Evaluation of the Catheter Clamp over Hydrophilic Guide Wire Central Venous Catheter Exchange Technique for Air Embolism Prophylaxis in an In Vitro Model.

PURPOSE: To develop a reproducible in vitro model simulating central venous catheter (CVC) exchange with high potential for air embolization and test the hypothesis that a closed catheter clamp over hydrophilic guide wire exchange technique will significantly reduce the volume of air introduced during CVC exchange. MATERIALS AND METHODS: The model consisted of a 16-F valved sheath, 240-mL container, and pressure transducer submerged in water in a 1,200-mL suction canister system. Continuous wall suction was applied to the canister to maintain negative pressure at -7 mm Hg or -11 mm Hg. Each trial consisted of 0.035-inch hydrophilic guide wire introduction, over-the-wire catheter exchange, and wire removal following clinical protocol. A total of 256 trials were performed, 128 trials at each pressure with the catheter clamp open (n = 64) or closed (n = 64) around the hydrophilic guide wire. RESULTS: There was a statistically significant lower volume of air introduced with closed clamp over-the-wire exchanges than with open clamp exchanges at both pressures (2-tailed t-test, P < .001). At -7 mm Hg, a mean of 48.0 mL (SD ± 9.3) of air was introduced with open clamp and 20.6 mL (SD ± 4.7) of air was introduced with closed clamp. At -11 mm Hg, 97.8 mL (SD ± 11.9) of air was introduced with open clamp and 37.8 mL (SD ± 6.3) of air was introduced with closed clamp. CONCLUSIONS: This study demonstrated the use of a reproducible in vitro model mimicking conditions causing air embolism during CVC exchange. Results showed that CVC exchange using closed catheter clamp over hydrophilic guide wire exchange technique significantly reduced the volume of air introduced per exchange.

The Polyanalgesic Consensus Conference (PACC)®: Intrathecal Drug Delivery Guidance on Safety and Therapy Optimization When Treating Chronic Noncancer Pain.

INTRODUCTION: The International Neuromodulation Society convened a multispecialty group of physicians and scientists based on expertise with international representation to establish evidence-based guidance on intrathecal drug delivery in treating chronic pain. This Polyanalgesic Consensus Conference (PACC)® project, created more than two decades ago, intends to provide evidence-based guidance for important safety and efficacy issues surrounding intrathecal drug delivery and its impact on the practice of neuromodulation. MATERIALS AND METHODS: Authors were chosen on the basis of their clinical expertise, familiarity with the peer-reviewed literature, research productivity, and contributions to the neuromodulation literature. Section leaders supervised literature searches of MEDLINE, BioMed Central, Current Contents Connect, Embase, International Pharmaceutical Abstracts, Web of Science, Google Scholar, and PubMed from 2017 (when PACC® last published guidelines) to the present. Identified studies were graded using the United States Preventive Services Task Force criteria for evidence and certainty of net benefit. Recommendations are based on the strength of evidence or consensus when evidence is scant. RESULTS: The PACC® examined the published literature and established evidence- and consensus-based recommendations to guide best practices. Additional guidance will occur as new evidence is developed in future iterations of this process. CONCLUSIONS: The PACC® recommends best practices regarding intrathecal drug delivery to improve safety and efficacy. The evidence- and consensus-based recommendations should be used as a guide to assist decision-making when clinically appropriate.

Impact of Maximal Transurethral Resection on Pathological Outcomes at Cystectomy in a Large, Multi-institutional Cohort.

PURPOSE: While the presence of residual disease at the time of radical cystectomy for bladder cancer is an established prognostic indicator, controversy remains regarding the importance of maximal transurethral resection prior to neoadjuvant chemotherapy. We characterized the influence of maximal transurethral resection on pathological and survival outcomes using a large, multi-institutional cohort. MATERIALS AND METHODS: We identified 785 patients from a multi-institutional cohort undergoing radical cystectomy for muscle-invasive bladder cancer after neoadjuvant chemotherapy. We employed bivariate comparisons and stratified multivariable models to quantify the effect of maximal transurethral resection on pathological findings at cystectomy and survival. RESULTS: Of 785 patients, 579 (74%) underwent maximal transurethral resection. Incomplete transurethral resection was more frequent in patients with more advanced clinical tumor (cT) and nodal (cN) stage (P < .001 and P < .01, respectively), with more advanced ypT stage at cystectomy and higher rates of positive surgical margins (P < .01 and P < .05, respectively). In multivariable models, maximal transurethral resection was associated with downstaging at cystectomy (adjusted odds ratio 1.6, 95% CI 1.1-2.5). In Cox proportional hazards analysis, maximal transurethral resection was not associated with overall survival (adjusted HR 0.8, 95% CI 0.6-1.1). CONCLUSIONS: In patients undergoing transurethral resection for muscle-invasive bladder cancer prior to neoadjuvant chemotherapy, maximal resection may improve pathological response at cystectomy. However, the ultimate effects on long-term survival and oncologic outcomes warrant further investigation.

Bridging the Divide: Unintended Consequences of the Shift to Home-Based Telemedicine.

OBJECTIVE: To evaluate the impact on health care access of the change in telemedicine delivery from a clinic-based model, in which patients connect with their healthcare provider from local telemedicine clinics, to a home-based model, in which patients independently connect from their homes. STUDY DESIGN: In this retrospective analysis, we compared relative uptake in telemedicine services in Period 1 (01/01/2019 to 03/15/2020, prepandemic, clinic-based model) vs Period 2 (03/16/2020 to 06/30/2022, home-based model) within a tertiary pediatric hospital system. Using multivariable logistic regression, we investigated the influence of telemedicine delivery model on patient sociodemographic characteristics of completed telemedicine visits. RESULTS: We analyzed 400 539 patients with 1 406 961 completed outpatient encounters (52% White, 35% Black), of which 62 920 (4.5%) were telemedicine. In the clinic-based model (Period 1), underserved populations had greater likelihoods of accessing telemedicine: Hispanic ethnicity (OR = 1.41, P = .028) vs reference group non-Hispanic, Medicaid (OR = 2.62, P < .001) vs private insurance, and low-income neighborhood (OR = 3.40, P < .001) vs medium-income. In aggregate, telemedicine utilization rapidly increased from Period 1 (1.5 encounters/day) to Period 2 (107.9 encounters/day). However, underserved populations saw less relative increase (Medicaid [OR = 0.28, P < .001], Hispanic [OR = 0.53, P < .001], low-income [OR = 0.23, P < .001]). CONCLUSIONS: We observe that the clinic-based model offers more equitable access, while the home-based model offers more absolute access, suggesting that a hybrid model that offers both home-based and clinic-based services may result in more absolute and equitable access to telemedicine.

Vestibular Vertigo and Disparities in Healthcare Access Among Adults in the United States.

OBJECTIVE: Vertigo and dizziness have a high lifetime prevalence with significant impacts on daily life. We sought to explore differences in access to and ability to afford care among adults with vestibular vertigo by race/ethnicity, income, and insurance type. DESIGN: This is a cross-sectional study using the 2016 National Health Interview Survey. A total of 32,047 adults who completed the 2016 National Health Interview Survey Balance Supplement were analyzed. We used a previously validated definition of vertigo defined as (1) positional vertigo, (2) rotational vertigo, or (3) recurrent dizziness with nausea and either oscillopsia or imbalance. We examined several self-reported measures of healthcare utilization and access. RESULTS: Among adults with vestibular vertigo, African Americans had significantly increased odds of delayed care due to lack of transportation; Hispanic ethnicity was associated with decreased odds of skipping medication doses and asking a doctor for a lower-cost medication. Adults with public insurance had significantly lower odds of reporting delayed care due to worry about cost, not receiving medical care due to cost, and delayed filling of a prescription, but had greater odds of reporting delayed care due to lack of transportation. Lack of insurance and lower income were associated with increased odds of delaying and not receiving care due to cost. CONCLUSION: These findings demonstrate significant differences in access to care among adults with vestibular vertigo in the United States based on race, income, and health insurance status.

Baseline Quality of Life in Pediatric Patients With Low-flow Vascular Malformations.

OBJECTIVE: The aim of this study was to quantify and describe baseline patient and parent-proxy health-related quality of life scores in patients with low-flow vascular malformations at a single, tertiary-care vascular anomalies clinic. STUDY DESIGN: This is a retrospective study of data collected on patients with low-flow vascular malformations between the ages of 2 to 25 who were seen at a single, tertiary-care center vascular anomalies clinic. A total of 266 patients are included in this study. RESULTS: Patients with lymphatic malformations report decreased quality of life scores as compared with venous malformations in the emotional, psychological, school, and social domains. Patients with lower extremity malformation report decreased quality of life scores as compared with head/neck, trunk, upper extremity, and multifocal malformations; most notably in the physical domain. CONCLUSIONS: Treatment of low-flow vascular malformations should aim to improve patient quality of life. The use of standardized health-related quality of life measures in this study quantifies baseline quality of life scores among patients with low-flow vascular malformations.

Degenerative lumbar spondylolisthesis: review of current classifications and proposal of a novel classification system.

PURPOSE: To review existing classification systems for degenerative spondylolisthesis (DS), propose a novel classification designed to better address clinically relevant radiographic and clinical features of disease, and determine the inter- and intraobserver reliability of this new system for classifying DS. METHODS: The proposed classification system includes four components: 1) segmental dynamic instability, 2) location of spinal stenosis, 3) sagittal alignment, and 4) primary clinical presentation. To establish the reliability of this system, 12 observers graded 10 premarked test cases twice each. Kappa values were calculated to assess the inter- and intraobserver reliability for each of the four components separately. RESULTS: Interobserver reliability for dynamic instability, location of stenosis, sagittal alignment, and clinical presentation was 0.94, 0.80, 0.87, and 1.00, respectively. Intraobserver reliability for dynamic instability, location of stenosis, sagittal alignment, and clinical presentation were 0.91, 0.88, 0.87, and 0.97, respectively. CONCLUSION: The UCSF DS classification system provides a novel framework for assessing DS based on radiographic and clinical parameters with established implications for surgical treatment. The almost perfect interobserver and intraobserver reliability observed for all components of this system demonstrates that it is simple and easy to use. In clinical practice, this classification may allow subclassification of similar patients into groups that may benefit from distinct treatment strategies, leading to the development of algorithms to help guide selection of an optimal surgical approach. Future work will focus on the clinical validation of this system, with the goal of providing for more evidence-based, standardized approaches to treatment and improved outcomes for patients with DS.

Evidence for an association of serum microanalytes and myofascial pain syndrome.

BACKGROUND: Myofascial Pain Syndrome (MPS) is a common pain disorder. Diagnostic criteria include physical findings which are often unreliable or not universally accepted. A precise biosignature may improve diagnosis and treatment effectiveness. The purpose of this study was to assess whether microanalytic assays significantly correlate with characteristic clinical findings in people with MPS. METHODS: This descriptive, prospective study included 38 participants (25 women) with greater than 3 months of myofascial pain in the upper trapezius. Assessments were performed at a university laboratory. The main outcome measures were the Beighton Index, shoulder range of motion, strength asymmetries and microanalytes: DHEA, Kynurenine, VEGF, interleukins (IL-1b, IL-2, IL-4, IL-5, IL-7, IL-8, IL-13), growth factors (IGF-1, IGF2, G-CSF, GM-CSF), MCP-1, MIP-1b, BDNF, Dopamine, Noradrenaline, NPY, and Acetylcholine. Mann-Whitney test and Spearman's multivariate correlation were applied for all variables. The Spearman's analysis results were used to generate a standard correlation matrix and heat map matrix. RESULTS: Mean age of participants was 32 years (20-61). Eight (21%) had widespread pain (Widespread Pain Index ≥ 7). Thirteen (34%) had MPS for 1-3 years, 14 (37%) 3-10 years, and 11 (29%) for > 10 years. The following showed strong correlations: IL1b,2,4,5,7,8; GM-CSF and IL 2,4,5,7; between DHEA and BDNF and between BDNF and Kynurenine, NPY and acetylcholine. The heat map analysis demonstrated strong correlations between the Beighton Index and IL 5,7, GM-CSF, DHEA. Asymmetries of shoulder and cervical spine motion and strength associated with select microanalytes. CONCLUSION: Cytokine levels significantly correlate with selected clinical assessments. This indirectly suggests possible biological relevance for understanding MPS. Correlations among some cytokine clusters; and DHEA, BDNF kynurenine, NPY, and acetylcholine may act together in MPS. These findings should be further investigated for confirmation that link these microanalytes with select clinical findings in people with MPS.

Guided Wave Ultrasonic Testing for Crack Detection in Polyethylene Pipes: Laboratory Experiments and Numerical Modeling.

The use of guided wave-based Ultrasonic Testing (UT) for monitoring Polyethylene (PE) pipes is mostly restricted to detecting defects in welded zones, despite its diversified success in monitoring metallic pipes. PE's viscoelastic behavior and semi-crystalline structure make it prone to crack formation under extreme loads and environmental factors, which is a leading cause of pipeline failure. This state-of-the-art study aims to demonstrate the potential of UT for detecting cracks in non-welded regions of natural gas PE pipes. Laboratory experiments were conducted using a UT system consisting of low-cost piezoceramic transducers assembled in a pitch-catch configuration. The amplitude of the transmitted wave was analyzed to study wave interaction with cracks of different geometries. The frequency of the inspecting signal was optimized through wave dispersion and attenuation analysis, guiding the selection of third- and fourth- order longitudinal modes for the study. The findings revealed that cracks with lengths equal to or greater than the wavelength of the interacting mode were more easily detectable, while smaller crack lengths required greater crack depths for detection. However, there were potential limitations in the proposed technique related to crack orientation. These insights were validated using a finite element-based numerical model, confirming the potential of UT for detecting cracks in PE pipes.

Adenotonsillectomy for Snoring and Mild Sleep Apnea in Children: A Randomized Clinical Trial.

Importance: The utility of adenotonsillectomy in children who have habitual snoring without frequent obstructive breathing events (mild sleep-disordered breathing [SDB]) is unknown. Objectives: To evaluate early adenotonsillectomy compared with watchful waiting and supportive care (watchful waiting) on neurodevelopmental, behavioral, health, and polysomnographic outcomes in children with mild SDB. Design, Setting, and Participants: Randomized clinical trial enrolling 459 children aged 3 to 12.9 years with snoring and an obstructive apnea-hypopnea index (AHI) less than 3 enrolled at 7 US academic sleep centers from June 29, 2016, to February 1, 2021, and followed up for 12 months. Intervention: Participants were randomized 1:1 to either early adenotonsillectomy (n = 231) or watchful waiting (n = 228). Main Outcomes and Measures: The 2 primary outcomes were changes from baseline to 12 months for caregiver-reported Behavior Rating Inventory of Executive Function (BRIEF) Global Executive Composite (GEC) T score, a measure of executive function; and a computerized test of attention, the Go/No-go (GNG) test d-prime signal detection score, reflecting the probability of response to target vs nontarget stimuli. Twenty-two secondary outcomes included 12-month changes in neurodevelopmental, behavioral, quality of life, sleep, and health outcomes. Results: Of the 458 participants in the analyzed sample (231 adenotonsillectomy and 237 watchful waiting; mean age, 6.1 years; 230 female [50%]; 123 Black/African American [26.9%]; 75 Hispanic [16.3%]; median AHI, 0.5 [IQR, 0.2-1.1]), 394 children (86%) completed 12-month follow-up visits. There were no statistically significant differences in change from baseline between the 2 groups in executive function (BRIEF GEC T-scores: -3.1 for adenotonsillectomy vs -1.9 for watchful waiting; difference, -0.96 [95% CI, -2.66 to 0.74]) or attention (GNG d-prime scores: 0.2 for adenotonsillectomy vs 0.1 for watchful waiting; difference, 0.05 [95% CI, -0.18 to 0.27]) at 12 months. Behavioral problems, sleepiness, symptoms, and quality of life each improved more with adenotonsillectomy than with watchful waiting. Adenotonsillectomy was associated with a greater 12-month decline in systolic and diastolic blood pressure percentile levels (difference in changes, -9.02 [97% CI, -15.49 to -2.54] and -6.52 [97% CI, -11.59 to -1.45], respectively) and less progression of the AHI to greater than 3 events/h (1.3% of children in the adenotonsillectomy group compared with 13.2% in the watchful waiting group; difference, -11.2% [97% CI, -17.5% to -4.9%]). Six children (2.7%) experienced a serious adverse event associated with adenotonsillectomy. Conclusions: In children with mild SDB, adenotonsillectomy, compared with watchful waiting, did not significantly improve executive function or attention at 12 months. However, children with adenotonsillectomy had improved secondary outcomes, including behavior, symptoms, and quality of life and decreased blood pressure, at 12-month follow-up. Trial Registration: ClinicalTrials.gov Identifier: NCT02562040.

Difference in Perception of Nasal Aesthetic Appearance Between Surgeons and Rhinoplasty Patients: A Single-Center Perspective.

BACKGROUND: Patient satisfaction is an essential outcome measure after a rhinoplasty. Yet it is not known whether the opinions of rhinoplasty patients and surgeons on nasal aesthetic appearance differ. OBJECTIVES: The aim of this study was to determine the differences between patients and surgeons in their perception of nasal aesthetic appearance. METHODS: A retrospective cohort of 300 patients seen in consultation for cosmetic, functional, or combined cosmetic and functional rhinoplasty at a single tertiary care center from June 2017 to June 2020 was studied. Based on preoperative patient images, 6 surgeons with varying levels of expertise assessed nasal aesthetics utilizing a modified Standardized Cosmesis and Health Nasal Outcomes Survey for nasal cosmesis (SCHNOS-C). These scores were then compared to the patient-reported SCHNOS-C scores. RESULTS: The cosmetic, functional, and combined subgroups consisted of 100 patients each. The mean [standard deviation] age was 35.4 [13.7] years and 64% were women. The modified SCHNOS-C scores were well-correlated among the 6 surgeons but showed only weak correlations of 0.07 to 0.20 between patient-reported scores and scores assessed by the surgeons. Compared with the surgeon's scores, patients in the cosmetic subgroup perceived their nasal aesthetic problems to be more severe whereas the those in the functional subgroup perceived their nasal aesthetic problems to be milder compared with the surgeons' assessment. CONCLUSIONS: Our findings suggest that patients and surgeons perceive nasal cosmesis differently. This difference should be considered carefully when planning rhinoplasty or assessing its outcome.

Multicenter evaluation of neoadjuvant and induction gemcitabine-carboplatin versus gemcitabine-cisplatin followed by radical cystectomy for muscle-invasive bladder cancer.

PURPOSE: Cisplatin-based chemotherapy followed by radical cystectomy (RC) is recommended in patients with muscle-invasive bladder cancer (MIBC). However, up to 50% of patients are cisplatin ineligible. The aim of this study was to compare clinical outcomes after ≥ 3 cycles of preoperative gemcitabine-carboplatin (gem-carbo) versus gemcitabine-cisplatin (gem-cis). METHODS: We identified 1865 patients treated at 19 centers between 2000 and 2013. Patients were included if they had received ≥ 3 cycles of neoadjuvant (cT2-4aN0M0) or induction (cTanyN + M0) gem-carbo or gem-cis followed by RC. RESULTS: We included 747 patients treated with gem-carbo (n = 147) or gem-cis (n = 600). Patients treated with gem-carbo had a higher Charlson Comorbidity Index (p = 0.016) and more clinically node-positive disease (32% versus 20%; p = 0.013). The complete pathological response (pCR; ypT0N0) rate did not significantly differ between gem-carbo and gem-cis (20.7% versus 22.1%; p = 0.73). Chemotherapeutic regimen was not significantly associated with pCR (OR 0.99 [95%CI 0.61-1.59]; p = 0.96), overall survival (OS) (HR 1.20 [95%CI 0.85-1.67]; p = 0.31), or cancer-specific survival (CSS) (HR 1.35 [95%CI 0.93-1.96]; p = 0.11). Median OS of patients treated with gem-carbo and gem-cis was 28.6 months (95%CI 18.1-39.1) and 45.1 months (95%CI 32.7-57.6) (p = 0.18), respectively. Median CSS of patients treated with gem-carbo and gem-cis was 28.8 months (95%CI 9.8-47.8) and 71.0 months (95%CI median not reached) (p = 0.02), respectively. Subanalyses of the neoadjuvant and induction setting did not show significant survival differences. CONCLUSION: Our results show that a subset of cisplatin-ineligible patients with MIBC achieve pCR on gem-carbo and that survival outcomes seem comparable to gem-cis provided patients are able to receive ≥ 3 cycles and undergo RC.

Anterior cruciate ligament foot plate anatomy: 3-dimensional and 2-dimensional MRI evaluation with arthroscopy assessment in a subset of patients.

OBJECTIVES: ACL reconstruction tunnel location is an important predictor for outcomes after surgery. The aim was to establish 3D and 2D MRI radiological measurements for native ACL tibial footprint that can provide information to facilitate pre-operative planning for anatomical graft placement. The measurements were also correlated in a subset of patients on arthroscopy. METHODS: Retrospective evaluation of a consecutive series of knee MRIs with both 2D and 3D MR imaging was performed in 101 patients with 43 men and 66 women and ages 39.5 ± 11.9 years. Two measurements were obtained, tibial to ACL and intermeniscal ligament to ACL (T-ACL) and (IM-ACL), respectively. In a cohort of 18 patients who underwent knee arthroscopy, the T-ACL and IML-ACL distances were also determined by an orthopedic surgeon using a standard scale. ICC, Pearson correlation, and Bland-Altman plot were generated. RESULTS: For readers 1 and 2, the mean differences between 2D and 3D measurements of T-ACL and IM-ACL were 1.17 and 1.03 mm and 0.65 and 0.65 mm, respectively. The 2D measurements of T-ACL and IM-ACL were larger than the 3D measurements for both readers. The inter-reader reliability was excellent on 2D (0.81-0.96) and fair to excellent on 3D MRI (0.59-0.90). The mean arthroscopic IML-ACL was closer to that of 3D MRI compared to 2D MRI. The mean arthroscopic T-ACL was closer to 2D MRI than 3D MRI. CONCLUSIONS: Both 2D and 3D MRI show inter-reader reliability with small inter-modality mean differences in the measurements from the tibial or inter-meniscal ligament margins. KEY POINTS: • The mean differences between 2D and 3D measurements of tibia-ACL and intermeniscal ligament-ACL are small (< 1.2 mm). • As compared to arthroscopy, the mean T-ACL and IML-ACL were closer to measurements from 2D and 3D MRI, respectively. • Both 2D and 3D MRI can be reliably used to delineate ACL foot plate anatomy.

Anterior cruciate ligament reconstruction related complications: 2D and 3D high-resolution magnetic resonance imaging evaluation.

Anterior cruciate ligament (ACL) injury is a common indication for sports-related major surgery and accounts for a large proportion of ligamentous injuries in athletes. The advancements in 2D and 3D MR imaging have provided considerable potential for a one-stop shop radiation-free assessment with an all-in-one modality examination of the knee, for both soft-tissue and bone evaluations. This article reviews ACL injuries and types of surgical managements with illustrative examples using high resolution 2D and 3D MR imaging. Various complications of ACL reconstruction procedures are highlighted with a focus on the use of advanced MR imaging and relevant arthroscopic correlations.

Deep residual inception encoder-decoder network for amyloid PET harmonization.

INTRODUCTION: Multiple positron emission tomography (PET) tracers are available for amyloid imaging, posing a significant challenge to consensus interpretation and quantitative analysis. We accordingly developed and validated a deep learning model as a harmonization strategy. METHOD: A Residual Inception Encoder-Decoder Neural Network was developed to harmonize images between amyloid PET image pairs made with Pittsburgh Compound-B and florbetapir tracers. The model was trained using a dataset with 92 subjects with 10-fold cross validation and its generalizability was further examined using an independent external dataset of 46 subjects. RESULTS: Significantly stronger between-tracer correlations (P < .001) were observed after harmonization for both global amyloid burden indices and voxel-wise measurements in the training cohort and the external testing cohort. DISCUSSION: We proposed and validated a novel encoder-decoder based deep model to harmonize amyloid PET imaging data from different tracers. Further investigation is ongoing to improve the model and apply to additional tracers.

The Neurostimulation Appropriateness Consensus Committee (NACC): Recommendations for Surgical Technique for Spinal Cord Stimulation.

INTRODUCTION: The field of neurostimulation for the treatment of chronic pain is a rapidly developing area of medicine. Although neurostimulation therapies have advanced significantly as a result of technologic improvements, surgical planning, device placement, and postoperative care are of equal importance to optimize outcomes. This Neurostimulation Appropriateness Consensus Committee (NACC) project intends to provide evidence-based guidance for these often-overlooked areas of neurostimulation practice. MATERIALS AND METHODS: Authors were chosen based on their clinical expertise, familiarity with the peer-reviewed literature, research productivity, and contributions to the neuromodulation literature. Section leaders supervised literature searches of MEDLINE, BioMed Central, Current Contents Connect, Embase, International Pharmaceutical Abstracts, Web of Science, Google Scholar, and PubMed from the last NACC publication in 2017 to the present. Identified studies were graded using the United States Preventive Services Task Force criteria for evidence and certainty of net benefit. Recommendations are based on evidence strength and consensus when evidence was scant. RESULTS: This NACC project provides guidance on preoperative assessment, intraoperative techniques, and postoperative management in the form of consensus points with supportive evidence. These results are based on grade of evidence, strength of consensus, and expert opinion. CONCLUSIONS: The NACC has given guidance for a surgical plan that encompasses the patient journey from the planning stage through the surgical experience and postoperative care. The overall recommendations are designed to improve efficacy and the safety of patients undergoing these neuromodulation procedures and are intended to apply throughout the international community.

Neoadjuvant chemotherapy plus radical cystectomy versus radical cystectomy alone in clinical T2 bladder cancer without hydronephrosis.

OBJECTIVES: To assess the efficacy of neoadjuvant chemotherapy (NAC) before radical cystectomy (RC) in a retrospective multicentre cohort of patients with cT2N0M0 bladder cancer (BCa) without preoperative hydronephrosis. PATIENTS AND METHODS: This was a propensity-based analysis of 619 patients. Of these, 316 were treated with NAC followed by RC and 303 with upfront RC. After multiple imputations, inverse probability of treatment weighting (IPTW) was used to account for potential selection bias. Multivariable logistic regression analysis was performed to evaluate the impact of NAC on pathological complete response and downstaging at RC, while IPTW-adjusted Kaplan-Meier curves and Cox regression models were built to evaluate the impact of NAC on overall survival (OS). RESULTS: After IPTW-adjusted analysis, standardised differences between groups were <15%. A complete response (pT0N0) at final pathology was achieved in 94 (30%) patients receiving NAC and nine (3%) undergoing upfront RC. Downstaging to non-muscle-invasive disease (

Association of age with response to preoperative chemotherapy in patients with muscle-invasive bladder cancer.

PURPOSE: To assess the association of patient age with response to preoperative chemotherapy in patients with muscle-invasive bladder cancer (MIBC). MATERIALS AND METHODS: We analyzed data from 1105 patients with MIBC. Patients age was evaluated as continuous variable and stratified in quartiles. Pathologic objective response (pOR; ypT0-Ta-Tis-T1N0) and pathologic complete response (pCR; ypT0N0), as well survival outcomes were assessed. We used data of 395 patients from The Cancer Genome Atlas (TCGA) to investigate the prevalence of TCGA molecular subtypes and DNA damage repair (DDR) gene alterations according to patient age. RESULTS: pOR was achieved in 40% of patients. There was no difference in distribution of pOR or pCR between age quartiles. On univariable logistic regression analysis, patient age was not associated with pOR or pCR when evaluated as continuous variables or stratified in quartiles (all p > 0.3). Median follow-up was 18 months (IQR 6-37). On Cox regression and competing risk regression analyses, age was not associated with survival outcomes (all p > 0.05). In the TCGA cohort, patient with age ≤ 60 years has 7% less DDR gene mutations (p = 0.59). We found higher age distribution in patients with luminal (p < 0.001) and luminal infiltrated (p = 0.002) compared to those with luminal papillary subtype. CONCLUSIONS: While younger patients may have less mutational tumor burden, our analysis failed to show an association of age with response to preoperative chemotherapy or survival outcomes. Therefore, the use of preoperative chemotherapy should be considered regardless of patient age.

Short-Wave Infrared Emitting Nanocomposites for Fluorescence-Guided Surgery.

Fluorescence-guided surgery (FGS) is an emerging technique for tissue visualization during surgical procedures. Structures of interest are labeled with exogenous probes whose fluorescent emissions are acquired and viewed in real-time with optical imaging systems. This study investigated rare-earth-doped albumin-encapsulated nanocomposites (REANCs) as short-wave infrared emitting contrast agents for FGS. Experiments were conducted using an animal model of 4T1 breast cancer. The signal-to-background ratio (SBR) obtained with REANCs was compared to values obtained using indocyanine green (ICG), a near-infrared dye used in clinical practice. Prior to resection, the SBR for tumors following intratumoral administration of REANCs was significantly higher than for tumors injected with ICG. Following FGS, evaluation of fluorescence intensity levels in excised tumors and at the surgical bed demonstrated higher contrast between tissues at these sites with REANC contrast than ICG. REANCs also demonstrated excellent photostability over 2 hours of continuous illumination, as well as the ability to perform FGS under ambient lighting, establishing these nanocomposites as a promising contrast agent for FGS applications.

Variation in additional testing and patient outcomes after stress echocardiography or myocardial perfusion imaging, according to accreditation status of testing site.

BACKGROUND: The purpose of the present study was to determine whether patients receiving a stress echocardiogram or myocardial perfusion imaging (MPI) test have differences in subsequent testing and outcomes according to accreditation status of the original testing facility. METHODS AND RESULTS: An all-payer claims dataset from Maine Health Data Organization from 2012 to 2014 was utilized to define two cohorts defined by an initial stress echocardiogram or MPI test. The accreditation status (Intersocietal Accreditation Commission (IAC), American College of Radiology (ACR) or none) of the facility performing the index test was known. Descriptive statistics and multivariate regression were used to examine differences in subsequent diagnostic testing and cardiac outcomes. We observed 4603 index stress echocardiograms and 8449 MPI tests. Multivariate models showed higher odds of subsequent MPI testing and hospitalization for angina if the index test was performed at a non-accredited facility in both the stress echocardiogram cohort and the MPI cohort. We also observed higher odds of percutaneous coronary interventions (PCI) performed (OR 1.68, 95% CI 1.13-2.50), if the initial MPI test was done in a non-accredited facility. CONCLUSION: Cardiac testing completed in non-accredited facilities were associated with higher odds of subsequent MPI testing, hospitalization for angina, and PCI.