor-patient discussions regarding the risks of surgery, and assist in perioperative management.
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Pérdida de Líquido Cefalorraquídeo , Rinorrea de Líquido Cefalorraquídeo , Humanos , Persona de Mediana Edad , Estudios Retrospectivos , Pérdida de Líquido Cefalorraquídeo/etiología , Pérdida de Líquido Cefalorraquídeo/complicaciones , Base del Cráneo/cirugía , Rinorrea de Líquido Cefalorraquídeo/etiología , Factores de Riesgo , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/etiología , Complicaciones Posoperatorias/cirugíaRESUMEN
BACKGROUND: As the obesity epidemic grows, the number of morbidly obese patients undergoing anterior cervical discectomy and fusion (ACDF) continues to increase. Despite the association of obesity with perioperative complications in anterior cervical surgery, the impact of morbid obesity on ACDF complications remains controversial, and studies examining morbidly obese cohorts are limited. METHODS: A single-institution, retrospective analysis of patients undergoing ACDF from September 2010 to February 2022 was performed. Demographic, intraoperative, and postoperative data were collected via review of the electronic medical record. Patients were categorized as nonobese (body mass index [BMI] <30), obese (BMI 30-39.9), or morbidly obese (BMI ≥40). Associations of BMI class with discharge disposition, length of surgery, and length of stay were assessed using multivariable logistic regression, multivariable linear regression, and negative binomial regression, respectively. RESULTS: The study included 670 patients undergoing single-level or multilevel ACDF: 413 (61.6%) nonobese, 226 (33.7%) obese, and 31 (4.6%) morbidly obese patients. BMI class was associated with prior history of deep venous thrombosis (P < 0.01), pulmonary thromboembolism (P < 0.05), and diabetes mellitus (P < 0.001). In bivariate analysis, there was no significant association between BMI class and reoperation or readmission rates at 30, 60, or 365 days postoperatively. In multivariable analysis, greater BMI class was associated with increased length of surgery (P = 0.03), but not length of stay or discharge disposition. CONCLUSIONS: For patients undergoing ACDF, greater BMI class was associated with increased length of surgery, but not reoperation rate, readmission rate, length of stay, or discharge disposition.
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Obesidad Mórbida , Fusión Vertebral , Humanos , Estudios de Cohortes , Estudios Retrospectivos , Obesidad Mórbida/complicaciones , Obesidad Mórbida/epidemiología , Obesidad Mórbida/cirugía , Fusión Vertebral/métodos , Complicaciones Posoperatorias/etiología , Discectomía/métodos , Vértebras Cervicales/cirugíaRESUMEN
INTRODUCTION: Many pediatric patients with malignant tumors continue to suffer poor outcomes. The current standard of care includes maximum safe surgical resection followed by chemotherapy and radiation which may be associated with considerable long-term morbidity. The emergence of oncolytic virotherapy (OVT) may provide an alternative or adjuvant treatment for pediatric oncology patients. AREAS COVERED: We reviewed seven virus types that have been investigated in past or ongoing pediatric tumor clinical trials: adenovirus (AdV-tk, Celyvir, DNX-2401, VCN-01, Ad-TD-nsIL-12), herpes simplex virus (G207, HSV-1716), vaccinia (JX-594), reovirus (pelareorep), poliovirus (PVSRIPO), measles virus (MV-NIS), and Senecavirus A (SVV-001). For each virus, we discuss the mechanism of tumor-specific replication and cytotoxicity as well as key findings of preclinical and clinical studies. EXPERT OPINION: Substantial progress has been made in the past 10 years regarding the clinical use of OVT. From our review, OVT has favorable safety profiles compared to chemotherapy and radiation treatment. However, the antitumor effects of OVT remain variable depending on tumor type and viral agent used. Although the widespread adoption of OVT faces many challenges, we are optimistic that OVT will play an important role alongside standard chemotherapy and radiotherapy for the treatment of malignant pediatric solid tumors in the future.
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Neoplasias , Viroterapia Oncolítica , Virus Oncolíticos , Humanos , Niño , Virus Oncolíticos/genética , Neoplasias/terapia , Simplexvirus/genética , Virus Vaccinia , Terapia GenéticaRESUMEN
Background: The optimal treatment for metastatic renal cell carcinoma (mRCC) patients who have progressed after both immune checkpoint inhibitor (ICI) and VEGFR tyrosine kinase inhibitor (TKI) remains uncertain. Lenvatinib and everolimus (LE) are frequently used in combination as salvage therapy because of their different antitumor mechanisms, but efficacy and toxicity data in this setting are lacking. Methods: We retrospectively reviewed charts from two academic centers for 71 adult mRCC patients who received LE after prior ICI and TKI exposure. We evaluated patient demographics, histology, International mRCC Database Consortium (IMDC) risk group, treatment history, and toxicity details. Outcomes of interest included objective response rate (ORR), time to treatment failure (TTF), overall survival (OS), ≥grade 3 toxicities, and schedule or dosage changes, which were evaluated using descriptive statistics, chi-square test, Cox proportional hazards model, and the Kaplan-Meier method. Results: The median age was 64 (range 31-84). Most patients had clear cell histology (84.5%) and had undergone nephrectomy (80.3%). IMDC risks were favorable (19.7%), intermediate (int) (66.2%), poor (11.3%), and unknown (2.8%). The average ORR was 26.8%, while the median TTF was 5.5 months (95% confidence interval [CI], 3.5-7.6) and the median OS was 9 months (95% CI, 7.6-12.9). Intermediate and poor IMDC risks were independently associated with a significantly worse TTF compared to favorable risk (hazard ratio (HR), 3.03, 95% CI, 1.18-7.79), as was ≥4L treatment vs. 2L/3L treatment (HR, 2.02, 95% CI, 1.08-3.8). Of the 71 patients, 57.7% had ≥grade 3 adverse events, 60% had treatment interruption, 44.3% had dose reduction, and 21% stopped treatment due to intolerance. Conclusions: LE therapy is feasible but has modest efficacies following ICI/TKI treatment. Patients with favorable risk or treated earlier may have a better treatment response. These observations need to be confirmed in prospective studies.
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BACKGROUND: To evaluate effect and outcomes of combination primary immunotherapy (IO) and nephrectomy for advanced renal cell carcinoma (RCC). METHODS: We conducted a multicenter, retrospective analysis of patients with advanced/metastatic RCC who received IO followed by nephrectomy. Primary outcome was Bifecta (negative surgical margins and no 30-day surgical complications). Secondary outcomes included progression-free survival (PFS) following surgery, reduction in tumor/thrombus size, RENAL score, and clinical/pathologic downstaging. Cox regression multivariable analysis was conducted for predictors of Bifecta and PFS. Kaplan-Meier analysis assessed PFS, comparing Bifecta and non-Bifecta groups. RESULTS: A total of 56 patients were analyzed (median age 63 years; median follow-up 22.5 months). A total of 40 (71.4%) patients were intermediate IMDC risk. Patients were treated with immunotherapy for median duration of 8.1 months. Immunotherapy resulted in reductions in tumor size (P < .001), thrombus size (P = .02), and RENAL score (P < .001); 38 (67.9%) patients were clinically downstaged on imaging (P < .001) and 25 (44.6%) patients were pathologically downstaged following surgery (P < .001). Bifecta was achieved in 38 (67.9%) patients. Predictors for bifecta achievement included decreasing tumor size (HR 1.08, P = .043) and pathological downstaging (HR 2.13, P = .047). Bifecta (HR 5.65, P = .009), pathologic downstaging (HR 5.15, P = .02), and increasing reduction in tumor size (HR 1.2, P = .007) were associated with improved PFS. Bifecta patients demonstrated improved 2-year PFS (84% vs. 71%, P = .019). CONCLUSIONS: Primary immunotherapy reduced tumor/thrombus size and complexity. Pathologically downstaged patients were more likely to achieve bifecta, and these patients displayed improved 2-year PFS. Our study supports further inquiry in the use of CRN following primary immunotherapy for advanced renal cancer.
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Carcinoma de Células Renales , Neoplasias Renales , Trombosis , Humanos , Persona de Mediana Edad , Carcinoma de Células Renales/cirugía , Estudios Retrospectivos , Neoplasias Renales/cirugía , Nefrectomía/métodos , Trombosis/cirugía , InmunoterapiaRESUMEN
BACKGROUND: Cytoreductive nephrectomy (CN) for the treatment of metastatic renal cell carcinoma (mRCC) was called into question following the publication of the CARMENA trial. While previous retrospective studies have supported CN alongside targeted therapies, there is minimal research establishing its role in conjunction with immune checkpoint inhibitor (ICI) therapy. OBJECTIVE: To evaluate the association between CN and oncological outcomes in patients with mRCC treated with immunotherapy. MATERIALS AND METHODS: A multicenter retrospective cohort study of patients diagnosed with mRCC between 2000 and 2020 who were treated at the Seattle Cancer Care Alliance and The Ohio State University and who were treated with ICI systemic therapy (ST) at any point in their disease course. Overall survival (OS) was estimated using Kaplan Meier analyses. Multivariable Cox proportional hazards models evaluated associations with mortality. RESULTS: The study cohort consisted of 367 patients (CN+ST n = 232, ST alone n = 135). Among patients undergoing CN, 30 were deferred. Median survivor follow-up was 28.4 months. ICI therapy was first-line in 28.1%, second-line in 17.4%, and third or subsequent line (3L+) in 54.5% of patients. Overall, patients who underwent CN+ST had longer median OS (56.3 months IQR 50.2-79.8) compared to the ST alone group (19.1 months IQR 12.8-23.8). Multivariable analyses demonstrated a 67% reduction in risk of all-cause mortality in patients who received CN+ST vs. ST alone (P < 0.0001). Similar results were noted when first-line ICI therapy recipients were examined as a subgroup. Upfront and deferred CN did not demonstrate significant differences in OS. CONCLUSIONS: CN was independently associated with longer OS in patients with mRCC treated with ICI in any line of therapy. Our data support consideration of CN in well selected patients with mRCC undergoing treatment with ICI.
Asunto(s)
Carcinoma de Células Renales , Neoplasias Renales , Humanos , Carcinoma de Células Renales/tratamiento farmacológico , Carcinoma de Células Renales/cirugía , Procedimientos Quirúrgicos de Citorreducción , Inhibidores de Puntos de Control Inmunológico/farmacología , Inhibidores de Puntos de Control Inmunológico/uso terapéutico , Estudios Retrospectivos , Neoplasias Renales/tratamiento farmacológico , Neoplasias Renales/cirugía , NefrectomíaRESUMEN
The financial exploitation (FE) of older adults affects not only victims' finances, but also their health. This preliminary study investigated the impacts of a financial coaching program on the financial, neurocognitive, physical, and emotional health of older adult victims of FE. Twenty older adults residing in a large urban area who had experienced FE were compared at baseline and follow-up with a group of 20 older adult of the same area who were making important financial decisions, but had not experienced FE and did not receive the intervention. At baseline, both groups were similar on demographic variables, but participants who had experienced FE had more health problems, poorer memory and executive functioning, less social support, and greater stress than the comparison group. Six months after financial coaching ended, program participants had significantly less anxiety. Overall, older adult victims of FE showed no significant declines and, in fact, showed some improvement.
RESUMEN
Background and Objectives: The prevalence of older adult financial exploitation (FE) is increasing. Population-based survey estimates of FE in the older adult population range from 5% to 11%. Given the growing prevalence of FE victimization in older adult populations, understanding the population's vulnerability to FE has increased in importance. This study investigates a conceptual framework in an attempt to understand how financial stressors and resources are associated with substantiated FE in a sample consisting largely of Black older adults. Research Design and Methods: The study uses a cross-sectional design to investigate group differences among a total sample of 142 community-dwelling older adult participants, 62 of whom sought services to address FE and 80 with no history of FE. Results: The group of older adults who sought services to address FE was more likely to be unmarried and had fewer years of education. Measures of financial literacy and perceived financial vulnerability had protective and risk effects, respectively. Discussion and Implications: The present study found that sociodemographic and financial stress and resource measures have significant relationships with FE. These findings support the conceptual framework describing their relationship. This new conceptual framework provides a guiding factor in better understanding vulnerability to FE in older adults. The study also adds to the paucity of research completed on FE with Black older adults.