Scoping review of values elicitation tools for treatment decisions in hepatocellular carcinoma.

BACKGROUND: Treatment choices in hepatocellular carcinoma (HCC) involve consideration of tradeoffs between the benefits, toxicities, inconvenience, and costs. Stated preference elicitation methods have been used in the medical field to help evaluate complex treatment decision-making. The aim of this study was to conduct a scoping review to assess the evidence base for the use of preference elicitation tools or willingness to pay/willingness to accept methods for HCC treatment decision-making from both the patient and provider perspective. METHODS: We performed a scoping review to identify abstracts or manuscripts focused on the role preference elicitation tools or willingness to pay/willingness to accept methods for HCC treatment options among patients, caregivers, and/or providers. Two researchers independently screened full-text references and resolved conflicts through discussion. We summarized key findings, including the type and setting of preference-elicitation tools used for HCC treatment decisions. RESULTS: Ten published abstracts or manuscripts evaluated the role of preference elicitation tools for HCC treatments. The studies revealed several attributes that are considered by patients and providers making HCC treatment decisions. Many of the studies reviewed suggested that while patients place the most value on extending their overall survival, they are willing to forgo overall survival to avoid risks of treatments and maintain quality of life. Studies of physicians and surgeons found that provider preferences are dependent on patient characteristics, provider specialty, and surgeon or hospital-related factors. CONCLUSION: This scoping review explored both patient and physician preferences towards treatment modalities in all stages of HCC. The studies revealed a large scope of potential attributes that may be important to patients and that many patients are willing to forgo survival to maintain quality of life. Further research should explore both preference elicitation of currently available and emerging therapies for HCC as well as the use of this data to develop patient-facing tools to assist in navigating treatment options.

Experiences of treatment decision-making among older newly diagnosed adults with acute myeloid leukemia: a qualitative descriptive study.

PURPOSE: Treatment decision-making for older adults with acute myeloid leukemia (AML) is complex and preference-sensitive. We sought to understand the patient experience of treatment decision-making to identify specific challenges in shared decision-making to improve clinical care and to inform the development of directed interventions. METHODS: We conducted in-depth interviews with newly diagnosed older (≥ 60 years) adults with AML and their caregivers following a semi-structured interview guide at a public safety net academic hospital. Interviews were digitally recorded, and qualitative thematic analysis was employed to synthesize findings. RESULTS: Eighteen in-depth interviews were conducted. Age ranged from 62 to 78 years. Patients received intermediate- (50%) or high-intensity (44%) chemotherapy or best supportive care only (6%). Six themes of patient experiences emerged from the analysis: patients (1) felt overwhelmed and in shock at diagnosis, (2) felt powerless to make decisions, (3) felt rushed and unprepared to make a treatment decision, (4) desired to follow oncologist recommendations for treatment, (5) balanced multiple competing factors during treatment decision-making, and (6) desired for ongoing engagement into their care planning. Patients reported many treatment outcomes that were important in treatment decision-making. CONCLUSIONS: Older adults with newly diagnosed AML feel devastated and in shock at their diagnosis which appears to contribute to a feeling of being overwhelmed, unprepared, and rushed into treatment decisions. Because no one factor dominated treatment decision-making for all patients, the use of strategies to elicit individual patient preferences is critical to inform treatment decisions. Interventions are needed to reduce distress and increase a sense of participation in treatment decision-making.

Time spent at home among older adults with acute myeloid leukemia receiving azacitidine- or venetoclax-based regimens.

Time at home is a critically important outcome to adults with acute myeloid leukemia (AML) when selecting treatment; however, no study to date has adequately described the amount of time older adults spend at home following initiation of chemotherapy. We queried records from a multi-institution health system to identify adults aged ≥60 years newly diagnosed with AML who were treated with azacitidine or venetoclax and evaluated the proportion of days at home (PDH) following diagnosis. Days were considered "at home" if patients were not admitted or seen in the emergency department or oncology/infusion clinic. Assessed covariates included demographics and disease risk. Associations between PDH and baseline characteristics were evaluated via linear regression, adjusted for log length of follow-up. From 2015-2020, 113 older adults were identified. Most received azacitidine plus venetoclax (51.3%) followed by azacitidine monotherapy (38.9%). The mean PDH for all patients was 0.58 (95% confidence interval: 0.54-0.63, median 0.63). PDH increased among survivors over time. PDH did not differ between therapy groups (adjusted mean, azacitidine plus venetoclax: 0.68; azacitidine monotherapy: 0.66; P=0.64) or between disease risk categories (P=0.34). Compared to patients receiving azacitidine monotherapy, patients receiving azacitidine plus venetoclax had longer clinic visits (median minutes: 127.9 vs. 112.9, P<0.001) and infusion visits (median minutes: 194.3 vs. 132.5, P<0.001). The burden of care for older adults with AML treated with "less intense" chemotherapy is high. The addition of venetoclax to azacitidine did not translate into increased time at home. Future prospective studies should evaluate patient-centered outcomes, including time at home, to inform shared decision-making and drug development.

Arrays of glass wedges for multi-dimensional optical diagnostics.

There is a common need in the advancement of optical diagnostic techniques to increase the dimensionality of measurements. For example, point measurements could be improved to multi-point, line, planar, volumetric, or time-resolved volumetric measurements. In this work, a unique optical element is presented to enable multi-dimensional measurements, namely, an array of glass wedges. A light source is passed through the wedges, and different portions of the illumination are refracted by different amounts depending on the glass wedge angle. Subsequent optics can be used to focus the light to multiple points, lines, or planes. Basic characterization of a glass wedge array is presented. Additional wedge-array configurations are discussed, including the use of a periodic intensity mask for multi-planar measurements via structured illumination. The utility of this optical element is briefly demonstrated in (a) multi-planar flame particulate measurements, (b) multi-point femtosecond-laser electronic excitation tagging for flow velocimetry, and (c) multi-line nitric oxide molecular tagging velocimetry in a hypersonic shock-tunnel. One significant advantage of this optical component is its compatibility with high-energy laser sources, which may be a limiting factor with other beam-splitting or beam-forming elements such as some diffractive optics. Additionally, an array of glass wedges is simple and easily customizable compared to other methods for forming multiple closely spaced illumination patterns. Suggestions for further development and applications are discussed.

Hybrid time-frequency domain dual-probe coherent anti-Stokes Raman scattering for simultaneous temperature and pressure measurements in compressible flows via spectral fitting.

We demonstrate a hybrid time-frequency spectroscopic method for simultaneous temperature/pressure measurements in nonreacting compressible flows with known gas composition. Hybrid femtosecond-picosecond, pure-rotational coherent anti-Stokes Raman scattering (CARS), with two independent, time-delayed probe pulses, is deployed for single-laser-shot measurements of temperature and pressure profiles along an ∼5-mm line. The theory of dual-probe CARS is presented, along with a discussion of the iterative fitting of experimental spectra. Temperature is obtained from spectra acquired with an early, near-collision-free probe time delay (τ 1=0p s) and pressure from spectra obtained at probe delays of τ 2=150-1000p s, where collisions significantly impact the spectral profile. Unique solutions for temperature and pressure are obtained by iteratively fitting the two spectra to account for small collisional effects observed for the near zero probe delay spectrum. A dual-probe pure-rotational CARS system, in a 1D line-imaging configuration, is developed to demonstrate effectively the simultaneous temperature and pressure profiles recorded along the axial centerline of a highly underexpanded jet. The underexpanded air jet permits evaluation of this hybrid time-frequency domain approach for temperature and pressure measurements across a wide range of low-temperature-low-pressure conditions of interest in supersonic ground-test facilities. Single-laser-shot measurement precisions in both quantities and pressure measurement accuracy are systematically evaluated in the quiet zone upstream of the Mach disk. Precise thermometry approaching 1%-2% is observed in regions of high CARS signal-to-noise ratios. Pressure measurements are optimized at probe time delays where the ratio of the late probe delay to the Raman lifetime exceeds four (τ 2/τ R>4). The impact of low-temperature Raman linewidths on CARS pressure measurements is evaluated, and comparisons of CARS pressures obtained with our recent low-temperature pure-rotational Raman linewidth data and extrapolated high-temperature Q-branch linewidths are presented. Considering all measurements with τ 2/τ R≥4.0, measured pressures were on average 7.9% of the computed isentropic values with average shot-to-shot deviations representing a combination of instrument noise and fluid fluctuations of  5.0%.

Time-domain self-broadened and air-broadened nitrogen S-branch Raman linewidths at 80-200 K recorded in an underexpanded jet.

We report pure-rotational N2-N2, N2-air, and O2-air S-branch linewidths for temperatures of 80-200 K by measuring the time-dependent decay of rotational Raman coherences in an isentropic free-jet expansion from a sonic nozzle. We recorded pure-rotational hybrid femtosecond/picosecond coherent anti-Stokes Raman scattering (fs/ps CARS) spectra along the axial centerline of the underexpanded jet, within the barrel shock region upstream of the Mach disk. The dephasing of the pure-rotational Raman coherence was monitored using probe-time-delay scans at different axial positions in the jet, corresponding to varying local temperatures and pressures. The local temperature was obtained by fitting CARS spectra acquired at zero probe time delay, where the impact of collisions was minimal. The measured decay of each available Raman transition was fit to a dephasing constant and corrected for the local pressure, which was obtained from the CARS-measured static temperature and thermodynamic relationships for isentropic expansion from the known stagnation state. Nitrogen self-broadened transitions decayed more rapidly than those broadened in air for all temperatures, corresponding to higher Raman linewidths. In general, the measured S-branch linewidths deviated significantly in absolute and relative magnitudes from those predicted by extrapolating the modified exponential gap model to low temperatures. The temperature dependence of the Raman linewidth for each measured rotational state of nitrogen (J ≤ 10) and oxygen (N ≤ 11) was fit to a temperature-dependent power law over the measurable temperature domain (80-200 K) and extrapolated to both higher rotational states and room temperature. The measured and modeled low-temperature linewidth data provided here will aid low temperature gas-phase pressure measurements with fs/ps CARS.

Prioritizing the worries of AML patients: Quantifying patient experience using best-worst scaling.

CONTEXT: Although patients with acute myeloid leukemia (AML) experience significant toxicities and poor outcomes, few studies have quantified patients' experience. METHODS: A community-centered approach was used to develop an AML-specific best-worst scaling (BWS) instrument involving 13 items in four domains (psychological, physical, decision-making, and treatment delivery) to quantify patient worry. A survey of patients and caregivers was conducted using the instrument. Data were analyzed using conditional logistic regression. RESULTS: The survey was completed by 832 patients and 237 caregivers. Patients were predominantly white (88%), married/partnered (72%), and in remission (95%). The median age was 55 years (range: 19-87). Median time since diagnosis was 8 years (range: 1-40). Patients worried most about "the possibility of dying from AML" (BWS score = 15.5, confidence interval [CI] [14.2-16.7]) and "long-term side effects of treatments" (14.0, CI [12.9-15.2]). Patients found these items more than twice as worrisome as all items within the domains of care delivery and decision-making. Patients were least worried about "communicating openly with doctors" (2.50, CI [1.97-3.04]) and "having access to the best medical care" (3.90, CI [3.28-4.61]). Caregiver reports were highly correlated to patients' (Spearman's ρ = 0.89) though noted significantly more worry about the possibility of dying and spending time in the hospital. CONCLUSION: This large convenience sample demonstrates that AML patients have two principal worries: dying from their disease and suffering long-term side effects from treatment. To better foster patient-centered care, therapeutic decision-making and drug development should reflect the importance of both potential outcomes. Further work should explore interventions to address these worries.

Genomic characteristics and prognostic significance of co-mutated ASXL1/SRSF2 acute myeloid leukemia.

The ASXL1 and SRSF2 mutations in AML are frequently found in patients with preexisting myeloid malignancies and are individually associated with poor outcomes. In this multi-institutional retrospective analysis, we assessed the genetic features and clinical outcomes of 43 patients with ASXL1mut SRSF2mut AML and compared outcomes to patients with either ASXL1 (n = 57) or SRSF2 (n = 70) mutations. Twenty-six (60%) had secondary-AML (s-AML). Variant allele fractions suggested that SRSF2 mutations preceded ASXL1 mutational events. Median overall survival (OS) was 7.0 months (95% CI:3.8,15.3) and was significantly longer in patients with de novo vs s-AML (15.3 vs 6.4 months, respectively; P = .04 on adjusted analysis). Compared to ASXL1mut SRSF2wt and ASXL1wt SRSF2mut , co-mutated patients had a 1.4 and 1.6 times increase in the probability of death, respectively (P = .049), with a trend towards inferior OS (median OS = 7.0 vs 11.5 vs 10.9 months, respectively; P = .10). Multivariable analysis suggests this difference in OS is attributable to the high proportion of s-AML patients in the co-mutated cohort (60% vs 32% and 23%, respectively). Although this study is limited by the retrospective data collection and the relatively small sample size, these data suggest that ASXL1mut SRSF2mut AML is a distinct subgroup of AML frequently associated with s-AML and differs from ASXL1mut SRSF2wt /ASXL1wt SRSF2mut with respect to etiology and leukemogenesis.

Three-beam rotational coherent anti-Stokes Raman spectroscopy thermometry in scattering environments.

Three-beam rotational coherent anti-Stokes Raman scattering (CARS) measurements performed in highly scattering environments are susceptible to contamination by two-beam CARS signals generated by the pump-probe and Stokes-probe interactions at the measurement volume. If this occurs, differences in the Raman excitation bandwidth between the two-beam and three-beam CARS signals can add significant errors to the spectral analysis. This interference to the best of our knowledge has not been acknowledged in previous three-beam rotational CARS experiments, but may introduce measurement errors up to 25% depending on the temperature, amount of scattering, and differences between the two-beam and three-beam Raman excitation bandwidths. In this work, the presence of two-beam CARS signal contamination was experimentally verified using a femtosecond-picosecond rotational CARS instrument in two scattering environments: (1) a fireball generated by a laboratory-scale explosion that contained particulate matter, metal fragments, and soot, and (2) a flow of air and small liquid droplets. A polarization scheme is presented to overcome this interference. By rotating the pump and Stokes polarizations +55∘ and -55∘ from the probe, respectively, the two-beam and three-beam CARS signals are orthogonally polarized and can be separated using a polarization analyzer. Using this polarization arrangement, the Raman-resonant three-beam CARS signal amplitude is reduced by a factor of 2.3 compared to the case where all polarizations are parallel. This method is successfully demonstrated in both scattering environments. A theoretical model is presented, and the temperature measurement error is studied for different experimental conditions. The criteria for when this interference may be present are discussed.

Psychiatric Care in Hematopoietic Stem Cell Transplantation.

BACKGROUND: Patients with cancer frequently experience neuropsychiatric symptoms due to their medical illness or its treatment. In recent decades, psychiatrists have become increasingly involved in the care of patients with cancer. However, psychiatrists may be less familiar with hematopoietic stem cell transplantation (HSCT), a distinct cancer treatment modality associated with multiple neuropsychiatric sequelae. OBJECTIVE: To provide an overview of HSCT, and describe the prevalence, impact, risk factors, and suggested management of psychiatric consequences of HSCT. METHODS: We performed literature searches in PubMed and PsychInfo to identify articles describing neuropsychiatric symptoms, including depression, anxiety, distress, post-traumatic stress disorder, delirium and cognitive impairment, resulting from HSCT in adults. Those articles most relevant to this manuscript were included. RESULTS: Psychiatrists may be involved in the treatment of patients before, during, or after inpatient hospitalization for HSCT. Each phase of treatment introduces unique stressors that may lead to or exacerbate psychiatric disorders. Appropriate management requires evaluation of HSCT-related medications, an understanding of the impact of complications from HSCT, and consideration of how the patient's underlying medical condition should influence psychiatric recommendations. CONCLUSION: To optimize patient outcomes, consulting psychiatrists should be familiar with the basic principles of HSCT, and the neuropsychiatric sequelae that may result from treatment. Further research is needed to identify strategies to manage psychiatric complications in this unique population.

Phase conjugate digital inline holography (PCDIH).

Digital inline holography (DIH) provides instantaneous three-dimensional (3D) measurements of diffracting objects; however, phase disturbances in the beam path can distort the imaging. In this Letter, a phase conjugate digital inline holography (PCDIH) configuration is proposed for removal of phase disturbances. Brillouin-enhanced four-wave mixing produces a phase conjugate signal that back propagates along the DIH beam path. The results demonstrate the removal of distortions caused by gas-phase shocks to recover 3D images of diffracting objects.

Single-camera, single-shot, time-resolved laser-induced incandescence decay imaging.

Knowledge of soot particle sizes is important for understanding soot formation and heat transfer in combustion environments. Soot primary particle sizes can be estimated by measuring the decay of time-resolved laser-induced incandescence (TiRe-LII) signals. Existing methods for making planar TiRe-LII measurements require either multiple cameras or time-gate sweeping with multiple laser pulses, making these techniques difficult to apply in turbulent or unsteady combustion environments. Here, we report a technique for planar soot particle sizing using a single high-sensitivity, ultra-high-speed 10 MHz camera with a 50 ns gate and no intensifier. With this method, we demonstrate measurements of background flame luminosity, prompt LII, and TiRe-LII decay signals for particle sizing in a single laser shot. The particle sizing technique is first validated in a laminar non-premixed ethylene flame. Then, the method is applied to measurements in a turbulent ethylene jet flame.

Femtosecond, two-photon, planar laser-induced fluorescence of carbon monoxide in flames.

Two-photon, planar laser-induced fluorescence (TP-PLIF) of carbon monoxide was performed in steady and driven flames using femtosecond (fs) laser pulses at 1 kHz. Excitation radiation at 230.1 nm (full-width at half-maximum bandwidth of 270 cm-1) was used to pump many rovibrational two-photon transitions in the B1∑+←X1∑+ system. Visible fluorescence in the range 362-516 nm was captured using an image intensifier and high-speed camera. The signal dependence on excitation energy and wavelength is presented. Photolytic interferences from the ultraviolet laser were explored in a sooting diffusion flame. Using an excitation laser intensity of 1010 W/cm2, negligible photolytic interferences were observed, and PLIF imaging of dynamic flame events was performed at 1 kHz.

Mixture-fraction imaging at 1 kHz using femtosecond laser-induced fluorescence of krypton.

Femtosecond, two-photon-absorption laser-induced-fluorescence (TALIF) imaging measurements of krypton (Kr) are demonstrated to study mixing in gaseous flows. A measurement approach is presented in which observed Kr TALIF signals are 7 times stronger than the current state-of-the-art methodology. Fluorescence emission is compared for different gas pressures and excitation wavelengths, and the strongest fluorescence signals were observed when the excitation wavelength was tuned to 212.56 nm. Using this optimized excitation scheme, 1-kHz, single-laser-shot visualizations of unsteady flows and two-dimensional measurements of mixture fraction and scalar dissipation rate of a Kr-seeded jet are demonstrated.

Comparison of chirped-probe-pulse and hybrid femtosecond/picosecond coherent anti-Stokes Raman scattering for combustion thermometry.

A comparison is made between two ultrashort-pulse coherent anti-Stokes Raman scattering (CARS) thermometry techniques-hybrid femtosecond/picosecond (fs/ps) CARS and chirped-probe-pulse (CPP) fs-CARS-that have become standards for high-repetition-rate thermometry in the combustion diagnostics community. These two variants of fs-CARS differ only in the characteristics of the ps-duration probe pulse; in hybrid fs/ps CARS a spectrally narrow, time-asymmetric probe pulse is used, whereas a highly chirped, spectrally broad probe pulse is used in CPP fs-CARS. Temperature measurements were performed using both techniques in near-adiabatic flames in the temperature range 1600-2400 K and for probe time delays of 0-30 ps. Under these conditions, both techniques are shown to exhibit similar temperature measurement accuracies and precisions to previously reported values and to each other. However, it is observed that initial calibration fits to the spectrally broad CPP results require more fitting parameters and a more robust optimization algorithm and therefore significantly increased computational cost and complexity compared to the fitting of hybrid fs/ps CARS data. The optimized model parameters varied more for the CPP measurements than for the hybrid fs/ps measurements for different experimental conditions.

Congenital Paradoxical Lower Eyelid Retraction With Upgaze due to an Anomalous Extraocular Muscle.

Congenital anomalous orbital structures are rare and associated with strabismus, globe retraction, and dystopia. The authors present a case of congenital paradoxical right lower eyelid retraction with upgaze due to an anomalous extraocular muscle in a 17-year-old, healthy, female patient. Orbital computed tomography showed an intraconal, inferolateral soft-tissue band extending from the orbital apex to the inferior oblique muscle and lower eyelid. There was resolution of lower eyelid retraction and exposure symptoms after resection of the anterior portion of the fibromuscular band from the lower eyelid retractors and eyelid elevation with ear cartilage. To the authors' knowledge, this case is the first to report anomalous orbital structure as a rare cause of congenital paradoxical lower eyelid retraction, which can be improved with resection.

Comprehensive genomic profiling reveals molecular subsets of ASXL1-mutated myeloid neoplasms.

A large-scale genomic analysis of patients with ASXL1-mutated myeloid disease has not been performed to date. We reviewed comprehensive genomic profiling results from 6043 adults to characterize clinicopathologic features and co-mutation patterns by ASXL1 mutation status. ASXL1 mutations occurred in 1414 patients (23%). Mutation co-occurrence testing revealed strong co-occurrence (p < 0.01) between mutations in ASXL1 and nine genes (SRSF2, U2AF1, RUNX1, SETBP1, EZH2, STAG2, CUX1, CSF3R, CBL). Further analysis of patients with these co-mutations yielded several novel findings. Co-mutation patterns supported that ASXL1/SF3B1 co-mutation may be biologically distinct from ASXL1/non-SF3B1 spliceosome co-mutation. In AML, ASXL1/SRSF2 co-mutated patients frequently harbored STAG2 mutations (42%), which were dependent on the presence of both ASXL1 and SRSF2 mutation (p < 0.05). STAG2 and SETBP1 mutations were also exclusive in ASXL1/SRSF2 co-mutated patients and associated with divergent chronic myeloid phenotypes. Our findings support that certain multi-mutant genotypes may be biologically relevant in ASXL1-mutated myeloid disease.

Home Time Among Older Adults With Acute Myeloid Leukemia Following Chemotherapy.

Importance: Patients with acute myeloid leukemia (AML) recognize days spent at home (home time) vs in a hospital or nursing facility as an important factor in treatment decision making. No study has adequately described home time among older adults with AML. Objective: To describe home time among older adults with AML (aged ≥66 years) and compare home time between 2 common treatments: anthracycline-based chemotherapy and hypomethylating agents (HMAs). Design, Setting, and Participants: A cohort of adults aged 66 years or older with a new diagnosis of AML from the Surveillance, Epidemiology, and End Results (SEER)-Medicare linked database in 2004 to 2016 was identified. Individuals were stratified into anthracycline-based therapy, HMAs, or chemotherapy, not otherwise specified (NOS) using claims. Main Outcomes and Measures: The primary outcome was home time, quantified by subtracting the total number of person-days spent in hospitals and nursing facilities from the number of person-days survived and dividing by total person-days. A weighted multinomial regression model with stabilized inverse probability of treatment weighting to estimate adjusted home time was used. Results: The cohort included 7946 patients with AML: 2824 (35.5%) received anthracyclines, 2542 (32.0%) HMAs, and 2580 (32.5%) were classified as chemotherapy, NOS. Median (IQR) survival was 11.0 (5.0-27.0) months for those receiving anthracyclines and 8.0 (3.0-17.0) months for those receiving HMAs. Adjusted home time for all patients in the first year was 52.4%. Home time was highest among patients receiving HMAs (60.8%) followed by those receiving anthracyclines (51.9%). Despite having a shorter median survival, patients receiving HMAs had more total days at home and 33 more days at home in the first year on average than patients receiving anthracyclines (222 vs 189). Conclusions and Relevance: This retrospective study of older adults with AML using SEER-Medicare data and propensity score weighting suggests that the additional survival afforded by receiving anthracycline-based therapy was entirely offset by admission to the hospital or to nursing facilities.