scholarly journals CyberKnife stereotactic radiosurgery for the treatment of symptomatic vertebral hemangiomas: a single-institution experience

2017 ◽  
Vol 42 (1) ◽  
pp. E13 ◽  
Author(s):  
Michael Zhang ◽  
Yi-Ren Chen ◽  
Steven D. Chang ◽  
Anand Veeravagu
Keyword(s):  
Stereotactic Radiosurgery ◽  
Clinical Decision Making ◽  
Clinical Decision ◽  
Lesion Size ◽  
Neurological Deficits ◽  
Radiographic Outcomes ◽  
Relative Rarity ◽  
Vertebral Hemangiomas ◽  
Future Patient ◽  
Insight Into

OBJECTIVE Symptomatic vertebral hemangiomas (SVHs) are a very rare pathology that can present with persistent pain or neurological deficits that warrant surgical intervention. Given the relative rarity and difficulty in assessment, the authors sought to present a dedicated series of SVHs treated using stereotactic radiosurgery (SRS) to provide insight into clinical decision making. METHODS A retrospective review of a single institution's experience with hypofractionated radiosurgery for SVH from 2004 to 2011 was conducted to determine the clinical and radiographic outcomes following SRS treatment. The authors report and analyze the treatment course of 5 patients with 7 lesions, 2 of which were treated primarily by SRS. RESULTS Of the 5 patients studied, 4 presented with a chief complaint of pain refractory to conservative measures. Three patients reported dysesthesias, and 2 reported upper-extremity weakness. Following radiosurgery, 4 of 5 patients exhibited improvement in their primary symptoms (3 for pain and 1 for weakness), achieving a clinical response after a mean period of 1 year. In 2 cases there was 20%–40% reduction in lesion size in the most responsive dimension as noted on images. All treatments were well tolerated. CONCLUSIONS SRS for SVH is a safe and feasible treatment strategy, comparable to prior radiotherapy studies, and in select cases may successfully confer delayed decompressive effects. Additional investigation will determine future patient selection and how conformal SRS treatment can best be administered.

scholarly journals Blood transfusion prescribing in the ACT: an insight into clinical decision making

2005 ◽  
Vol 29 (2) ◽  
pp. 240 ◽  
Author(s):  
Philip J Crispin ◽  
Bethany J Crowe ◽  
Anne M McDonald
Keyword(s):  
Decision Making ◽  
Clinical Decision Making ◽  
Clinical Decision ◽  
Early Discharge ◽  
Organisation Of Care ◽  
Metropolitan Hospital ◽  
Loss Of Appetite ◽  
Insight Into ◽  
Structured Questionnaire

This study aimed to determine the perspectives of a group of patients categorised as ?long-stay outliers? at a large South Australian metropolitan hospital about aspects of organisation of care and the perceived impact of long-term hospitalisation. Nineteen patients were interviewed using a semi-structured questionnaire. Eighty-nine percent of participants stated that they had no knowledge of how long they were to be in hospital. Forty-two percent indicated that they did not know when they would be discharged from hospital. This was of concern, especially considering the vulnerability of this patient group and the known benefits of patient involvement in decision making and the improvements this can make to health outcomes and early discharge. Participants indicated concern about sleep deprivation, diet, ability to return to paid employment, and missing their family as the main areas of impact of their long hospitalisation. Concerns about being discharged from hospital included: apprehension as to whether they were well enough to leave; the recurrence of infection; whether they would be able to sleep well when they got home; their recent loss of appetite and associated weight loss; mobility concerns; and what supports they would have when they were discharged home. All these issues require staff to be more patient and family-centred in their approach to preparing for discharge.

Diagnostic conversations: Clinical Decision Making in surgery – Part 2

Diagnosis ◽  
2014 ◽  
Vol 1 (2) ◽  
pp. 189-193 ◽  
Author(s):  
David Allan Watters ◽  
Spencer Wynyard Beasley ◽  
Wendy Crebbin
Keyword(s):  
Decision Making ◽  
Clinical Decision Making ◽  
Clinical Decision ◽  
Learning Opportunities ◽  
Clinical Decisions ◽  
Decision Making Processes ◽  
Royal Australasian College ◽  
Insight Into ◽  
Made In

AbstractProceduralists who fail to review their decision making are unlikely to learn from their experiences, irrespective of whether the operative outcome is successful or not. Teaching junior surgeons to develop ‘insight’ into their own decision making has long been a challenge. Surgeons and staff of the Royal Australasian College of Surgeons worked together to develop a model to help explain the processes around clinical decision making and incorporated this model into a Clinical Decision Making (CDM) training course. In this course, faculty apply the model to specific surgical cases, within the model’s framework of how clinical decisions are made; thus providing an opportunity to identify specific decision making processes as they occur and to highlight some of the learning opportunities they provide. The conversation in this paper illustrates the kinds of case-based interactions which typically occur in the development and teaching of the CDM course.The focus in this, the second of two papers, is on reviewing post-operative clinical decisions made in relation to one case, to improve the quality of subsequent decision making.

Ability of multiparametric magnetic resonance imaging (MRI) to predict prostate tumor heterogeneity on targeted biopsy.

2018 ◽  
Vol 36 (6_suppl) ◽  
pp. 113-113 ◽  
Author(s):  
Samuel Gold ◽  
Jonathan Bloom ◽  
Graham R. Hale ◽  
Kareem Rayn ◽  
Sherif Mehralivand ◽  
...  
Keyword(s):  
Clinical Decision Making ◽  
Clinical Decision ◽  
Lesion Size ◽  
Future Research ◽  
Imaging Features ◽  
Targeted Biopsy ◽  
Impact Risk ◽  
The Difference ◽  
Magnetic Resonance Imaging Mri ◽  
Grade 3

113 Background: Prostate cancer (PCa) can show heterogeneous histology within lesions. MRI-targeted biopsy (Tbx) of the prostate improves PCa detection, but sampling within lesions has yet to be standardized. Furthermore, Tbx results are often heterogeneous as evidenced by differing histologic grades of Tbx cores within the same lesion. This introduces potential variability in biopsy results, on which clinical decisions are made. Here we aim to characterize lesion heterogeneity and identify predictive multiparametric MRI (mpMRI) features. Methods: A cohort of men who underwent mpMRI and Tbx between 2014-2017 were selected for analysis from a prospectively maintained database. To characterize lesion heterogeneity, only men with ≥2 positive Tbx cores were included. Histologic grades were scored according to International Society of Urological Pathology (ISUP) grades. Lesion heterogeneity, reported as a heterogeneity index (HI), was calculated as the difference of the average ISUP grades of Tbx cores per lesion from the maximum sampled ISUP grade of that lesion. Statistical analyses identified associations between imaging features and lesion heterogeneity. Results: 157 lesions in 114 patients met inclusion criteria. Maximum ISUP grade ranged from 1 to 5, with a median ISUP grade of 2. Higher ISUP grades were associated with greater lesion heterogeneity, HI for ISUP grade ≥3 = 0.58±0.11 vs <3 = 0.29±0.08, p = 0.0001. In addition, increasing lesion size on mpMRI was associated with greater lesion heterogeneity, HI for ≥2cm = 0.52±0.14 vs <2cm = 0.32±0.08, p = 0.0096. Finally, higher mpMRI suspicion scores were associated with increased heterogeneity vs lower suspicion scores, p = 0.048. Conclusions: mpMRI aids in characterizing PCa lesion heterogeneity to predict variability of histologic grades on Tbx. This information can assist Tbx planning to potentially reduce risks of upgrading on final pathology. Future research will examine how lesion heterogeneity can impact risk stratification and clinical decision-making for patients and practitioners. This research was supported by the Intramural Research Program of the National Cancer Institute, NIH and NIH Medical Research Scholars Program.

Nivolumab plus cabozantinib (N+C) versus sunitinib (S) for advanced renal cell carcinoma (aRCC): Outcomes by baseline disease characteristics in the phase 3 CheckMate 9ER trial.

2021 ◽  
Vol 39 (15_suppl) ◽  
pp. 4553-4553
Author(s):  
Andrea B. Apolo ◽  
Thomas Powles ◽  
Mauricio Burotto ◽  
Maria Teresa Bourlon ◽  
James J Hsieh ◽  
...  
Keyword(s):  
Clinical Decision Making ◽  
Objective Response ◽  
Progression Free Survival ◽  
Complete Response ◽  
Clinical Decision ◽  
Lesion Size ◽  
First Line ◽  
Phase 3 ◽  
Risk Status ◽  
Disease Characteristics

4553 Background: First-line N+C significantly improved progression-free survival (PFS), overall survival (OS), and objective response rate (ORR) vs S in aRCC patients (pts) in the phase 3 CheckMate 9ER trial, leading to FDA approval of N+C in this setting. A deeper understanding of how baseline disease characteristics may impact clinical outcomes with N+C vs S may inform clinical decision making. Methods: Pts with clear cell aRCC were randomized to N 240 mg IV Q2W + C 40 mg PO QD vs S 50 mg PO QD (4 weeks of 6-week cycles). In this post hoc exploratory analysis, PFS, OS, and ORR were evaluated across pt subgroups defined by baseline IMDC risk status, organ sites of metastases (mets), number of organs with any lesions, or target lesion size. Consistent with primary/secondary efficacy endpoints in ITT pts, PFS and ORR were evaluated per RECIST v1.1 by blinded independent central review in subgroups. Results: Median follow-up in ITT pts was 23.5 months. PFS, OS, and ORR (including complete response [CR]) outcomes are summarized in the table across subgroups: IMDC risk (favorable [FAV], intermediate [I], poor [P]); number of organs with ≥ 1 target/nontarget lesion (T/NT; 1 and ≥ 2); sum of diameters of target lesions (sDTL; < and ≥ median [72.1 mm]), and in pts with liver, bone, or lung mets. The PFS HR favored N+C vs S and median (m) PFS was longer with N+C vs S across all subgroups. The OS HR also favored N+C vs S across most subgroups. ORR ranged from 38%–66% (N+C) vs 10%–44% (S) across subgroups, and CR benefits were seen with N+C in most subgroups. Additional outcomes including landmark OS and response details in subgroups will be reported. Conclusions: Consistent with outcomes in ITT pts, efficacy benefits with N+C vs S were observed regardless of IMDC risk status, organ site of mets, or extent of tumor burden at baseline. These results support N+C as a new first-line treatment option for pts with aRCC. Clinical trial information: NCT03141177. [Table: see text]

Onyx embolization prior to stereotactic radiosurgery for brain arteriovenous malformations: a single-center treatment algorithm

2017 ◽  
Vol 10 (3) ◽  
pp. 258-267 ◽  
Author(s):  
John D Nerva ◽  
Jason Barber ◽  
Michael R Levitt ◽  
Jason K Rockhill ◽  
Danial K Hallam ◽  
...  
Keyword(s):  
Stereotactic Radiosurgery ◽  
Complication Rate ◽  
Arteriovenous Malformations ◽  
Treatment Algorithm ◽  
Latency Period ◽  
Neurological Deficits ◽  
Brain Arteriovenous Malformations ◽  
Radiographic Outcomes ◽  
Ethylene Copolymer

BackgroundEmbolization before stereotactic radiosurgery (SRS) for brain arteriovenous malformations (BAVMs) is controversial.ObjectiveTo compare clinical and radiographic outcomes in patients undergoing pre-SRS embolization with ethylene copolymer (Onyx) with outcomes in patients undergoing SRS alone.MethodsSeventy consecutive patients with BAVMs who underwent SRS were retrospectively reviewed. Univariate and multivariate analyses were performed to assess the factors associated with radiographic obliteration and complication.ResultsForty-one (59%) patients presented without BAVM rupture and 29 (41%) patients presented with rupture. Pre-SRS embolization was used in 20 patients (28.6%; 7 unruptured and 13 ruptured). Twenty-five of 70 (36%) patients sustained a complication from treatment, including 6 (9%) patients with a post-SRS latency period hemorrhage. Ten (14%) patients had persistent neurological deficits after treatment. Functional outcome (as modified Rankin Scale), complication rate, and radiographic obliteration at last follow-up were not significantly different between embolized and non-embolized groups in both unruptured and ruptured BAVMs. For unruptured BAVMs, 3- and 5-year rates of radiographic obliteration were 23% and 73% for non-embolized patients and 20% and 60% for embolized patients, respectively. For ruptured BAVMs, 3- and 5-year rates of radiographic obliteration were 45% and 72% for non-embolized patients and 53% and 82% for embolized patients, respectively.ConclusionPre-SRS embolization with Onyx was not associated with worse clinical or radiographic outcomes than SRS treatment without embolization. Pre-SRS embolization has a low complication rate and can safely be used to target high-risk BAVM features in carefully selected patients destined for SRS.

scholarly journals FUTURES: Forecasting the Unexpected Transfer to Upgraded Resources in Sepsis

2019 ◽  
Vol 8 (1) ◽  
pp. 187-191
Author(s):  
Alexa Profozich ◽  
Trevor Sytsma ◽  
Ryan Arnold ◽  
Kristen Miller ◽  
Muge Capan
Keyword(s):  
Decision Making ◽  
Emergency Department ◽  
Clinical Decision Making ◽  
Point Of Care ◽  
Initial Point ◽  
Clinical Decision ◽  
Sepsis Management ◽  
Insight Into

Sepsis is one of the most deadly and costly diseases. The Emergency Department (ED) is the initial point of care for most patients who become hospitalized due to sepsis. Quantifying the accuracy of ED clinician forecasting regarding patients’ clinical trajectories and outcomes can provide insight into clinical decision making and inform sepsis management.

scholarly journals Determinants of Longitudinal Adherence in Smartphone-Based Self-Tracking for Chronic Health Conditions

2021 ◽  
Vol 5 (1) ◽  
pp. 1-24
Author(s):  
Simon L. Jones ◽  
William Hue ◽  
Ryan M. Kelly ◽  
Rosemarie Barnett ◽  
Violet Henderson ◽  
...  
Keyword(s):  
Clinical Decision Making ◽  
Clinical Decision ◽  
Health Conditions ◽  
Smartphone Apps ◽  
Data Logging ◽  
Activity Tracker ◽  
Area Of Interest ◽  
Health Tracking ◽  
Tracking Devices ◽  
Insight Into

The use of interactive mobile and wearable technologies for understanding and managing health conditions is a growing area of interest for patients, health professionals and researchers. Self-tracking technologies such as smartphone apps and wearable devices for measuring symptoms and behaviours generate a wealth of patient-centric data with the potential to support clinical decision making. However, the utility of self-tracking technologies for providing insight into patients' conditions is impacted by poor adherence with data logging. This paper explores factors associated with adherence in smartphone-based tracking, drawing on two studies of patients living with axial spondyloarthritis (axSpA), a chronic rheumatological condition. In Study 1, 184 axSpA patients used the uMotif health tracking smartphone app for a period of up to 593 days. In Study 2, 108 axSpA patients completed a survey about their experience of using self-tracking technologies. We identify six significant correlates of self-tracking adherence, providing insight into the determinants of tracking behaviour. Specifically, our data provides evidence that adherence correlates with the age of the user, the types of tracking devices that are being used (smartphone OS and physical activity tracker), preferences for types of data to record, the timing of interactions with a self-tracking app, and the reported symptom severity of the user. We discuss how these factors may have implications for those designing, deploying or using mobile and wearable tracking technologies to support monitoring and management of chronic diseases.

Beyond the Fingerstick: Complications of Diabetes in the Acutely Ill Patient with Covid-19 with Lessons from Translation Biology and Therapeutics

2021 ◽  
Vol 8 (1) ◽  
Author(s):  
Nashawi M ◽  
◽  
Ahmed M ◽  
Jarrar Y ◽  
Abualfoul M ◽  
...  
Keyword(s):  
Clinical Decision Making ◽  
Contemporary Literature ◽  
Clinical Decision ◽  
Medical Interventions ◽  
Biomedical Equipment ◽  
Decision Making Capacity ◽  
Clinical Literature ◽  
Acute Diabetes ◽  
Hyperosmolar Hyperglycemic State ◽  
Insight Into

The affliction that the Coronavirus Disease 2019 (COVID-19) pandemic has placed on the infrastructure of healthcare institutions across the globe permeates to the level of the provider, hampering clinical decision-making capacity and capability. Associated with the latter has been unprecedented, sweeping changes in biomedical equipment manufacturing, triage dynamics, and implementation of medical interventions in a landscape replete with clinical literature attempting to characterize features in COVID-19 patients. Preliminary assessments into the elements of the SARS-CoV-2 virus (the strain of coronavirus responsible for COVID-19) in addition to the delineation of patient flux pertaining to COVID-19 has identified diabetes as a prevalent comorbidity with increased mortality and increased disease burden in the acutely ill. The volume of patients with COVID-19 superimposed upon complicated diabetes exemplifies that insight into this association offers an expanded perspective of diabetes mellitus. Moreover, given the extensive organ compromise seen in COVID-19 in addition to the established notion that diabetes is a systemic syndrome of metabolism, an appraisal of the literature of medical management and precursory findings serve as bearings that help render clinical principles into viable treatments. In this review we investigate the array of contemporary literature surrounding COVID-19 with a perspective centered upon the management of acute diabetes complications, namely diabetic ketoacidosis and hyperosmolar hyperglycemic state, with emphases into translational biology and pharmacotherapeutics.

Stereotactic radiosurgery of cavernous malformations

2000 ◽  
Vol 93 (6) ◽  
pp. 987-991 ◽  
Author(s):  
Bruce E. Pollock ◽  
Yolanda I. Garces ◽  
Scott L. Stafford ◽  
Robert L. Foote ◽  
Paula J. Schomberg ◽  
...  
Keyword(s):  
Radiation Dose ◽  
Mr Imaging ◽  
Stereotactic Radiosurgery ◽  
Lesion Size ◽  
Neurological Deficits ◽  
Morbidity Rate ◽  
Cavernous Malformations ◽  
Content Type ◽  
Latency Interval ◽  
Fine Print

Object. The use of stereotactic radiosurgery to treat cerebral cavernous malformations (CMs) is controversial. To evaluate the efficacy and safety of CM radiosurgery, the authors reviewed the experience at the Mayo Clinic during the past 10 years.Methods. Seventeen patients underwent radiosurgery for high-surgical-risk CMs in the following sites: thalamus/basal ganglia (four patients), brainstem (12 patients), and corpus callosum (one patient). All patients had experienced at least two documented hemorrhages before undergoing radiosurgery. Stereotactic magnetic resonance (MR) imaging was used for target localization in all cases. The median margin radiation dose was 18 Gy and the median maximum dose was 32 Gy. The median length of follow-up review following radiosurgery was 51 months.The annual hemorrhage rate during the 51 months preceding radiosurgery was 40.1%, compared with 8.8% in the first 2 years following radiosurgery and 2.9% thereafter. In 10 patients (59%) new neurological deficits developed that were associated with regions of increased signal on long—repetition time MR imaging performed a median of 8 months (range 5–16 months) after radiosurgery. Three patients recovered, giving the group a permanent radiation-related morbidity rate of 41%. Compared with 31 patients harboring arteriovenous malformations (AVMs) of sizes and in locations similar to those of the aforementioned CMs, who underwent radiosurgery during the same time period, the patients with CMs were more likely to experience radiation-related complications (any complication, 59% compared with 10%; p < 0.001; permanent complication, 41% compared with 10%; p = 0.02).Conclusions. It is impossible to conclude that radiosurgery protects patients with CMs against future hemorrhage risk based on the available data, although it appears that some reduction in the bleeding rate occurs after a latency interval of several years. The risk of radiation-related complications after radiosurgery to treat CMs is greater than that found after radiosurgery in AVMs, even when adjusting for lesion size and location and for radiation dose.

scholarly journals Visibility of significant prostate cancer on multiparametric magnetic resonance imaging (MRI)—do we still need contrast media?

2020 ◽  
Author(s):  
Nicolai Alexander Huebner ◽  
Stephan Korn ◽  
Irene Resch ◽  
Bernhard Grubmüller ◽  
Tobias Gross ◽  
...  
Keyword(s):  
Prostate Cancer ◽  
Linear Regression ◽  
Clinical Decision Making ◽  
Peripheral Zone ◽  
Clinical Decision ◽  
Lesion Size ◽  
Multiparametric Mri ◽  
Characteristic Analysis ◽  
Visual Grading ◽  
Clinically Significant

Abstract Objectives To assess the visibility of clinically significant prostate cancer (PCA) lesions on the sequences multiparametric MRI of the prostate (mpMRI) and to evaluate whether the addition of dynamic contrast–enhanced imaging (DCE) improves the overall visibility. Methods We retrospectively evaluated multiparametric MRI images of 119 lesions in 111 patients with biopsy-proven clinically significant PCA. Three readers assigned visual grading scores for visibility on each sequence, and a visual grading characteristic analysis was performed. Linear regression was used to explore which factors contributed to visibility in individual sequences. Results The visibility of lesions was significantly better with mpMRI when compared to biparametric MRI in visual grading characteristic (VGC) analysis, with an AUCVGC of 0.62 (95% CI 0.55–0.69; p < 0.001). This benefit was seen across all readers. Multivariable linear regression revealed that a location in the peripheral zone was associated with better visibility on T2-weighted imaging (T2w). A higher Prostate Imaging-Reporting and Data System (PI-RADS) score was associated with better visibility on both diffusion-weighted imaging (DWI) and DCE. Increased lesion size was associated with better visibility on all sequences. Conclusions Visibility of clinically significant PCA is improved by using mpMRI. DCE and DWI images independently improve lesion visibility compared to T2w images alone. Further research into the potential of DCE to impact on clinical decision-making is suggested. Key Points • DCE and DWI images independently improve clinically significant prostate cancer lesion visibility compared to T2w images alone. • Multiparametric MRI (DCE, DWI, T2w) achieved significantly higher visibility scores than biparametric MRI (DWI, T2w). • Location in the transition zone is associated with poor visibility on T2w, while it did not affect visibility on DWI or DCE.

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