Imaging Strategies for Evaluating Low-Flow, Low-Gradient Aortic Stenosis with Reduced and Preserved Left Ventricular Ejection Fraction.

PURPOSE OF REVIEW: Aortic stenosis (AS) is one of the most common valvular heart diseases, and aortic valve replacement (AVR) provides both symptomatic and survival benefit in symptomatic severe AS patients. The purpose of this review is to discuss low-flow low-gradient AS which is still a challenging diagnostic entity. RECENT FINDINGS: Thirty-forty percent of patients with AS have low flow which makes it difficult to differentiate truly severe AS that benefits from AVR compared to pseudo-severe AS which is currently managed conservatively. Patients with low-flow low-gradient AS (LF-LG AS) include those with reduced left ventricular systolic function (classical LF-LG AS) and those with preserved left ventricular systolic function (paradoxical LF-LG AS). Low-dose dobutamine stress echocardiography (DSE) helps to identify truly severe stenosis in patients with classical LF-LG AS. Aortic valve calcium scoring with multidetector computed tomography plays a major role in patients with paradoxical LF-LG AS and also among classical LF-LG AS patients who have reduced contractile reserve on DSE. This article will provide an overview of imaging strategies for evaluating LF-LG AS with reduced and preserved left ventricular ejection fraction.

Rate and predictors of electrical failure in non-recalled defibrillator leads.

BACKGROUND: Implantable cardioverter defibrillator (ICD) leads are considered as the 'weakest link' in defibrillator systems due to FDA recalls and advisories involving popular lead models from major manufacturers. The rate of electrical failure of ICD leads not implicated in a recall is however not well determined. METHODS: Medical records of patients implanted with ICDs at hospitals of the University of Pittsburgh Medical Center between 2002 and 2014 were analyzed. Leads were classified as having electrically failed if removed or replaced for reasons other than infection or heart transplantation. Patients were followed to endpoint of death or electrical lead failure. RESULTS: 2410 consecutive ICD recipients (mean age 66 ±â€¯13 years, women 22%, single/dual/biventricular-ICD 20%/44%/36%) were included. During a mean follow-up of 3.9 ±â€¯3.3 years, 1272 patients (53%) died, 55 patients (2.3%) had ICD lead electrical failure, and 1052 (44%) patients were alive with functional leads at the time of last follow-up. Patients with failed leads had higher BMI (p = 0.07), better functional status (p = 0.04), higher serum creatinine (p = 0.004), wider QRS complex (p = 0.01), higher number of implanted leads (p = 0.06) and were more likely to have ischemic cardiomyopathy (p = 0.03). After adjusting for these variables in a binary logistic regression model, only a lower BMI, presence of non-ischemic cardiomyopathy, and a better functional status remained independently predictive of electrical failure. CONCLUSIONS: Only 2.3% of non-recalled ICD leads experience electrical failure (annual failure rate of 0.6%). A higher patient functional status, lower BMI, and non-ischemic etiology of cardiomyopathy are independently associated with higher rates of ICD lead failure.

Prognostic Value of FDG PET/CT-Derived Parameters in Pancreatic Adenocarcinoma at Initial PET/CT Staging.

OBJECTIVE: The purpose of this study is to evaluate the performance of PET-derived parameters as prognostic markers for overall survival (OS) and progression-free survival (PFS) outcome in patients with pancreatic adenocarcinoma. MATERIALS AND METHODS: We conducted a retrospective study of 106 patients (62 men and 44 women) with histologically proven pancreatic adenocarcinoma who underwent initial staging FDG PET/CT before treatment. Peak standardized uptake value (SUV), maximum SUV (SUVmax), metabolic tumor volume, and tumor glycolytic activity of the primary pancreatic tumor were measured. Two segmentation methods were performed to obtain the metabolic tumor volume and tumor glycolytic activity for all tumors: a gradient-based segmentation model (metabolic tumor volume and tumor glycolytic activity by gradient edge detection) and a fixed-threshold model with a threshold of 50% of the lesion's SUVmax and peak SUV. Univariate and multivariate Cox regression models were developed including clinical and imaging parameters for OS and PFS. RESULTS: Multivariate Cox regression analysis showed a statistically significant association between PFS and age, SUVmax, peak SUV, and tumor glycolytic activity by gradient edge detection. There was a statistically significant difference in PFS for patients with values above and below the median cutoff points for SUVmax (hazard ratio [HR], 1.12; p < 0.01), peak SUV (HR, 1.25; p < 0.02), and tumor glycolytic activity measured by gradient edge detection (HR, 1.00; p < 0.02) of the primary tumor. However, multivariate Cox regression analysis showed a statistically significant association only between tumor glycolytic activity by gradient edge detection and OS (p = 0.04), and there was a statistically significant difference in OS between patients with values above and below the median cutoff point for the tumor glycolytic activity by gradient edge detection of the primary tumor (HR, 1.42; p = 0.05). CONCLUSION: Age, SUVmax, peak SUV, and total lesion glycolysis (i.e., tumor glycolytic activity) of the primary tumor are associated with PFS, and tumor glycolytic activity is associated with OS in patients with pancreatic adenocarcinoma.

Prognostic value of FDG PET metabolic tumor volume in human papillomavirus-positive stage III and IV oropharyngeal squamous cell carcinoma.

OBJECTIVE: The purpose of this study was to establish the prognostic utility in human papillomavirus (HPV)-positive stage III and IV oropharyngeal squamous cell carcinoma (SCC) of the (18)F-FDG parameters maximal, mean, and peak standardized uptake value (SUVmax, SUVmean, and SUVpeak, respectively); metabolic tumor volume (MTV); and total lesion glycolysis (TLG). MATERIALS AND METHODS: We included 70 patients in the present study who had a biopsy-proven HPV-positive (by in situ hybridization) stage III and IV oropharyngeal SCC and had a baseline PET/CT examination at our institution. Outcome endpoint was event-free survival (EFS), which included recurrence-free and overall survival. Cox proportional hazards multivariate regression analyses were performed. Survival analysis was performed using Kaplan-Meier survival curves. RESULTS: In Cox regression proportional hazard univariate analysis, total MTV (hazard ratio [HR], 1.02; p = 0.008), primary-tumor MTV (HR, 1.02; p = 0.024), neck nodal MTV (HR, 1.03; p = 0.006), neck nodal TLG (HR, 1.01; p = 0.006), and neck node status (HR, 4.45; p = 0.03) showed a statistically significant association with EFS. There was no statistically significant association of EFS with SUVmax, SUVmean, SUVpeak, and primary-tumor or overall TLG. In Cox regression proportional hazard multivariate model I, total MTV remained an independent prognostic marker for EFS when adjusted for every other variable individually in the model; in model II, primary-tumor MTV, neck node status, and SUVpeak are independent prognostic markers for EFS. The Kaplan-Meier survival curves using optimum cut point of 41 mL of total MTV were not significant (p = 0.09). CONCLUSION: Total MTV and primary-tumor MTV are associated with survival outcomes in patients with HPV-positive stage III and IV oropharyngeal SCC.

Therapy for Stage IV Non-Small Cell Lung Cancer With Driver Alterations: ASCO Living Guideline, Version 2023.3.

PURPOSE: To provide evidence-based recommendations for patients with stage IV non-small cell lung cancer with driver alterations. METHODS: This ASCO living guideline offers continually updated recommendations based on an ongoing systematic review of randomized clinical trials (RCTs), with the latest time frame spanning February to October 2023. An Expert Panel of medical oncology, pulmonary, community oncology, research methodology, and advocacy experts were convened. The literature search included systematic reviews, meta-analyses, and randomized controlled trials. Outcomes of interest include efficacy and safety. Expert Panel members used available evidence and informal consensus to develop evidence-based guideline recommendations. RESULTS: This guideline consolidates all previous updates and reflects the body of evidence informing this guideline topic. Eight new RCTs were identified in the latest search of the literature to date. RECOMMENDATIONS: Evidence-based recommendations were updated to address first, second, and subsequent treatment options for patients based on targetable driver alterations.Additional information is available at www.asco.org/living-guidelines.

Therapy for Stage IV Non-Small Cell Lung Cancer Without Driver Alterations: ASCO Living Guideline, Version 2023.3.

PURPOSE: To provide evidence-based recommendations for patients with stage IV non-small cell lung cancer (NSCLC) without driver alterations. METHODS: This ASCO living guideline offers continually updated recommendations based on an ongoing systematic review of randomized clinical trials (RCTs), with the latest time frame spanning February to October 2023. An Expert Panel of medical oncology, pulmonary, community oncology, research methodology, and advocacy experts were convened. The literature search included systematic reviews, meta-analyses, and randomized controlled trials. Outcomes of interest include efficacy and safety. Expert Panel members used available evidence and informal consensus to develop evidence-based guideline recommendations. RESULTS: This guideline consolidates all previous updates and reflects the body of evidence informing this guideline topic. Ten new RCTs were identified in the latest search of the literature to date. RECOMMENDATIONS: Evidence-based recommendations were updated to address first, second, and subsequent treatment options for patients without driver alterations.Additional information is available at www.asco.org/living-guidelines.

Systemic Therapy for Melanoma: ASCO Guideline Update.

PURPOSE: To provide guidance to clinicians regarding the use of systemic therapy for melanoma. METHODS: American Society of Clinical Oncology convened an Expert Panel and conducted an updated systematic review of the literature. RESULTS: The updated review identified 21 additional randomized trials. UPDATED RECOMMENDATIONS: Neoadjuvant pembrolizumab was newly recommended for patients with resectable stage IIIB to IV cutaneous melanoma. For patients with resected cutaneous melanoma, adjuvant nivolumab or pembrolizumab was newly recommended for stage IIB-C disease and adjuvant nivolumab plus ipilimumab was added as a potential option for stage IV disease. For patients with unresectable or metastatic cutaneous melanoma, nivolumab plus relatlimab was added as a potential option regardless of BRAF mutation status and nivolumab plus ipilimumab followed by nivolumab was preferred over BRAF/MEK inhibitor therapy. Talimogene laherparepvec is no longer recommended as an option for patients with BRAF wild-type disease who have progressed on anti-PD-1 therapy. Ipilimumab- and ipilimumab-containing regimens are no longer recommended for patients with BRAF-mutated disease after progression on other therapies.This full update incorporates the new recommendations for uveal melanoma published in the 2022 Rapid Recommendation Update.Additional information is available at www.asco.org/melanoma-guidelines.

Systemic Therapy for Melanoma: ASCO Guideline.

PURPOSE: To provide guidance to clinicians regarding the use of systemic therapy for melanoma. METHODS: ASCO convened an Expert Panel and conducted a systematic review of the literature. RESULTS: A systematic review, one meta-analysis, and 34 additional randomized trials were identified. The published studies included a wide range of systemic therapies in cutaneous and noncutaneous melanoma. RECOMMENDATIONS: In the adjuvant setting, nivolumab or pembrolizumab should be offered to patients with resected stage IIIA/B/C/D BRAF wild-type cutaneous melanoma, while either of those two agents or the combination of dabrafenib and trametinib should be offered in BRAF-mutant disease. No recommendation could be made for or against the use of neoadjuvant therapy in cutaneous melanoma. In the unresectable/metastatic setting, ipilimumab plus nivolumab, nivolumab alone, or pembrolizumab alone should be offered to patients with BRAF wild-type cutaneous melanoma, while those three regimens or combination BRAF/MEK inhibitor therapy with dabrafenib/trametinib, encorafenib/binimetinib, or vemurafenib/cobimetinib should be offered in BRAF-mutant disease. Patients with mucosal melanoma may be offered the same therapies recommended for cutaneous melanoma. No recommendation could be made for or against specific therapy for uveal melanoma. Additional information is available at www.asco.org/melanoma-guidelines.

Systemic therapy for melanoma: ASCO guideline update

To provide guidance to clinicians regarding the use of systemic therapy for melanoma. American Society of Clinical Oncology convened an Expert Panel and conducted an updated systematic review of the literature. The updated review identified 21 additional randomized trials. Neoadjuvant pembrolizumab was newly recommended for patients with resectable stage IIIB to IV cutaneous melanoma. For patients with resected cutaneous melanoma, adjuvant nivolumab or pembrolizumab was newly recommended for stage IIB-C disease and adjuvant nivolumab plus ipilimumab was added as a potential option for stage IV disease. For patients with unresectable or metastatic cutaneous melanoma, nivolumab plus relatlimab was added as a potential option regardless of BRAF mutation status and nivolumab plus ipilimumab followed by nivolumab was preferred over BRAF/MEK inhibitor therapy. Talimogene laherparepvec is no longer recommended as an option for patients with BRAF wild-type disease who have progressed on anti­PD-1 therapy. Ipilimumab- and ipilimumab-containing regimens are no longer recommended for patients with BRAF-mutated disease after progression on other therapies. This full update incorporates the new recommendations for uveal melanoma published in the 2022 Rapid Recommendation Update. Additional information is available at www.asco.org/melanoma-guidelines

Usefulness of the CHA2DS2-VASc Score to Predict Mortality in Defibrillator Recipients.

The CHA2DS2-VASC score is a well-validated stratification tool that predicts the risk of thromboembolism and stroke in patients with nonvalvular atrial fibrillation. Several studies have examined its application as a predictor of mortality in clinical applications other than atrial fibrillation. However, there are current no studies examining its use as an outcome prediction tool in a population of patients with implantable cardiac defibrillators (ICDs). In this study, we examined data from 2,258 patients who underwent ICD device implantation at the hospitals of the University of Pittsburgh Medical Center from February 2002 to April 2014 (median follow-up 5.1 years) and examined the impact of their CHA2DS2-VASC score at the time of device implantation on all-cause mortality. Survival curves based on CHA2DS2-VASC scores were generated using the Kaplan-Meier method and were adjusted for unbalanced covariates using the Cox proportional hazards model. The mean CHA2DS2-VASC score was 3.15 ± 1.52 (range 1 to 8, mode 3). The CHA2DS2-VASC score predicted all-cause mortality in a significant and dose-dependent fashion. Analyzing the population by quartiles revealed increasing all-cause mortality from Q1 to Q4 (p <0.001). Using a Cox multivariate model adjusting for ejection fraction, BMI, serum creatinine, hemoglobin level, and QRS width, the CHA2DS2-VASC score remained a strong predictor of all-cause mortality (hazard ratio 1.26 per 1-point increase, 95% confidence interval 1.20 to 1.32). In conclusion, the CHA2DS2-VASC score is a simple tool that highly predicts all-cause mortality in patients with ICD.

Failure rates of single- versus dual-coil nonrecalled sprint quattro defibrillator leads.

Electrical failure is more common in single-coil compared with dual-coil implantable cardioverter defibrillator (ICD) leads in the case of the recalled Riata lead. Single-coil leads are however favored in most patients given their lower risk of extraction. We therefore evaluated the failure-free survival of single- versus dual-coil ICD leads not included in Food and Drug Administration recalls. All patients receiving a Medtronic transvenous Sprint Quattro single- or dual-coil ICD lead were included in this analysis. Leads were followed to the end point of electrical failure. A total of 1,020 dual-coil and 631 single-coil ICD leads were implanted at our institution from November 2000 to March 2014. As expected, dual-coil leads had a longer follow-up time (3.4 ± 2.6 years vs 1.3 ± 1.0 years, p <0.001) because they were approved many years earlier by the Food and Drug Administration. The overall lead survival rates free from electrical failure at 1, 2, and 3 years after implantation were 98.8%, 98.2%, and 95.1%, respectively, for the single-coil leads versus 99.7%, 99.4%, and 99.3%, respectively, for the dual-coil leads (p = 0.0013). In conclusion, single-coil leads are associated with higher electrical failure rates compared with dual-coil leads even for nonrecalled lead models from the same family and manufacturer. These findings have implications on the choice of ICD lead at the time of device implantation.

Scoring of coronary artery calcium scans: history, assumptions, current limitations, and future directions.

Coronary artery calcium (CAC) scanning is a reliable, noninvasive technique for estimating overall coronary plaque burden and for identifying risk for future cardiac events. Arthur Agatston and Warren Janowitz published the first technique for scoring CAC scans in 1990. Given the lack of available data correlating CAC with burden of coronary atherosclerosis at that time, their scoring algorithm was remarkable, but somewhat arbitrary. Since then, a few other scoring techniques have been proposed for the measurement of CAC including the Volume score and Mass score. Yet despite new data, little in this field has changed in the last 15 years. The main focus of our paper is to review the implications of the current approach to scoring CAC scans in terms of correlation with the central disease - coronary atherosclerosis. We first discuss the methodology of each available scoring system, describing how each of these scores make important indirect assumptions in the way they account (or do not account) for calcium density, location of calcium, spatial distribution of calcium, and microcalcification/emerging calcium that might limit their predictive power. These assumptions require further study in well-designed, large event-driven studies. In general, all of these scores are adequate and are highly correlated with each other. Despite its age, the Agatston score remains the most extensively studied and widely accepted technique in both the clinical and research settings. After discussing CAC scoring in the era of contrast enhanced coronary CT angiography, we discuss suggested potential modifications to current CAC scanning protocols with respect to tube voltage, tube current, and slice thickness which may further improve the value of CAC scoring. We close with a focused discussion of the most important future directions in the field of CAC scoring.

Imaging modality utilization trends in patients with stage III-IV oropharyngeal squamous cell carcinoma.

The objective of this study is to establish the utilization trends of CT, MRI, and FDG-PET/CT for evaluation of oropharyngeal squamous cell carcinoma (OPSCC) patients. A total of 173 patients with newly diagnosed stage III or IV OPSCC between 2003 and 2009 were included. Frequency of imaging modality use, divided into four time periods (2003-04, 2005-06, 2007-08 and 2009), was evaluated. For initial staging, percentage of PET/CT use was 64.6%, 87.5%, 94.1% and 96.3%, with an increasing trend (p < 0.001). The CT (p = 0.762) and MRI (p = 0.224) use demonstrated no change in trend. For post-treatment imaging, percentage of PET/CT use was 59.5%, 68.6%, 89.7% and 100%, with an increasing trend (p < 0.001). The CT use demonstrated a decreasing trend (p = 0.004) and MRI showed no trend change (p = 0.231). PET/CT is used with an increasing trend for initial staging and has become a central imaging modality for follow up evaluation after treatment, for advanced OPSCC.

Liver standardized uptake value corrected for lean body mass at FDG PET/CT: effect of FDG uptake time.

OBJECTIVE: The objective of this study is to establish the magnitude change and interreader reliability of the liver standardized uptake value corrected for lean body mass (SULmean) in dual-time-point imaging at 1 and 2 hours and 1 and 4 hours. PATIENTS AND METHODS: Early and delayed FDG PET/CT scans were included for 28 patients (13 men and 15 women) who had normal liver by CT or ultrasound. The average uptake time between the early and delayed scans were 55 minutes (range, 44-69 minutes) for pancreatic adenocarcinoma patients (n = 19) and 184 minutes (range, 140-197 minutes) for neurofibromatosis patients (n = 9). A 30-mm-diameter spherical volume of interest was placed within the right lobe of the liver above, below, and at the level of the main portal vein by 2 independent readers. Correlation coefficients, analysis of variance, intraclass correlation coefficient, and Bland-Altman analysis were performed. RESULTS: The mean liver SULmean was between 1.39 and 1.42 and between 1.28 and 1.3 in early and delayed images, respectively (P = 0.001). There is time-dependent reduction in the mean liver SULmean at 2-hour (7%-8%) and 4-hour uptake time (15%-21%) compared with 1-hour uptake time. The correlation coefficient between delayed uptake time and liver SULmean reduction is 0.39 to 0.41 at the upper aspect of the liver. The intraclass correlation coefficient for 2 readers varied between 0.997 and 0.998 and between 0.995 and 0.999 in early and delayed images, respectively (P = 0.001). CONCLUSIONS: There is time-dependent reduction of mean liver SULmean, about 7% to 8% within the clinically relevant FDG uptake time, in the same patient with excellent interreader agreement in early and delayed images within the right lobe of the liver. Therefore, liver SULmean could represent a useful reference parameter in quantitative analysis of dual-phase FDG PET/CT in malignancy or atypical infection/inflammatory disease. Furthermore, it may be suitable as a normalization factor in currently available formulae quantifying therapy response on PET imaging.

Distribution and burden of newly detected coronary artery calcium: Results from the Multi-Ethnic Study of Atherosclerosis.

BACKGROUND: The transition from no coronary artery calcium (CAC) to detectable CAC is important, as even mild CAC is associated with increased cardiovascular events. We sought to characterize the anatomic distribution and burden of newly detectable CAC over 10-year follow-up. METHODS: We evaluated 3112 participants (mean age, 58 years; 64% female) with baseline CAC = 0 from the Multi-Ethnic Study of Atherosclerosis. Participants underwent repeat CAC testing at different time intervals (between 2-10 years after baseline) per the Multi-Ethnic Study of Atherosclerosis protocol. Among participants who developed CAC on a follow-up scan, we used logistic regression and marginal probability modeling to describe the coronary distribution and burden of new CAC by age, sex, and race after adjustment for cardiovascular risk factors and time to detection. RESULTS: A total of 1125 participants developed detectable CAC during follow-up with a mean time to detection of 6.1 ± 3 years. New CAC was most commonly isolated to 1 vessel (72% of participants), with the left anterior descending artery (44% of total) most commonly affected followed by the right coronary (12%), left circumflex (10%), and left main (6%). These patterns were similar across age, sex, and race. In multivariate models, residual predictors of multivessel CAC (28% of total) included male sex, African American or Hispanic race, hypertension, obesity, and diabetes. At the first detection of CAC >0, burden was usually low with median Agatston CAC score of 7.1 and <5% with CAC scores >100. CONCLUSION: New-onset CAC most commonly involves just 1 vessel, occurs in the left anterior descending artery, and has low CAC burden. New CAC can be detected at an early stage when aggressive preventive strategies may provide benefit.

PET/CT imaging and human papilloma virus-positive oropharyngeal squamous cell cancer: evolving clinical imaging paradigm.

Human papillomavirus (HPV)-positive oropharyngeal squamous cell carcinoma (OPSCC) represents an emerging disease that differs from HPV-negative OPSCC in natural history and prognosis. Contrast-enhanced PET/CT is essential to accurately stage the primary site when there are smaller tumors; neck nodal metastases, which tend to have a more cystic component; and distant metastases that manifest in unusual sites (disseminating phenotype) such as bones and other solid organs, including brain. Metastases tend to appear later in the disease course during follow-up for HPV-positive OPSCC than for HPV-negative OPSCC. Because HPV-positive OPSCC patients have a better clinical outcome, there is a need for treatment deintensification to spare the patient from treatment-related toxicities. (18)F-FDG PET/CT would play a role in monitoring patients with deintensified treatments to ensure that no adverse outcome is introduced. The better prognosis and outcome of HPV-positive OPSCC patients would warrant imaging follow-up that is less intense but continues longer because of the manifestation of distant metastases later in the disease course and at unusual sites. All these clinical paradigms facilitate a definite role for PET/CT imaging in the management of HPV-positive OPSCC.

FDG PET/CT imaging of oropharyngeal squamous cell carcinoma: characteristics of human papillomavirus-positive and -negative tumors.

OBJECTIVE: The objective of this study was to assess differences in morphological and glycolytic characteristics of primary tumors and locoregional nodal disease between human papillomavirus (HPV)-positive and HPV-negative oropharyngeal head and neck squamous cell carcinoma. METHODS: This was a retrospective analysis of 123 baseline FDG PET/CT scans from patients (aged 57.0 ± 10.6 years) with newly diagnosed oropharyngeal SCC between January 2003 and June 2012. There were 98 HPV-positive and 25 HPV-negative patients. SUVmax, SUVpeak, and SUVmean based on lean body mass, as well as RECIST (Response Evaluation Criteria In Solid Tumors) dimensions, metabolic tumor volume (gradient and threshold-segmentation methods) and total lesion glycolysis, were determined for primary and locoregional nodal disease. RESULTS: Human papillomavirus-negative primary tumors were significantly larger as measured by RECIST longest diameter (P = 0.002) and slightly more heterogeneous as measured by the heterogeneity index (P = 0.07), higher SUVmax (P < 0.01), SUVpeak (P = 0.01), SUVmean (P = 0.01), metabolic tumor volume (P = 0.002), and total lesion glycolysis (P = 0.001), for both segmentation methods. Index parameters of HPV-positive nodal disease tend to be larger, but some with no statistical significance (P > 0.05). There was no significant difference in the metabolic parameters of primary tumor or nodal metastases for HPV-positive patients with and without smoking history. CONCLUSIONS: Index morphologic and glycolytic parameters as measured in FDG PET/CT are significantly larger in HPV-negative as compared with HPV-positive primary oropharyngeal carcinoma. In contrast, the same parameters trended to be larger in HPV-positive regional nodal disease.

Risk factors for colonization due to carbapenem-resistant Enterobacteriaceae among patients exposed to long-term acute care and acute care facilities.

BACKGROUND: This study aimed to identify risk factors associated with carbapenem-resistant Enterobacteriaceae (CRE) colonization among patients screened with rectal cultures upon admission to a hospital or long-term acute care (LTAC) center and to compare risk factors among patients who were screen positive for CRE at the time of hospital admission with those screen positive prior to LTAC admission. METHODS: A retrospective nested matched case-control study was conducted from June 2009 to December 2011. Patients with recent LTAC exposure were screened for CRE carriage at the time of hospital admission, and patients admitted to a regional LTAC facility were screened prior to LTAC admission. Cases were patients with a positive CRE screening culture, and controls (matched in a 3∶1 ratio to cases) were patients with negative screening cultures. RESULTS: Nine hundred five cultures were performed on 679 patients. Forty-eight (7.1%) cases were matched to 144 controls. One hundred fifty-eight patients were screened upon hospital admission and 521 prior to LTAC admission. Independent predictors for CRE colonization included Charlson's score greater than 3 (odds ratio [OR], 4.85 [95% confidence interval (CI), 1.64-14.41]), immunosuppression (OR, 3.92 [95% CI, 1.08-1.28]), presence of indwelling devices (OR, 5.21 [95% CI, 1.09-2.96]), and prior antimicrobial exposures (OR, 3.89 [95% CI, 0.71-21.47]). Risk factors among patients screened upon hospital admission were similar to the entire cohort. Among patients screened prior to LTAC admission, the characteristics of the CRE-colonized and noncolonized patients were similar. CONCLUSIONS: These results can be used to identify patients at increased risk for CRE colonization and to help target active surveillance programs in healthcare settings.

Addition of 18F-FDG PET/CT to clinical assessment predicts overall survival in HNSCC: a retrospective analysis with follow-up for 12 years.

UNLABELLED: (18)F-FDG PET/CT is used in the follow-up of patients with head and neck squamous cell cancer (HNSCC). However, its impact on clinical decision making and patient outcome is not fully established. The objective of this study was to determine the prognostic value of (18)F-FDG PET/CT for overall survival (OS) of HNSCC patients when performed in addition to clinical assessment between 4 and 24 mo after treatment. METHODS: This was a retrospective study at a single tertiary center. The institutional review board approved this study, and the requirement to obtain informed consent was waived. The study included 134 biopsy-proven HNSCC patients with 227 follow-up PET/CT scans. The primary outcome measure was OS. Median follow-up was 40 mo (range, 7-145 mo). Survival is presented as Kaplan-Meier plots with Mantel-Cox log-rank test. The multivariate Cox model included clinical covariates. RESULTS: Of the 227 PET/CT scans, 41 (18%) were positive for tumor and 186 (82%) were negative for tumor. PET/CT identified recurrence in 5% (9/194) of scans performed without prior clinical concern and ruled out tumor in 51.5% (17/33) of scans performed to evaluate clinical suspicion or uncertainty of recurrence. The median survival of PET-positive and -negative groups from the date of the scan was 20 and 30.5 mo, respectively (P < 0.0001). There was a significant difference in OS from the scan date between patients who had a positive PET/CT result for tumor and those who had a negative result (log-rank, P < 0.0001), with a hazard ratio of 29.74. Human papillomavirus status (P = 0.001) and PET/CT result (P = 0.04) were the only factors significantly associated with OS, adjusted for all other covariates. CONCLUSION: (18)F-FDG PET/CT performed between 4 and 24 mo after treatment adds value to clinical assessment at the time of the study, especially when there is clinical suspicion or uncertainty, and can serve as a prognostic marker of OS in HNSCC.