P14.85 Impact of the neuro-radiologist and neuro-surgeon in contouring with the neuro-oncologist on local relapse rates for brain metastases treated with stereotactic radiosurgery

2021 ◽  
Vol 23 (Supplement_2) ◽  
pp. ii54-ii54
Author(s):  
M Robinson ◽  
K Sayal ◽  
C Tunstall ◽  
S Padmanaban ◽  
R Watson ◽  
...  
Keyword(s):  
Stereotactic Radiosurgery ◽  
Strong Association ◽  
Local Relapse ◽  
Initial Contour ◽  
Published Data ◽  
Recurrence Rates ◽  
Local Institution ◽  
The Impact ◽  
Free Rate ◽  
Over Time

Abstract BACKGROUND The audit evaluates the value of MDT, including neuro-radiologist and neuro-surgeon, review of contouring carried out by a clinical oncologist in stereotactic radiosurgery (SRS). MATERIAL AND METHODS A sequential audit was conducted of all patients receiving intracranial SRS at our local institution for the first 22 months of a new SRS service. Lesions were contoured first by clinical oncologist then reviewed/edited by the MDT. The initial contour was compared with final contour using Jaccard conformity and geographical miss indices. The dosimetric impact of a contouring change was assessed using plan metrics to both original and final contour. The impact of the contouring review on local relapse, overall survival and radio necrosis rate was evaluated with at least 24 months follow up (24–46 months). RESULTS 113 patients and 142 lesions treated over 22 months were identified. Mean JCI was 0.92 (0.32–1.00) and 38% needed significant editing (JCI<0.95). Mean GMI was 0.03 (0.0–0.65) and 17% showed significant miss (GMI>0.05). Resection cavities showed more changes, with lower JCI and higher GMI (p<0.05). There was no significant improvement on JCI or GMI shown over time. Dosimetric analysis indicated a strong association of conformity metrics with PTV dose metrics; a 0.1 change in GTV conformity metric association with 6–17% change in dose to 95% of resulting PTV. Greater association was seen in resection cavity suggesting the geographical nature of a typical contouring error gives rise to greater potential change in dose. Clinical outcomes compared well with published series. Median survival was 20 months and local relapse free rate in the treated areas of 0.89 (0.8–0.94) at 40 months, and 0.9 (0.83–0.95) radio-necrosis free rate at 40 months with a median 17 months to developing radio-necrosis for those that did. CONCLUSION This work highlights that a MDT contour review adds significant value to SRS and the approach translates into reduced local recurrence rates at our local institution compared with previously published data. Radio-necrosis rates are below 10%. No improvement in clinical oncologist contouring over time was shown indicating a collaborative approach is needed regardless of experience of clinical oncologist. MDT input is recommended in particular in contouring of resection cavities.

scholarly journals 55. A RANDOMIZED, MULTICENTER PHASE III TRIAL OF SURGERY PLUS STEREOTACTIC RADIOSURGERY (SRS) COMPARED WITH SURGERY PLUS PERMANENTLY IMPLANTED COLLAGEN TILE BRACHYTHERAPY (CTBT) FOR RESECTABLE METASTATIC BRAIN TUMORS-PROTOCOL IN PROGRESS

2020 ◽  
Vol 2 (Supplement_2) ◽  
pp. ii11-ii11
Author(s):  
Jeffrey Weinberg ◽  
Mary Frances McAleer ◽  
Hussein Tawbi ◽  
Frederick Lang
Keyword(s):  
Brain Tumors ◽  
Stereotactic Radiosurgery ◽  
Word Association ◽  
Verbal Learning ◽  
Phase Iii ◽  
Secondary Outcome ◽  
Karnofsky Performance Scale ◽  
Metastatic Brain Tumors ◽  
Recurrence Rates ◽  
The Impact

Abstract BACKGROUND Resection (R) followed by single or multi-fraction stereotactic radiosurgery (SRS) lowers resection bed recurrence compared to R alone. Nevertheless for larger brain metastasis (>2.5 cm) 12-month recurrence rates after R+SRS can exceed 20–30%. Aiming to improve outcomes, a permanently implanted collagen tile brachytherapy (CTBT) device (GammaTile, GT Medical Technologies, Tempe AZ) utilizing Cs-131 was developed, hypothesizing that immediate adjuvant radiotherapy (RT) and/or RT dose intensification could improve outcomes. The device received FDA clearance for this indication, based on a single-arm pre-commercial study and in early commercial use due to the excellent safety and local control of R+CTBT. It is hypothesized that R+CTBT will increase the time to post-resection-recurrence, while prolonging survival and reducing the impact on functional and neurocognitive status compared to R+SRS. STUDY DESIGN Multicenter, randomized, comparison trial. Patients with resectable, previously untreated “index” brain metastases measuring >2.5–5 cm and 0–3 other tumors will be preoperatively randomized 1:1 to undergo either R+ SRS or R+CTBT to the index lesion; unresected tumors in both groups will receive SRS. Planned sample size is 160 from ~5 sites; accrual to start in Q3-2020. Primary endpoint is surgical bed-recurrence free survival. Secondary endpoints include overall survival, quality of life (Functional Assessment of Cancer Therapy-Brain, Linear Analog Self-Assessment), neurocognition (Hopkins Verbal Learning Test, Trail Making Tests, Mini-Mental Status Exam, Controlled Oral Word Association), functional decline (Karnofsky Performance Scale, Barthel-ADL), and adverse events. Follow-up will be at 1,3,6,9, and 12 months, then q 6 months through 5 years. CONCLUSIONS This will be the first randomized trial comparing R+SRS versus R+CTBT delivered by Cs-131 sources in permanently implanted resorbable collagen tile carriers. Primary and secondary outcome measures will be captured to elucidate the potential risks and benefits of these two differing approaches for patients with metastatic brain tumors.

Can “Seven Be The New Ten” - Adoption Of Restrictive Transfusion Strategies In a Community Hospital

Blood ◽  
2013 ◽  
Vol 122 (21) ◽  
pp. 2935-2935
Author(s):  
Rahul Singh ◽  
Charin Hanlon
Keyword(s):  
Conflicts Of Interest ◽  
The United States ◽  
General Medical Service ◽  
Published Data ◽  
Chi Square ◽  
Coronary Syndrome ◽  
Pre Treatment ◽  
New Guidelines ◽  
The Impact ◽  
Over Time

Abstract Background An estimated 13,785,000 units of packed red blood cells (PRBC) were transfused in the United States in 2011 of which an estimated 57.9% were found to be from the general medical service, the ICU or hematology/oncology. Risks of blood transfusion include infections, transfusion reactions circulatory overload, and transfusion-related immunomodulation. Furthermore, there is an economic cost to the administration of blood and a personal cost to those volunteers who give their time. There have been a number of guidelines published for the administration of PRBCs. In the past year, the American Association of Blood Banks released new guidelines for PRBC transfusion in hospitalized, hemodynamically stable patients. These guidelines set a threshold Hb of ≤7 g/dL in critically-ill patients, and a Hb ≤8 g/dL for surgical patients, for patients with pre-existing cardiovascular disease, or for patients with relevant symptoms. Symptoms were defined as tachycardia, chest pain or hypotension not corrected by crystalloids. We studied the potential impact on our inpatient hospital utilization of PRBC over time in relation to the publication of recent guidelines. Methods With IRB approval, a retrospective study of PRBC transfusion at New Hanover Regional Medical Center in Wilmington, NC was conducted. The primary endpoint of the study was to evaluate the impact of the new AABB guidelines on the transfusion utilization in the first 12 months. Secondary endpoints included a cost analysis, an evaluation of the use of PRBC for two pre-specified Hb levels, and a quantification of the number of units transfused. A total of 337 patients were reviewed. 116 were excluded due to one of the following reasons: anemia attributed to active blood loss, the presence of stage 5 chronic kidney disease, the presence of an acute coronary syndrome, the recent administration of outpatient transfusions, the use of blood products besides PRBCS, and the timing of a transfusion in the postoperative period. We randomly assigned two separate timeframes to review transfusions at ≤ 4 months and 8-12 months after the AABB guidelines were published. Data was analyzed using Chi-square and T tests. Results The average pre-treatment hemoglobin for the group ≤4 months was 7.82 ± 0.85 and 7.42 ± 0.92 for the 8-12 month group (p=0.0009). The average number of units transfused were 1.66 ± 0.53 and 1.78 ± 0.58 (P=0.1133), respectively. For those patients whose Hb was ≤ 7.0, there was a 21.6% reduction in inappropriate transfusions 8-12 months after the guidelines were released compared with the first 4 months (Chi-Square p = 0.0070). For those patients whose Hb was ≤ 8.0, the number of inappropriate transfusions went from 40.7% in the first group to 17.3% in the second group (Chi-Square p=0.0001). The total cost of transfusions to the patients was estimated to be $102,400 and $55,600 to the hospital. The potential savings if all transfusions were given according to the new guidelines is estimated to be $66,389 to the patients and $36,037 to the hospital. A total of 11,577 transfusions were given between 6/12/12-3/13/13. If the guidelines had been strictly followed, the number of transfusions would have been reduced to 3,855 transfusions. Discussion An improvement in adherence to AABB guidelines with a more restrictive PRBC transfusion strategy was found over time. This can be attributed to physicians practicing evidenced-based medicine. Data of transfusions at pre-treatment Hb ≤7, suggest that physicians are becoming more restrictive in their threshold for transfusions with a statistically significance in the drop of the average pre-treatment hemoglobin. Despite this restrictive pattern, physicians are still uncomfortable at transfusing 1 unit at a time. Although it was not statistically significant between the two groups, the average number of units transfused were ≥1.5, and 67% of the time 2 units were given. Overtransfusion with PRBCs is a problem that needs to be addressed. Physicians should give one unit and reassess for an appropriate response. This strategy will reduce cost to the patient and hospital. We feel that additional improvement is still possible and we are forming a blood management committee to promote better PRBC transfusion practice guidelines. We plan a series of educational presentations to each department along with a new Computerized Physician Order Set to improve patient care and reduce overall cost to the health care system. Disclosures: No relevant conflicts of interest to declare.

scholarly journals Health-related quality of life in adult patients with brain metastases after stereotactic radiosurgery: a systematic, narrative review

2019 ◽  
Vol 28 (2) ◽  
pp. 473-484 ◽  
Author(s):  
Eline Verhaak ◽  
Karin Gehring ◽  
Patrick E. J. Hanssens ◽  
Neil K. Aaronson ◽  
Margriet M. Sitskoorn
Keyword(s):  
Quality Of Life ◽  
Brain Metastases ◽  
Stereotactic Radiosurgery ◽  
Health Related Quality ◽  
Number Of Patients ◽  
Related Quality ◽  
Health Related ◽  
The Impact ◽  
Over Time

Abstract Purpose A growing number of patients with brain metastases (BM) are being treated with stereotactic radiosurgery (SRS), and the importance of evaluating the impact of SRS on the health-related quality of life (HRQoL) in these patients has been increasingly acknowledged. This systematic review summarizes the current knowledge about the HRQoL of patients with BM after SRS. Methods We searched EMBASE, Medline Ovid, Web-of-Science, the Cochrane Database, PsycINFO Ovid, and Google Scholar up to November 15, 2018. Studies in patients with BM in which HRQoL was assessed before and after SRS and analyzed over time were included. Studies including populations of several types of brain cancer and/or several types of treatments were included if the results for patients with BM and treatment with SRS alone were described separately. Results Out of 3638 published articles, 9 studies met the eligibility criteria and were included. In 4 out of 7 studies on group results, overall HRQoL of patients with BM remained stable after SRS. In small study samples of longer-term survivors, overall HRQoL remained stable up to 12 months post-SRS. Contradictory results were reported for physical and general/global HRQoL, which might be explained by the different questionnaires that were used. Conclusions In general, SRS does not have significant negative effects on patients’ overall HRQoL over time. Future research is needed to analyze different aspects of HRQoL, differences in individual changes in HRQoL after SRS, and factors that influence these changes. These studies should take into account several methodological issues as discussed in this review.

scholarly journals The evolution of percutaneous nephrolithotomy: Analysis of a single institution experience over 25 years

2018 ◽  
Vol 13 (10) ◽  
Author(s):  
Jennifer Bjazevic ◽  
Linda Nott ◽  
Philippe D. Violette ◽  
Thomas Tailly ◽  
Marie Dion ◽  
...  
Keyword(s):  
Length Of Stay ◽  
Percutaneous Nephrolithotomy ◽  
Complication Rate ◽  
Hospital Length Of Stay ◽  
Transfusion Rate ◽  
Patient Demographics ◽  
Stone Free Rate ◽  
The Impact ◽  
Free Rate ◽  
Over Time

Introduction: Over time, the incidence of nephrolithiasis has risen significantly, and patient populations have become increasingly complex. Our study aimed to determine the impact of changes in patient demographics on percutaneous nephrolithotomy (PCNL) outcomes. Methods: A retrospective analysis of a prospectively collected database was carried out from 1990–2015. Patient demographics, comorbidities, stone and procedure characteristics were analyzed. Multivariate logistic regression was used to evaluate differences in operative duration, complications, stone-free rate, and length of stay. Results: A total of 2486 patients with a mean age of 54±15 years, body mass index (BMI) of 31±8, and stone surface area of 895±602 mm2 were analyzed; 47% of patients had comorbidities, including hypertension (22%), diabetes mellitus (14%), and cardiac disease (13%). Complication rate was 19%, including a 2% rate of major complications (Clavien grade III–V). There was a statistically significant increase in patient age, BMI, and comorbidities over time, which was correlated with an increased complication rate (odds ratio [OR] 1.15; p=0.010). The overall transfusion rate was 1.0% and remained stable (p=0.131). With time, both OR duration (mean Δ 16 minutes; p<0.001) and hospital length of stay (mean Δ 2.4 days; p<0.001) decreased significantly. Stone-free rate of 1873 patients with available three-month followup was 87% and decreased significantly over time (OR 1.09; p<0.001), but was correlated with an increased use of computed tomography (CT) scans for followup imaging. Conclusions: Despite an increasingly complex patient population, PCNL remains a safe and effective procedure with a high stone-free rate and low risk of complications.

The Therapist’s Reaction to a Patient’s Suicide

Crisis ◽  
2011 ◽  
Vol 32 (2) ◽  
pp. 99-105 ◽  
Author(s):  
Friedrich Martin Wurst ◽  
Isabella Kunz ◽  
Gregory Skipper ◽  
Manfred Wolfersdorf ◽  
Karl H. Beine ◽  
...  
Keyword(s):  
Emotional Responses ◽  
Well Being ◽  
Emotional Reaction ◽  
Emotional Reactions ◽  
Analog Scale ◽  
General Hospitals ◽  
Item Questionnaire ◽  
Retrospective Nature ◽  
The Impact ◽  
Over Time

Background: A substantial proportion of therapists experience the loss of a patient to suicide at some point during their professional life. Aims: To assess (1) the impact of a patient’s suicide on therapists distress and well-being over time, (2) which factors contribute to the reaction, and (3) which subgroup might need special interventions in the aftermath of suicide. Methods: A 63-item questionnaire was sent to all 185 Psychiatric Clinics at General Hospitals in Germany. The emotional reaction of therapists to patient’s suicide was measured immediately, after 2 weeks, and after 6 months. Results: Three out of ten therapists suffer from severe distress after a patients’ suicide. The item “overall distress” immediately after the suicide predicts emotional reactions and changes in behavior. The emotional responses immediately after the suicide explained 43.5% of the variance of total distress in a regression analysis. Limitations: The retrospective nature of the study is its primary limitation. Conclusions: Our data suggest that identifying the severely distressed subgroup could be done using a visual analog scale for overall distress. As a consequence, more specific and intensified help could be provided to these professionals.

Has Aid Helped in Pakistan?

1997 ◽  
Vol 36 (4II) ◽  
pp. 947-957 ◽  
Author(s):  
Shahrukh Rafi Khan
Keyword(s):  
Economic Growth ◽  
Negative Impact ◽  
Negative Association ◽  
Causal Impact ◽  
The Impact ◽  
Over Time

This paper has a two-fold objective: first, to examine the terms on which Pakistan receives aid and whether its debt situation is sustainable, and second, to examine the impact of aid and debt on economic growth. It is found that there is little encouraging that can be said about how the terms on which Pakistan has received aid over time have changed, and its current debt situation is not sustainable. Also reported is the analysis done elsewhere which shows that aid has a negative (Granger) causal impact on GDP, and aid has a robust negative impact on economic growth after controlling for supplyside shocks. We provide various reasons for this negative association.

The Role of Vascular Aging in Atherosclerotic Plaque Development and Vulnerability

2019 ◽  
Vol 25 (29) ◽  
pp. 3098-3111 ◽  
Author(s):  
Luca Liberale ◽  
Giovanni G. Camici
Keyword(s):  
Atherosclerotic Plaque ◽  
Molecular Mechanisms ◽  
Driving Forces ◽  
Plaque Burden ◽  
Vascular Aging ◽  
Age Related ◽  
Plaque Development ◽  
Increased Risk ◽  
The Impact ◽  
Over Time

Background: The ongoing demographical shift is leading to an unprecedented aging of the population. As a consequence, the prevalence of age-related diseases, such as atherosclerosis and its thrombotic complications is set to increase in the near future. Endothelial dysfunction and vascular stiffening characterize arterial aging and set the stage for the development of cardiovascular diseases. Atherosclerotic plaques evolve over time, the extent to which these changes might affect their stability and predispose to sudden complications remains to be determined. Recent advances in imaging technology will allow for longitudinal prospective studies following the progression of plaque burden aimed at better characterizing changes over time associated with plaque stability or rupture. Oxidative stress and inflammation, firmly established driving forces of age-related CV dysfunction, also play an important role in atherosclerotic plaque destabilization and rupture. Several genes involved in lifespan determination are known regulator of redox cellular balance and pre-clinical evidence underlines their pathophysiological roles in age-related cardiovascular dysfunction and atherosclerosis. Objective: The aim of this narrative review is to examine the impact of aging on arterial function and atherosclerotic plaque development. Furthermore, we report how molecular mechanisms of vascular aging might regulate age-related plaque modifications and how this may help to identify novel therapeutic targets to attenuate the increased risk of CV disease in elderly people.

Conclusion

2018 ◽  
Author(s):  
Manuel Fröhlich ◽  
Abiodun Williams
Keyword(s):  
Security Council ◽  
International Context ◽  
Peace And Security ◽  
Executive Action ◽  
Trends Over Time ◽  
The Impact ◽  
Over Time ◽  
The Way ◽  
Guiding Questions

The Conclusion returns to the guiding questions introduced in the Introduction, looking at the way in which the book’s chapters answered them. As such, it identifies recurring themes, experiences, structures, motives, and trends over time. By summarizing the result of the chapters’ research into the interaction between the Secretaries-General and the Security Council, some lessons are identified on the changing calculus of appointments, the conditions and relevance of the international context, the impact of different personalities in that interaction, the changes in agenda and composition of the Council as well as different formats of interaction and different challenges to be met in the realm of peace and security, administration, and reform, as well as concepts and norms. Taken together, they also illustrate the potential and limitations of UN executive action.

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