Implementation of a Multi-Disciplinary Team and Quality of Goals of Care Discussions in Palliative Surgical Oncology Patients.

BACKGROUND: Palliative surgical oncology patients represent a unique group with complex needs who often require multidisciplinary input for the provision of timely and holistic care. The authors assembled a multi-disciplinary palliative intervention team and evaluated its association with the quality of discussions on goals of care (GOC) among advanced cancer patients undergoing palliative interventions. METHODS: This prospective cohort study analyzed advanced cancer patients undergoing palliative interventions at a single urban academic center from October 2019 to March 2022. In January 2021, a multi-disciplinary palliative surgical intervention (MD-PALS) team was assembled. All palliative surgical oncology patients were discussed at multi-disciplinary meetings and managed by members of the MD-PALS team. An interrupted time series (ITS) model was built to evaluate the association of MD-PALS implementation and the quality of GOC discussions as measured by a consensus-derived four-point GOC discussion quality score. RESULTS: The study recruited 126 palliative surgical oncology patients: 44 in the pre-MD-PALS group and 82 in the post-MD-PALS group. The two groups did not differ significantly in baseline demographics, treatment, or postoperative and survival outcomes. Compared with the pre-MD-PALS group, the post-MD-PALS group had a significantly higher mean GOC discussion quality score (1.34 vs 2.61; p < 0.001). Based on the ITS model, the average quarterly GOC discussion quality score increased significantly among patients after implementation of the MD-PALS team (change = 1.93; 95 % confidence interval, 0.96-2.90; P = 0.003). CONCLUSION: The implementation of an MD-PALS team was associated with improvements in the quality of GOC discussions among palliative surgical oncology patients.

Intra-Arterial Therapy for Unresectable Colorectal Liver Metastases: A Meta-Analysis.

PURPOSE: To evaluate the efficacy of hepatic arterial infusion (HAI), conventional transarterial chemoembolization, drug-eluting embolic transarterial chemoembolization (DEE-TACE), transarterial radioembolization, and their combinations with systemic chemotherapy (SCT) for unresectable colorectal liver metastases. METHODS: A search was conducted on Embase, Scopus, PubMed, and Web of Science for prospective nonrandomized studies and randomized controlled trials (RCTs) from inception to June 20, 2020. Survival data of patients were recovered from original Kaplan-Meier curves by exploiting a graphical reconstructive algorithm. One-stage meta-analyses were conducted for the median overall survival (OS), survival rates (SRs), and restricted mean survival time (RMST), whereas two-stage meta-analyses of proportions were conducted to determine response rates (RRs) and conversion to resection rates (CRRs). RESULTS: A total of 71 prospective nonrandomized studies and 21 RCTs were identified, comprising 6,695 patients. Among patients treated beyond the first-line, DEE-TACE + SCT (n = 152) had the best survival outcomes of median OS of 26.5 (95% confidence interval [CI], 22.5-29.1) months and a 3-year RMST of 23.6 (95% CI, 21.8-25.5) months. Upon further stratification by publication year, DEE-TACE + SCT appeared to consistently have the highest pooled SRs at 1 year (81.9%) and 2 years (66.1%) in recent publications (2015-2020). DEE-TACE + SCT and HAI + SCT had the highest pooled RRs of 56.7% (I2 = 0.90) and 62.6% (I2 = 0.87) and pooled CRRs of 35.5% (I2 = 0.00) and 30.3% (I2 = 0.80), respectively. CONCLUSIONS: Albeit significant heterogeneity, the paucity of high-quality evidence, and the noncomparative nature of all analyses, the overall evidence suggests that patients treated with DEE-TACE + SCT have the best oncological outcomes and greatest potential to be converted for resection.

"Angioplasty-First" Approach for Limb Salvage in Asian Patients with Critical Limb Ischemia: Outcomes from 3,303 Angioplasties on 2,402 Limbs in a Single Tertiary Hospital.

PURPOSE: To review outcomes of patients with critical limb ischemia (CLI) who underwent conventional percutaneous transluminal angioplasty (PTA) as first-line treatment for revascularization. MATERIALS AND METHODS: Retrospective review of 3,303 angioplasty procedures on 2,402 limbs in 1,968 patients with CLI was conducted. Mean patient age was 68 years ± 11, and 1,057 patients (54%) were male. Diabetes mellitus (DM) was present in 1,736 patients (88%), and end-stage renal disease (ESRD) in 579 (29%). A majority of patients (90%) had tissue loss. Limb salvage rates were generated by Kaplan-Meier plot. Univariate and multivariate Cox regression analysis was conducted to investigate associations between clinical predictors and time-to-event outcome. RESULTS: Limb salvage rates at 1, 3, 5, and 10 years were 75%, 73%, 72%, and 62%, respectively, and overall survival rates were 79%, 64%, 56%, and 34%, respectively. In multivariable Cox regression analysis with the outcome of major amputation, significant predictors included age < 69 years (P = .032), Malay race (P = .029), DM (P < .001), history of cerebral vascular disease (P = .003), ESRD (P < .001), Rutherford classification (P = .042), repeat intervention (P = .034), and number of straight-line flows (P < .001) and plantar arch integrity (P < .001) on completion angiography. Significant associations with mortality were age < 69 years (P < .001), male sex (P = .030), Malay race (P = .027), history of ischemic heart disease (P < .001), ESRD (P < .001), and repeat intervention (P < .001). CONCLUSIONS: PTA as first-line revascularization for patients with CLI is safe and effective. Further studies are suggested to validate the outcome predictive model.

The Role of Drug-Coated Balloon in Haemodialysis Arteriovenous Fistula Stenosis Management.

Arteriovenous fistula (AVF) stenosis is a common problem leading to dialysis access dysfunction. The conventional balloon (CB) is the most commonly used device during angioplasty but suffers from poor durability of results due to neointimal hyperplasia-mediated recurrence. The drug-coated balloon (DCB) is an adjunct to balloon angioplasty that reduces neointimal hyperplasia, thereby improving post-angioplasty patency. Despite the heterogeneity of DCB clinical trials to date, the evidence suggests that DCBs of different brands are not necessarily equal, and that patient selection, adequate lesion preparation and proper DCB procedural technique are important to realize the benefit of DCB angioplasty.

Recurrent Stenoses in Arteriovenous Fistula (AVF) for Dialysis Access: cuttIng ballooN angioplaSTy combined wITh paclitaxel drUg-coaTed balloon angioplasty, an observatIONal study (INSTITUTION Study).

PURPOSE: To study the safety and efficacy of cutting balloon angioplasty (CBA) followed by paclitaxel drug-coated balloon (PCB) angioplasty for recurrent venous lesions in arteriovenous fistulas (AVFs). MATERIALS AND METHODS: We conducted a prospective single-arm cohort study of CBA followed by PCB angioplasty for recurrent AVF stenoses between September 2017 and April 2019. In total, 44 participants were recruited. Target lesions were included if they had recurred within 12 months post-angioplasty, were > = 0.5 cm upstream from the arteriovenous anastomosis, and did not involve the central veins. Up to two non-target lesions per circuit/participant with the same definition were allowed. Lesions were considered separate when there was an intervening 2-cm segment of normal vessel. Technical success was defined as complete lesion effacement on angioplasty. End-points of target and circuit patency were evaluated clinically at 3, 6, and 12 months post-procedure. RESULT: Technical success was 96% (42/44): Two participants were excluded from analysis due to the need for high-pressure balloon angioplasty as the target lesions did not efface with CBA. The median follow-up duration was 337.5 days. Mean stenosis pre- and post-angioplasty was 69.0% (51.6-84.8) and 20.8% (0-44.8), respectively. The target lesion primary, primary assisted and circuit patency for the entire study population (n = 42) were 61.6 ± 7.8%, 92.7 ± 4.0%, and 54.7 ± 7.9%, respectively, at 12 months. For participants without non-target lesions (n = 22), the rates were 77.3 ± 8.9%, 90.9 ± 6.1%, and 60.7 ± 11.0%, respectively, at 12 months. CONCLUSION: CBA followed by PCB angioplasty appears safe and feasible for treatment of recurrent venous lesions in dysfunctional AVFs.

A Randomized Phase 2 Trial of Nivolumab Versus Nivolumab-Ipilimumab Combination in EGFR-Mutant NSCLC.

Introduction: Although immune checkpoint inhibitors (ICIs) have dramatically improved outcomes for nononcogene-addicted NSCLC, monotherapy with programmed cell death protein-1 (PD1) inhibition has been associated with low efficacy in the EGFR-mutant setting. Given the potential for synergism with combination checkpoint blockade, we designed a trial to test the activity of combination nivolumab (N)-ipilimumab (NI) in EGFR-mutant NSCLC. Methods: This is a randomized phase 2 study (NCT03091491) of N versus NI combination in EGFR tyrosine kinase inhibitor (TKI)-resistant NSCLC, with crossover permitted on disease progression. The primary end point was the objective response rate, and the secondary end points included progression-free survival, overall survival, and safety of ICI after EGFR TKI. Results: Recruitment ceased owing to futility after 31 of 184 planned patients were treated. A total of 15 patients received N and 16 received NI combination. There were 16 patients (51.6%) who had programmed death-ligand (PDL1) 1 greater than or equal to 1%, and 15 (45.2%) harbored EGFR T790M. Five patients derived clinical benefits from ICI with one objective response (objective response rate 3.2%), and median progression-free survival was 1.22 months (95% confidence interval: 1.15-1.35) for the overall cohort. None of the four patients who crossed over achieved salvage response by NI. PDL1 and tumor mutational burden (TMB) were not able to predict ICI response. Rates of all grade immune-related adverse events were similar (80% versus 75%), with only two grade 3 events. Conclusions: Immune checkpoint inhibition is ineffective in EGFR TKI-resistant NSCLC. Whereas a small subgroup of EGFR-mutant NSCLC may be immunogenic and responsive to ICI, better biomarkers are needed to select appropriate patients.

The bug stops with me: Prevention of COVID-19 nosocomial transmission during radiographic procedures.

INTRODUCTION: Nosocomial transmission of Coronavirus Disease 2019 (COVID-19) is a preventable risk to the patient population and radiographer workforce. This article aims to describe the prevention of COVID-19 nosocomial transmission during radiographic procedures by the utilization of stringent infection prevention measures at a leading tertiary hospital in Singapore. METHODS: The implemented measures are the appropriate use of personal protective equipment, staff education, infection controls measures such as equipment disinfection, physical distancing and segregation of staff and patients. RESULTS: Despite the handling of 1637 COVID-19 cases as of July 25, 2020, there has not been a single case of known nosocomial transmission of the disease in the institution. DISCUSSION: The absence of nosocomial transmission suggests that the implemented measures are adequate. These measures will need to be sustainable for the long term in order to ensure continued success. CONCLUSION: Radiographers are a crucial part of the team in the fight against COVID-19 and are at risk of contracting COVID-19. Strict adherence to appropriate infection control measures is essential for the safety of Radiology staff and their patients, and the successful control of this pandemic.

Vertical displacement of the precordial leads alters electrocardiographic morphology.

BACKGROUND: The present study was undertaken to assess whether the vertical displacement of electrodes affects the waveforms of precordial leads. METHODS AND RESULTS: Two hundred forty healthy, adult volunteers had a standard 12-lead electrocardiogram, a 12-lead electrocardiogram with the precordial leads displaced 2 cm cranially, and another with the precordial leads displaced 2 cm caudally from the standard positions. All the three sets of electrocardiograms were visually compared, and changes noted. One hundred twenty male and 120 female volunteers, 20-68 years of age, were analyzed. Fifty-four males (45.0%) and 2 females (1.7%) showed no difference between the 3 sets of electrocardiograms, while 66 males (55.0%) and 118 females (98.3%) had some changes. R wave amplitude changes were noted in 63 male (52.5%) and 111 female (92.5%) volunteers; S wave amplitude changes were seen in 59 males (49.2%) and 99 females (82.5%,); T wave changes in 5 males (4.2%) and 3 females (2.5%); ST segment changes in 1 male (0.8%) and none of the females; and ORS morphologic changes in 1 male (0.8%) and 12 females (10.0%). CONCLUSIONS: Precordial electrocardiographic waveform changes were seen with the vertical displacement of the precordial leads. This will have implications on the interpretation of serial electrocardiograms. Healthcare providers should take into consideration this deviation when interpreting serial ECGs.