652 Early outcomes of an app acute checkpoint inhibitor (CPI) care clinic

2020 ◽  
Vol 8 (Suppl 3) ◽  
pp. A689-A689
Author(s):  
Lisa Kottschade ◽  
Casey Fazer ◽  
Anna Schwecke
Keyword(s):  
Acute Care ◽  
Outpatient Clinic ◽  
Checkpoint Inhibitors ◽  
Early Recognition ◽  
Care Clinic ◽  
Treatment Delays ◽  
Additional Hypothesis ◽  
Institutional Review ◽  
Long Term Follow Up

BackgroundCheckpoint inhibitors continue to be used for a wide variety of oncologic and hematologic indications. Early recognition and intervention is crucial to prevent significant morbidity and/or mortality from immune related adverse events (irAE’s). Physicians and APPs outside of hematology/oncology practices are generally not familiar with these types of side effects which may lead to treatment delays, and inappropriate management. We recently identified this as a gap in continuity of care amongst patients undergoing CPI therapy for their malignancy, and therefore developed a CPI acute care outpatient clinic, designed to meet this need.MethodsStarting April 2020, we developed an CPI focused clinic led by 3 APPs to provide outpatient irAE management 5 days a week. Three types of needs were identified: acute (within 24 hours), post hospitalization (within 48 hours of discharge), and long term follow-up (high grade irAE).ResultsFrom April 24-August 24, 2020 our CPI clinic had a total of 50 visits (30 unique patients). Given that many patients to our practice are from > 2 hours away, as well as the constraints of the current pandemic, visits were conducted as in person, video consult (telemedicine), or phone. The most common regimens for patients were PD-1 alone (10), PD-1 + targeted (7), dual CPI (6), PD-1 + chemotherapy, and clinical trial, PD-L1 alone, PD-L1 + chemotherapy (1 each). The top three types of malignancies seen were melanoma (7), lung (6) and gynecological (4). The most common irAE referral reason was hepatitis (8), diarrhea/colitis (6) and thyroiditis (4). Only three patients (10%) required higher level care (i.e ED or admission) than was able to be provided in the clinic. Twenty-two patients (73%) required steroids as their initial treatment for irAE, with 4 patients (13%) requiring referral to other specialties. Twelve patients (40%) presented with ≥2 irAE’s at the time of being seen in clinic.ConclusionsHerein we present early data from an acute care APP led CPI outpatient clinic. Most patients required initiation of steroids for their irAE, however only a small majority required higher level of care and were able to be managed as an outpatient. We acknowledge that while our cohort of patients is small, it does provide early evidence of the utility of a CPI acute care clinic and additional hypothesis generating clinical questions.Ethics ApprovalThis study was approved by the institutional review board at Mayo Clinic

Liver Resection Using a Four-Prong Radiofrequency Transection Device

2009 ◽  
Vol 75 (10) ◽  
pp. 991-994 ◽  
Author(s):  
Lawrence D. Wagman ◽  
Byrne Lee ◽  
Erick Castillo ◽  
Hisham El-Bayar ◽  
Lily Lai
Keyword(s):  
Blood Loss ◽  
Metastatic Tumor ◽  
New Device ◽  
Time To Recurrence ◽  
Institutional Review ◽  
Long Term Follow Up ◽  
Surgery Outcomes ◽  
Mean Time

Multiple techniques are available for division of hepatic parenchyma. This is the largest United States report examining the use of the Habib 4X tissue coagulator (AngioDynamics, Queensbury, NY). The objective was to collect standard parameters associated with successful, benchmarked liver surgery outcomes using this new device, and in particular, examine the risk of margin failure. Ninety-four consecutive operations using the Habib 4X were analyzed with special attention to local failure at resection margin, blood loss/transfusion, and operative times. An institutional review board approved protocol allowed collection and analysis of demographic information and outcomes for intraoperative, perioperative, and long term follow-up. Eighteen patients had biopsy only. Thirty-one had lobar resections and 46 had wedge or segmental resections. There were 30 primary hepatic and 46 metastatic tumor diagnoses. There were a total of 33 (43%) recurrences with a mean time to recurrence of 212 days (range 15-974). Of the 27 intrahepatic recurrences, four (15%) were at the margin. The OR time ranged from 115 to 642 minutes (average 283 min). The average recorded blood loss was 427 mL; 11 patients were transfused (average 0.43 units). The Habib 4X is a safe tool to use when evaluating the parameters of blood loss, transfusion, and margin recurrence.

scholarly journals A network approach to developing immuno-oncology combinations in Canada

2019 ◽  
Vol 26 (2) ◽  
Author(s):  
V. Higenell ◽  
R. Fajzel ◽  
G. Batist ◽  
P. K. Cheema ◽  
H. L. McArthur ◽  
...  
Keyword(s):  
Checkpoint Inhibitors ◽  
White Paper ◽  
Expert Advice ◽  
Patient Response ◽  
National Network ◽  
Long Term Follow Up ◽  
Advance Research ◽  
Network Collaboration

Immune checkpoint inhibitors have revolutionized care for many cancer indications, with considerable effort now being focused on increasing the rate, depth, and duration of patient response. One strategy is to combine immune strategies (for example, ctla-4 and PD-1/L1–directed agents) to harness additive or synergistic efficacy while minimizing toxicity. Despite encouraging results with such combinations in multiple tumour types, numerous clinical challenges remain, including a lack of biomarkers that reliably predict outcome, the emergence of therapeutic resistance, and optimal management of immune-related toxicities. Furthermore, the selection of ideal combinations from the myriad of immune, systemic, and locoregional therapies has yet to be determined. A longitudinal network-based approach could offer advantages in addressing those critical questions, including long-term follow-up of patients beyond individual trials.    The molecular cancer registry Personalize My Treatment, managed by the Networks of Centres of Excellence nonprofit organization Exactis Innovation, is uniquely positioned to accelerate Canadian immuno-oncology (io) research efforts throughout its national network of cancer sites. To gain deeper insight into how a pan-Canadian network could advance research in io combinations, Exactis invited preeminent clinical and scientific advisors from across Canada to a roundtable event in November 2017. The present white paper captures the expert advice provided: leverage longitudinal patient data collection; facilitate network collaboration and assay harmonization; synergize with existing initiatives, networks, and biobanks; and develop an io combination trial based on Canadian discoveries.

scholarly journals Long-term Outcomes of Patients with Anti–Leucine-Rich Glioma-Inactivated 1 Encephalitis

2020 ◽  
Author(s):  
Shan Qiao ◽  
Huai-kuan Wu ◽  
Ling-ling Liu ◽  
Ke-jun Zang ◽  
Xuewu liu
Keyword(s):  
Clinical Symptoms ◽  
Early Recognition ◽  
Chinese Patients ◽  
Long Term Outcomes ◽  
Ancillary Test ◽  
Behavioral Abnormalities ◽  
Long Term Follow Up ◽  
And Behavior

Abstract Background: This report aims to provide a detailed description of the clinical manifestation, immunotherapy, and long-term outcomes of 117 Chinese patients with anti-leucine-rich glioma-inactivated 1 (LGI1) encephalitis. Methods: We retrospectively selected 117 patients diagnosed with anti-LGI1 encephalitis from the databases of multiple clinical centers from September 2014 to December 2019. The clinical features, ancillary test results, and details of long-term outcomes were analyzed.Results: Among the 117 anti-LGI1 encephalitis patients, 81 (69%) were male and 36 (31%) were female; the median onset age was 51 years (range: 30-77 years). The median time from symptom onset until diagnosis was 8.7 weeks (range: 2-49 weeks). The main features evaluated in our cohort were seizures, cognitive impairment, and mental and behavioral abnormalities. One hundred and nine patients were treated with immunotherapy, After 3-5 days of treatment, the clinical symptoms were somewhat alleviated in all the patients, and their memory, mental ability, and behavior improved. The median follow-up time was 33 months (range: 6-59 months). A total of 19 (16%) patients experienced a relapse; the median duration from onset to the first relapse was 5 (0.3-27) months. There were no mortalities during the follow-up period.Conclusions: The outcome of patients with anti-LGI1 encephalitis is mostly favorable, although some patients continue to suffer from cognitive dysfunction. Early recognition is of great significance for the treatment of anti-LGI1 encephalitis. Prompt adequate immunotherapy has positive implications for the improvement of clinical symptoms of anti-LGI1 encephalitis. Long-term follow-up is important for the assessment of LGI1 antibody-mediated encephalitis.

scholarly journals ALLERGIC BRONCHOPULMONARY ASPERGILLOSIS

2019 ◽  
Vol 23 (1) ◽  
pp. 62-69
Author(s):  
Rashmi D’Mello ◽  
Sasikumar Kilaikode ◽  
Sami L. Bahna
Keyword(s):  
Environmental Control ◽  
Early Recognition ◽  
Natural Habitat ◽  
Allergic Bronchopulmonary Aspergillosis ◽  
Corticosteroid Treatment ◽  
Long Term Follow Up ◽  
Serum Total Ige ◽  
Routine Therapy

Aspergillus is a saprophytic mold and its natural habitat is the soil. It is found worldwide indoors and outdoors in potted soil, compost, freshly cut grasses, decaying vegetation and in sewers. Aspergillus produces a bountiful number of spores and releases 2-3 micron sized spores into the air daily. It grows best at 37-40 °C, which is similar to the temperature in the lungs. These spores will remain airborne for a long period of time. It is estimated that humans inhale hundreds of spores daily. Several fungi other than aspergillus have been known to be implicated. Hence, the term allergic bronchopulmonary mycoses would be more appropriate unless the specific fungus is identified - which could be candida, helminthosporium, curvularia, bipolaris, cladosporium, or others. The review article is focused on the prototype allergic bronchopulmonary aspergillosis, its epidemiology, pathogenesis, diagnosis and treatment. Bronchopulmonary aspergillosis should be considered in patients with poorly controlled asthma despite appropriate routine therapy and environmental control. The need for frequent courses of corticosteroids with temporary improvement should raise the index of suspicion and appropriate evaluation be done. Early recognition and prompt initiation of appropriate corticosteroid treatment regimen would reduce the risk of development or progression of bronchiectasis and lung tissue damage. Regular follow up and monitoring serum total IgE level can predict exacerbations and should prompt corticosteroid treatment. Long term follow-up is important as relapses can occur years of remission.

Twisting: Incidence and Risk Factors of an Intraprocedural Challenge Associated With Pipeline Flow Diversion of Cerebral Aneurysms

Neurosurgery ◽  
2020 ◽  
Vol 88 (1) ◽  
pp. 25-35
Author(s):  
Matthew T Bender ◽  
Robert W Young ◽  
David A Zarrin ◽  
Jessica K Campos ◽  
Justin M Caplan ◽  
...  
Keyword(s):  
Risk Factors ◽  
Rare Event ◽  
Cerebral Aneurysms ◽  
Flow Diversion ◽  
Institutional Review ◽  
Long Term Follow Up ◽  
Incidence Risk ◽  
Procedural Success ◽  
Large And Giant Aneurysms

Abstract BACKGROUND Pipeline Embolization Device (PED; Medtronic) “twisting” manifests with the appearance of a “figure 8” in perpendicular planes on digital subtraction angiography. This phenomenon has received little attention in the literature, requires technical precision to remediate, and has potential to cause ischemic stroke if not properly remediated. OBJECTIVE To report incidence, risk factors, and sequelae of PED twisting and to discuss techniques to remediate a PED twist. METHODS Case images were reviewed for instances of twisting from a prospectively-maintained, Institutional Review Board-approved cohort of patients undergoing flow diversion for cerebral aneurysm. RESULTS From August 2011 to December 2017, 999 PED flow diverting stents were attempted in 782 cases for 653 patients. A total of 25 PED twists were observed while treating 20 patients (2.50%, 25/999). Multivariate analysis revealed predictors of twisting to be: Large and giant aneurysms (odds ratio (OR) = 9.66, P = .005; OR = 27.47, P < .001), increased PED length (OR = 1.14, P < .001), and advanced patient age (OR = 1.07, P = .002). Twisted PEDs were able to be remediated 75% of the time, and procedural success was achieved in 90% of cases. PED twisting was not found to be a significant cause of major or minor complications. However, at long-term follow-up, there was a trend towards poor occlusion outcomes for the cases that encountered twisting. CONCLUSION Twisting is a rare event during PED deployment that was more likely to occur while treating large aneurysms with long devices in older patients. While twisting did not lead to major complications in this study, remediation can be challenging and may be associated with inferior occlusion outcomes.

Occipitocervical instrumentation in the pediatric population using a custom loop construct: initial results and long-term follow-up experience

2010 ◽  
Vol 5 (3) ◽  
pp. 285-291 ◽  
Author(s):  
Daniel Couture ◽  
Nathan Avery ◽  
Douglas L. Brockmeyer
Keyword(s):  
Pediatric Population ◽  
Loop System ◽  
Fixation Device ◽  
Occipitocervical Fixation ◽  
Institutional Review ◽  
Posttraumatic Instability ◽  
Long Term Follow Up ◽  
Halo Orthosis

Object Rigid occipitocervical instrumentation for craniovertebral instability is gaining widespread acceptance for use in pediatric patients; however, most of the instrumentation has been modified from adult-sized hardware. The Wasatch loop system (formerly the Avery-Brockmeyer-Thiokol loop system) is a rigid occipitocervical fixation device designed specifically for use in children. It affixes to the occiput and incorporates either C1–2 transarticular screws or C-2 pars screws. It is preformed and is available in a variety of sizes. The authors describe their clinical experience and long-term follow-up experience with the first 22 patients. Methods An institutional review board–approved retrospective review of medical records and radiographs was performed for patients who underwent occipitocervical fusion with the Wasatch loop. The mean patient age was 4.9 years (1.2–13 years), and the overall mean follow-up was 4 years (1.5–6.5 years). Six patients had posttraumatic instability, and 16 patients had congenital instability. Results Twelve patients underwent placement of bilateral C1–2 transarticular screws, 6 patients had placement of a combination of C1–2 transarticular and C-2 pars screws, and 4 patients had placement of bilateral C-2 pars screws. One patient required a halo orthosis; the others were treated postoperatively with a hard cervical collar. All patients had radiographic evidence of solid occipitocervical arthrodesis on last follow-up examination. Conclusions The Wasatch loop system is a novel internal fixation device for children who have posttraumatic or congenital occipitocervical instability. Successful arthrodesis was achieved in all patients with minimal use of halo orthoses.

MO404ACUTE KIDNEY INJURY DUE TO IMMUNE CHECKPOINT INHIBITORS (CPIS) NEPHROTOXICITY

2021 ◽  
Vol 36 (Supplement_1) ◽  
Author(s):  
Fausta Catapano ◽  
Elisa Persici ◽  
Giulia Ubaldi ◽  
Francesca Romani ◽  
Elena Mancini
Keyword(s):  
Acute Kidney Injury ◽  
Renal Function ◽  
Interstitial Nephritis ◽  
Immune Checkpoint ◽  
Immune Checkpoint Inhibitors ◽  
Checkpoint Inhibitors ◽  
Kidney Injury ◽  
Renal Outcome ◽  
Long Term Follow Up

Abstract Background and Aims The approved therapeutic indication for immune checkpoint inhibitors (CPIs) are rapidly expanding; however the immune-related toxicities associated with CPIs can limit its efficacy. Case Report. A 52 year-old female diagnosed with left ocular melanoma and treated for 14 months with nivolumab developed non-oliguric, stage 3 (KDIGO), Acute Kidney Injury (AKI) and mixed proteinuria (0.6 g/day), then was transferred in our Unit. As known causes of AKI were excluded, kidney biopsy was performed. By Optical Microscopy, there were 33 normal glomeruli; arteries and arterioles were normal. The main damage was interstitial and characterized by tubulitis, tubular necrosis, non-isometric citoplasmatic vacuolization and diffuse, acute and chronic, CD4+, inflammatory infiltrate (Figure 1, 2). By Immunofluorescence, 27 glomeruli were negative for all eight tested antibodies (IgA, IgM, IgG, F, C3, C1q, kappa and lambda light chains). On the basis of these histological findings, Nivolumab-induced Acute Tubulo-Interstitial Nephritis was diagnosed. Nivolumab was discontinuated. Patient was treated by steroids and she achieved almost complete renal function recovery (Figure 3). Conclusions. CPIs can induce a long-term Acute Kidney Injury. Histological features are characterized by Acute Tubulo-Interstitial Nephritis. Steroids can improve renal outcome. In patients treated with CPIs a multidisciplinary management between oncologists and nephrologists is desirable for monitoring renal function at basal, after drug administration and in the long-term follow-up.

Two distinct clinical trajectories of inflammatory thyroiditis evoked by checkpoint blockade in malignant melanoma.

2018 ◽  
Vol 36 (5_suppl) ◽  
pp. 131-131
Author(s):  
Anna Claire Olsson-Brown ◽  
Rosemary Lord ◽  
Joseph J Sacco ◽  
Mark Christopher Coles ◽  
Jonathan Wagg ◽  
...  
Keyword(s):  
Patient Outcomes ◽  
Retrospective Review ◽  
De Novo ◽  
Checkpoint Inhibitors ◽  
Hormone Replacement ◽  
Thyroid Stimulating Hormone ◽  
Thyroid Autoantibodies ◽  
Treatment Delays ◽  
Levothyroxine Replacement

131 Background: Oncological immune checkpoint inhibitors (CPI) commonly cause immune related adverse events (irAEs). Thyroid irAEs have a significant clinical impact requiring therapeutic intervention and clinical coordination whilst often causing treatment delays. Methods: Retrospective review of all patients treated with CPIs (pembrolizumab, nivolumab +/- ipilimumab) for metastatic melanoma at the Clatterbridge Cancer Centre, UK identified patients experiencing thyroid irAEs. Clinical/biochemical course (T4 and thyroid stimulating hormone (TSH) levels) and autoantibody titers were evaluated to identify characterisable trajectories. Results: From February 2016 to May 2017, 103 patients received anti-PD1 therapy; 90 receiving monotherapy and 13 combination. Thyroid irAEs were seen in 13(14.4%) and 3(23%) patients respectively. Two distinct trajectories were identified: a hyperthyroid phase with subsequent hypothyroidism (HH) and de novo hypothyroidism (DN). There were no outliers. HH was the predominant pattern (75%) and the sole manifestation in combination therapy. In the HH cohort 69% of patients were female. The peak T4 was 39.3pmol/L occurring, on average, 7.5 weeks after CPI initiation. T4 levels declined within 6-21 days and hypothyroidism occurred within 8 weeks. The DN cohort was exclusively female. Thyroid irAE occurred 12 weeks after CPI initiation. Baseline TSH in HH (2.49mU/l) was significantly lower than DN (5.77mU/l); p = 0.0092. Positive thyroid autoantibodies were detected in 5 patients across both groups. One patient (HH) had symptomatic thyroid dysfunction. Corticosteroids conveyed no benefit. All patients had permanent dysfunction requiring long term levothyroxine replacement. All continued with immunotherapy treatment; however notable irAE-related treatment hiatuses occurred. Conclusions: Retrospective review revealed two distinct thyroid irAE trajectories, HH and DN. The trajectories may have biochemical predictors, are rarely associated with symptoms and appear unrelated to thyroid autoantibodies. Trajectory identification will optimise patient outcomes, reduce ineffective steroid use and promote early hormone replacement.

scholarly journals Management of kyphoscoliosis patients with respiratory failure in the intensive care unit and during long term follow up

2012 ◽  
Vol 7 ◽  
Author(s):  
Nalan Adıgüzel ◽  
Zuhal Karakurt ◽  
Gökay Güngör ◽  
Özlem Yazıcıoğlu Moçin ◽  
Merih Balcı ◽  
...  
Keyword(s):  
Septic Shock ◽  
Respiratory Failure ◽  
Outpatient Clinic ◽  
Long Term Effect ◽  
Non Invasive Ventilation ◽  
Long Term Follow Up ◽  
Sepsis And Septic Shock ◽  
Lost To Follow Up

Background: We aimed to evaluate the ICU management and long-term outcomes of kyphoscoliosis patients with respiratory failure. Methods: A retrospective observational cohort study was performed in a respiratory ICU and outpatient clinic from 2002–2011. We enrolled all kyphoscoliosis patients admitted to the ICU and followed-up at regular intervals after discharge. Reasons for acute respiratory failure (ARF), ICU data, mortality, length of ICU stay and outpatient clinic data, non-invasive ventilation (NIV) device settings, and compliance were recorded. NIV failure in the ICU and the long term effect of NIV on pulmonary performance were analyzed. Results: Sixty-two consecutive ICU kyphoscoliosis patients with ARF were enrolled in the study. NIV was initially applied to 55 patients, 11 (20%) patients were intubated, and the majority had sepsis and septic shock (p < 0.001). Mortality in the ICU was 14.5% (n = 9), reduced pH, IMV, and sepsis/septic shock were significantly higher in the non-survivors (p values 0.02, 0.02, 0.028, 0.012 respectively). Among 46 patients attending the outpatient clinic, 17 were lost to follow up and six were died. The six minute walk distance was significantly increased in the final follow up (306 m versus 419 m, p < 0.001). Conclusions: We strongly discourage the use of NIV in the case of septic shock in ICU kyphoscoliosis patients with ARF. Pulmonary performance improved with NIV during long term follow up.

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