Wide-Awake Hand Trauma Surgery: Designing Strategies to Optimise Patient Experience.

INTRODUCTION: The regional hand trauma service in Greater Manchester, United Kingdom, underwent significant reorganisation early in the COVID-19 pandemic, with a shift from predominantly general anaesthesia (GA) procedures to the adoption of a Wide-Awake Local Anaesthetic No Tourniquet (WALANT) technique. We implemented strategies targeted towards optimising patient experience, largely applicable to most healthcare settings. METHODS: Four domains were explored: (i) compliance in timing to nationally agreed treatment guidelines, (ii) the role of patient information leaflets, (iii) the introduction of a post-operative analgesia protocol, and (iv) broadly evaluating the environmental impact following the implementation of a same-day 'see and treat' service. RESULTS: Following reorganisation to a predominantly WALANT service, we observed an increase in compliance with nationally agreed standards for the treatment of common hand injuries. Patient education and peri-operative counselling reduced anxiety, whereas post-operative pain was better managed with the introduction of an analgesic protocol. Using a travel carbon calculator, it can be inferred that there are significant reductions in carbon emissions generated when patients are evaluated and treated on the same day as their clinical presentation. CONCLUSIONS: It is widely acknowledged that WALANT benefits patients and the healthcare system. We contemplated whether further incremental changes in clinical practice could further improve patient experience. Given our findings, we advocate a multi-modal approach with a greater focus on patient outcomes (trials are currently underway, e.g., WAFER) supplemented by universally accepted validated patient-reported outcome measures (PROMs).

Minimally Invasive Pneumonectomy vs Open Pneumonectomy: Outcomes and Predictors of Conversion.

BACKGROUND: In the modern era, whether minimally invasive pneumonectomy for non-small cell lung cancer (NSCLC) provides a survival advantage over open pneumonectomy is unknown. METHODS: Patients who underwent pneumonectomy for NSCLC between 2015 and 2020 were queried from the National Cancer Database. Surgical approach was categorized as robot-assisted thoracoscopic surgery (RATS), video-assisted thoracoscopic surgery (VATS), or open pneumonectomy on an intention-to-treat basis. Propensity score matching was performed to balance patient cohorts. Univariate and multivariate regression analyses were used to examine the association between surgical approach and 30- and 90-day mortality, and a Cox proportional hazards model was used to assess overall survival. RESULTS: We identified 3784 patients, including 73% open (n = 2776), 19% VATS (n = 725), and 8% RATS (n = 283). The overall conversion rate from minimally invasive to open was 29.5% (n = 298). After propensity matching 212 patients per cohort, there were no differences between open, VATS, and RATS 30-day (9.4% vs 8.5% vs 7.5%, respectively; P = .807) or 90-day mortality (14.2% vs 12.3% vs 10.4%, respectively; P = .516). Median overall survival was similar among open (48 months; 95% CI, 35.6-64.1 months), VATS (51.0 months; 95% CI, 34.9-72.3 months), and RATS approaches (50 months; 95% CI, 42.6-NA months; P = .560). Multivariate analysis of the matched cohort found no association between approach and overall survival. RATS (odds ratio, 0.67; 95% CI, 0.47-0.94; P = .020) and neoadjuvant chemotherapy (odds ratio, 0.52, 95% CI, 0.27-0.98; P = .045) were found to be protective against conversion to open. CONCLUSIONS: Minimally invasive pneumonectomy can be performed with short-term and long-term survival that are equivalent to open pneumonectomy.

Examination of Firefighting as an Occupational Exposure Criteria for Lung Cancer Screening.

PURPOSE: Firefighting is known to be carcinogenic to humans. However, current lung cancer screening guidelines do not account for occupational exposure. We hypothesize that firefighting is an independent risk factor associated with the development of high-risk lung nodules on low-dose CT (LDCT). METHODS: Members of a firefighter's union underwent LDCT at a single institution between April 2022 and June 2023 within a lung cancer screening program. Results were interpreted by designated chest radiologists and reported using the Lung-RADS scoring system. Demographic and radiographic data were recorded, and summary statistics are reported. RESULTS: 1347 individuals underwent lung cancer screening, with a median age of 51 years (IQR 42-58), including 56 (4.2%) females. Overall, 899 (66.7%) were never smokers, 345 (25.6%) were former smokers, and 103 (7.7%) were current smokers. There were 41 firefighters (3.0%) who had high-risk (Lung-RADS 3 or 4) nodules requiring intervention or surveillance, of which 21 (1.5%) were Lung-RADS 3 and 20 (1.5%) that were Lung-RADS 4. Of the firefighters with high-risk nodules, only 6 (14.6%) were eligible for LDCT based on current screening guidelines. There were 7 high-risk nodules (0.5%) that required procedural intervention, 6 (85.7%) of which were from the non-screening eligible cohort. There were also 20 never-smoking firefighters (57.1%) with high-risk nodules that were non-screening eligible. CONCLUSION: Firefighting, even in the absence of smoking history, may be associated with the development of high-risk lung nodules on LDCT. Carefully selected occupational exposures should be considered in the development of future lung cancer screening guidelines.

Women are Underrepresented in Non-small Cell Lung Cancer Clinical Trials: A Systematic Review.

PURPOSE: To perform a systematic review of clinical trials examining non-small cell lung cancer (NSCLC) to better understand the equity afforded to women in the study of lung cancer. METHODS: An electronic search was conducted for all NSCLC clinical trials published between 2010 and 2020 with included words "carcinoma, non-small cell, lung" and "non-small cell lung cancer." Studies from PubMed, Cochrane, and SCOPUS were included and were uploaded into Covidence to assist with systematic review. All articles were screened by two separate individuals and reviewed for location, study type, cancer stage, field of study of the research team, and percentage of females included. Student's t-test was used to compare the means of males and females. RESULTS: Across the 269 studies that met inclusion criteria, fewer females than males were enrolled (38.7% vs. 61.1%; p < 0.0001). Compared with studies from 2010 to 2015, those from 2016 to 2020 had greater representation of females (36.7% vs. 41.4%, p = 0.0091, respectively). Both nonsurgical and surgical studies enrolled fewer female than male patients (38.1% vs. 61.7%, p < 0.0001; 43.1% vs. 57.2%, p = 0.0002, respectively). Clinical trials from the USA had the least difference between sexes with an average of 46.7% females enrolled. Less females compared with males were enrolled in early-stage NSCLC (37.6% female vs. 62.6% male, p < 0.0001) and late-stage NSCLC trials (37.6% female vs. 62.0% male, p < 0.0001). CONCLUSIONS: Despite recent improvement, there continues to be significant underrepresentation of females compared with males in NSCLC clinical trials.

Pericardioesophageal fistulae after left atrial ablation: a case series.

Pericardioesophageal fistula is an uncommon, yet serious complication that can occur after left atrial ablation for cardiac arrhythmias. Timing of this complication is variable; however, it has been reported to occur from a week to over a month post-ablation. The incidence of this complication after ablation is <0.05%; however with increasing rates of left atrial ablations, early recognition is imperative. Nonspecific symptoms, including chest pain, dysphagia, and fever, can indicate the presence of a fistula within the first month after ablation. Early drainage with subsequent definitive treatment is key to limiting morbidity. Here we report four cases of pericardioesophageal fistula all occurring ~1 month post-ablation, with two patients surviving after prompt diagnosis and surgical treatment. Successful treatment in these two cases was achieved with fistula takedown and intercostal muscle flap interposition and esophageal stenting.

15 years of patient-reported outcomes in clinical trials leading to GU cancer drug approvals: a systematic review on the quality of data reporting and analysis.

Background: Standardized, high-quality PRO data reporting is crucial for patient centered care in the field of oncology, especially in clinical trials that establish standard of care. This study evaluated PRO endpoint design, conduct and reporting methods in FDA approved drugs for GU malignancies. Methods: A systematic review of the FDA archives identified GU cancer drug approvals from Feb 2007 to July 2022. ClinicalTrials.gov and PubMed were used to retrieve relevant data. PRO data was screened, and analytic tools, interpretation methods in the published papers and study protocols were reviewed. Compliance with PRO reporting standards were assessed using PRO Endpoint Analysis Score (PROEAS), a 24-point scoring scale from Setting International Standards in Analyzing Patient-Reported Outcomes and Quality of Life Endpoints Data Consortium (SISAQOL). Findings: We assessed 40 trial protocols with 27,011 participants, resulting in 14 renal cell cancer (RCC), 16 prostate cancer (PC), and 10 urothelial cancer (UC) approvals. PRO data was published for 27 trials, with 23 PRO publications (85%) focusing solely on PRO data, while 4 (15%) included PRO data in the original paper. Median time between primary clinical and secondary paper with PRO data was 10.5 months (range: 9-25 months). PROs were not planned as primary endpoints for any study but 14 (52%) reported them as secondary, 10 (37%) as exploratory outcomes, and 3 (11%) lacked any clarity on PRO data as endpoint. Mean PROEAS score of all GU cancers was 11.10 (range: 6-15), RCC (11.86, range: 6-15), UC (11.50, range: 9-14), and PC (10.56, range: 6-15). None met all the SISAQOL recommendations. Interpretation: Low overall PROEAS score and delays in PRO data publication in GU cancer drug trials conducted in the past decade emphasize the need for improvement in quality of design and conduct of PRO endpoint in future trials and accelerated publication of PRO endpoints, using standardized analysis, and prespecified hypothesis driven endpoint. These improvements are essential for facilitating interpretation and application of PRO study findings to define patient care. Funding: None.

Cost Effectiveness of Treatment Sequences in Advanced Renal Cell Carcinoma.

BACKGROUND: The treatment landscape for metastatic renal cell carcinoma (mRCC) has significantly evolved in recent years. Without direct comparator trials, factors such as cost effectiveness (CE) are important to guide decision-making. OBJECTIVE: To assess the CE of guideline-recommended approved first- and second-line treatment regimens. DESIGN, SETTING, AND PARTICIPANTS: A comprehensive Markov model was developed to analyze the CE of the five current National Comprehensive Cancer Network-recommended first-line therapies with appropriate second-line therapy for patient cohorts with International Metastatic RCC Database Consortium favorable and intermediate/poor risk. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Life years, quality-adjusted life years (QALYs), and total accumulated costs were estimated using a willingness-to-pay threshold of $150 000 per QALY. One-way and probabilistic sensitivity analyses were performed. RESULTS AND LIMITATIONS: In patients with favorable risk, pembrolizumab + lenvatinib followed by cabozantinib added $32 935 in costs and yielded 0.28 QALYs, resulting in an incremental CE ratio (ICER) of $117 625 per QALY in comparison to pembrolizumab + axitinib followed by cabozantinib. In patients with intermediate/poor risk, nivolumab + ipilimumab followed by cabozantinib added $2252 in costs and yielded 0.60 QALYs compared to cabozantinib followed by nivolumab, yielding an ICER of $4184. Limitations include differences in median follow-up duration between treatments. CONCLUSIONS: Pembrolizumab + lenvatinib followed by cabozantinib, and pembrolizumab + axitinib followed by cabozantinib were cost-effective treatment sequences for patients with favorable-risk mRCC. Nivolumab +ipilimumab followed by cabozantinib was the most cost-effective treatment sequence for patients with intermediate-/poor-risk mRCC, dominating all preferred treatments. PATIENT SUMMARY: Because new treatments for kidney cancer have not been compared head to head, comparison of their cost and efficacy can help in making decisions about the best treatments to use first. Our model showed that patients with a favorable risk profile are most likely to benefit from pembrolizumab and lenvatinib or axitinib followed by cabozantinib, while patients with an intermediate or poor risk profile will probably benefit most from nivolumab and ipilimumab followed by cabozantinib.

Postoperative Air Leaks After Lung Surgery: Predictors, Intraoperative Techniques, and Postoperative Management.

Postoperative air leak is one of the most common complications after pulmonary resection and contributes to postoperative pain, complications, and increased hospital length of stay. Several risk factors, including both patient and surgical characteristics, increase the frequency of air leaks. Appropriate intraoperative tissue handling is the most important surgical technique to reduce air leaks. Digital drainage systems have improved the management of postoperative air leak via objective data, portability, and ease of use in the outpatient setting. Several treatment strategies have been used to address prolonged air leak, including pleurodesis, blood patch, placement of endobronchial valves, and reoperative surgery.

The association of spinal deformity with dural ectasia in neurofibromatosis type 1.

Objective: To establish the prevalence of dural ectasia in patients with complex neurofibromatosis type-1 (NF-1) and its association with spinal deformities that manifest alongside.Methods: Analysis of the neuroradiological notes from 24 months of multidisciplinary team meetings for patients with complex NF-1 (equating to 378 patients). Review of the MRI scans of all patients with dural ectasia with each scan graded using a novel grading system.Results: A total of 38 of the 378 patients were found to have dural ectasia (10.05%). The median age of these 38 patients was 36 years ranging from 18 to 64. The male: female ratio was 16:22. In all, 90.9% of patients with a 'major' form of dural ectasia had a concurrent spinal deformity present compared to 18.18% of patients with a minor form.Conclusions: The more severe the dural ectasia, the greater the likelihood a concurrent deformity with NF-1. The vertebral bodies and pedicles are more commonly involved than the posterior elements.

Incidence, Management, and Outcomes of Intraoperative Catastrophes During Robotic Pulmonary Resection.

BACKGROUND: Intraoperative catastrophes during robotic anatomical pulmonary resections are potentially devastating events. The present study aimed to assess the incidence, management, and outcomes of these intraoperative catastrophes for patients with primary lung cancers. METHODS: This was a retrospective, multiinstitutional study that evaluated patients who underwent robotic anatomical pulmonary resections. Intraoperative catastrophes were defined as events necessitating emergency thoracotomy or requiring an additional unplanned major surgical procedure. Standardized data forms were collected from each institution, with questions on intraoperative management strategies of catastrophic events. RESULTS: Overall, 1810 patients underwent robotic anatomical pulmonary resections, including 1566 (86.5%) lobectomies. Thirty-five patients (1.9%) experienced an intraoperative catastrophe. These patients were found to have significantly higher clinical TNM stage (P = .031) and lower forced expiratory volume in 1 second (81% vs 90%; P = .004). A higher proportion of patients who had a catastrophic event underwent preoperative radiotherapy (8.6% vs 2.3%; P = .048), and the surgical procedures performed differed significantly compared with noncatastrophic patients. Patients in the catastrophic group had higher perioperative mortality (5.7% vs 0.5%; P = .018), longer operative duration (195 minutes vs 170 minutes; P = .020), and higher estimated blood loss (225 mL vs 50 mL; P < .001). The most common catastrophic event was intraoperative hemorrhage from the pulmonary artery, followed by injury to the airway, pulmonary vein, and liver. Detailed management strategies were discussed. CONCLUSIONS: The incidence of catastrophic events during robotic anatomical pulmonary resections was low, and the most common complication was pulmonary arterial injury. Awareness of potential intraoperative catastrophes and their management strategies are critical to improving clinical outcomes.

Between a rux and a hard place: evaluating salvage treatment and outcomes in myelofibrosis after ruxolitinib discontinuation.

Ruxolitinib is a JAK1/2 inhibitor that is effective in managing symptoms and splenomegaly related to myelofibrosis (MF). Unfortunately, many patients must discontinue ruxolitinib, at which time treatment options are not well defined. In this study, we investigated salvage treatment options and clinical outcomes among MF patients who received and discontinued ruxolitinib outside the context of a clinical trial. Among 145 patients who received ruxolitinib, 23 died while on treatment, 58 remained on treatment at time of analysis, leaving 64 people available for analysis. Development of cytopenias was the most common reason for discontinuation (38%) after median treatment time of 3.8 months (mo). The majority of patients received some form of salvage therapy after ruxolitinib discontinuation (n = 42; 66%), with allogeneic hematopoietic stem cell transplant (alloHSCT) (n = 17), being most commonly employed. Lenalidomide, thalidomide, hydroxyurea, interferon, and danazol were used with similar frequency. The response rate to salvage treatment was 26% (8 responses) and responses were most often seen with lenalidomide or thalidomide. Improved outcomes were observed in patients who underwent alloHSCT or received salvage therapy compared to those who did not receive additional therapy. Median overall survival (OS) after ruxolitinib discontinuation was 13 months. These findings show that salvage therapy can provide clinical responses after ruxolitinib discontinuation; however, these responses are rare and outcomes in this patient population are poor. This represents an area of unmet clinical need in MF.

In Laparoscopic Myomectomy, Does a Caseload of 100 Patients During the Learning Curve Produce a Significant Improvement in Performance Measures?

PURPOSE: Laparoscopic myomectomy (LM) offers considerable advantages over open myomectomy; however, LM is technically complex and associated with a steep learning curve. Few studies have evaluated the effect of the learning curve, and the limitations of most of these studies were the number of women included and the multiplicity of surgeons undertaking the procedure. The aim of this study is to evaluate the effect of a caseload of 100 patients during the learning curve of a single experienced surgeon performing LM. METHODS: A prospective comparative analysis of 200 consecutive cases of LM was conducted between December 2004 and March 2013. Outcomes of the first 100 procedures (Group A) were compared with the later 100 (Group B). RESULTS: The mean age of the cohort was 39 years (24-54 years), with a mean BMI of 27 kg/m(2) (16-46). Both the groups were very similar with regard to the number, size and weight of myomas removed, the duration of surgery, and blood loss. More women were sent home within 24 h in the second group (27 vs 10.2 %, p = 0.002). Group A suffered significantly higher complication rates compared to Group B (11 vs 7, p < 0.05). The laparotomy conversion rate was 1.5 % (3 in Group A, none in Group B). CONCLUSIONS: After a caseload of 100 patients during the learning curve, there was no difference in outcomes apart from increased confidence to discharge patients after 24 h and reduced complication rates. Thus, mere numbers do not influence the number/size of fibroids removed, operating time, or blood loss but do influence complication rates and post-operative discharge times.

'Hubble-bubble leads to trouble'--waterpipe smoking and oral health.

UNLABELLED: Waterpipes are used to smoke tobacco by more than 100 million people worldwide. Use is not restricted to any single racial, ethnic, or cultural group, and dentists are almost certain to encounter waterpipe users amongst their patients. This article describes what the practice involves and seeks to inform members of the dental team of the significantly detrimental impacts of waterpipe smoking on both general and oral health and how'hubble-bubble really can lead to trouble'. Advising patients on ceasing waterpipe use is also discussed. CLINICAL RELEVANCE: This paper explains what smoking a waterpipe involves, the associated misconceptions of safety amongst users and the dangers to health.