Continuity and coordination of care in highly selected chronic cancer patients treated with multiple repeat radiation therapy

Introduction and background As cancer is developing into a chronic disease due to longer survival, continuity and coordination of oncological care are becoming more important for patients. As radiation oncology departments are an integral part of cancer care and as repeat irradiation becomes more commonplace, the relevance of continuity and coordination of care in operating procedures is increasing. This study aims to perform a single-institution analysis of cancer patients in which continuity and coordination of care matters most, namely the highly selected group with multiple repeat course radiotherapy throughout their chronic disease. Materials and methods All patients who received at least five courses of radiotherapy at the Department of Radiation Oncology at the University Hospital Zurich from 2011 to 2019 and who were alive at the time of the initiation of this project were included into this study. Patient and treatment characteristics were extracted from the hospital information and treatment planning systems. All patients completed two questionnaires on continuity of care, one of which was designed in-house and one of which was taken from the literature. Results Of the 33 patients identified at baseline, 20 (60.6%) participated in this study. A median of 6 years (range 3–13) elapsed between the first and the last visit at the cancer center. The median number of involved primary oncologists at the radiation oncology department was two (range 1–5). Fifty-seven percent of radiation therapy courses were preceded by a tumor board discussion. Both questionnaires showed high levels of experienced continuity of care. No statistically significant differences in experienced continuity of care between groups with more or less than two primary oncologists was found. Discussion and conclusion Patients treated with multiple repeat radiation therapy at our department over the past decade experienced high levels of continuity of care, yet further efforts should be undertaken to coordinate care among oncological disciplines in large cancer centers through better and increased use of interdisciplinary tumor boards.

Indications and Surgical Techniques for Repeat Corneal Transplantation in Eastern China: A Twelve-Year Study

Purpose. To analyze the indications and surgical procedures for repeat keratoplasty in eastern China from 2008 to 2019. Methods. This retrospective descriptive study included 418 eyes of 411 patients who underwent no less than 2 keratoplasties at the Eye, Ear, Nose and Throat Hospital of Fudan University from 2008 to 2019. Medical charts were reviewed. The primary indications for repeat keratoplasty, the reasons for regrafting, and the surgical techniques used in the treatment were collected and analyzed. Results. Among 418 eyes, 337 eyes (80.6%) had one repeat keratoplasty, and 81 eyes (19.4%) had multiple repeat keratoplasties (≥2 repeat keratoplasties). The median interval between the initial keratoplasty and the first repeat keratoplasty was 25 months, and that between two keratoplasties after the first repeat keratoplasty was 27.5 months. Infectious keratitis was the leading primary indication for single repeat keratoplasty (80 cases, 23.7%) and multiple repeat keratoplasties (19 cases, 23.5%). The second most common primary indication was bullous keratopathy for single repeat keratoplasty (49 eyes, 14.5%) and chemical injury for multiple repeat keratoplasties (14 eyes, 17.3%). The main reason for regrafting was allograft rejection (262 cases, 49.3%), followed by endothelial dysfunction (92 cases, 17.3%), and for vision improvement after tectonic keratoplasty (60 cases, 11.3%). Penetrating keratoplasty (PKP) was the major technique used in repeat keratoplasty (447 cases, 84.2%). However, Descemet stripping endothelial keratoplasty was more frequently used than PKP (72.4% vs. 27.6%, P < 0.001 ) in the treatment of failed endothelial keratoplasty. Conclusion. Infectious keratitis was still the leading cause of repeat keratoplasty in eastern China. Although PKP remains the major technique of repeat keratoplasty, the application of customized lamellar keratoplasty has greatly expanded in the last decade. Cautious selection of indications, surgical techniques, and timing for surgery is crucial for a good prognosis after repeat keratoplasty.

Maternal Morbidity Associated With Multiple Repeat Cesarean Deliveries

The article provides a review of a landmark study characterizing the risk of repeat cesarean deliveries. This multicenter prospective cohort study of over 30,000 cesarean deliveries demonstrates that risks of cesarean delivery increase sequentially, even in the absence of placenta accreta. The most dramatic increase is noted in the high rates of accreta with placenta previa and multiple cesarean deliveries, greater than 40% with 3 of more cesarean deliveries. This review highlights the key findings, methodology, and impact of this landmark study. It discusses other studies that continue to verify these results as well as contextualize them in the management of placenta accreta with developing centers of excellence. Finally, the article provides a sample clinical case scenario that applies the findings of this study.

Radiation Induced Checkpoint Immunotherapy Response in Refractory Colorectal and Pancreatic Adenocarcinoma

Immune checkpoint blockade has limited efficacy in microsatellite stable (MSS) colorectal (CRC) and pancreatic (PDAC) cancer. Preclinical models have demonstrated the use of radiation to activate the innate immune response and stimulate responsiveness to immune checkpoint blockade. Here, we describe a Phase 2 trial of radiation therapy combined with combined anti-CTLA4 (ipilimumab) and anti-PD1 (nivolumab) antibodies in MSS CRC and PDAC. In the per protocol analysis disease control rate was 37% (10/27) in CRC and 29% (5/17) in PDAC with an overall response rate of 15% (4/27) and 18% (3/17), respectively. Whole exome and RNA sequencing of biopsies from 17 patients revealed low tumor mutational burden in all tumors, but a notable upregulation of interferon stimulated genes with concordant high expression of multiple repeat RNA transcripts in responders. Altogether, this study provides foundational human proof of concept of radiation with combination immune checkpoint blockade therapy in otherwise immunotherapy resistant cancers.

Anaesthesia management in a child with Apert syndrome with craniosynostosis

Apert syndrome is a rare congenial anomaly with multisystem involvement. It is characterized by craniosynostosis, midfacial hypoplasia and global syndactyly. Altered upper and lower airway anatomy, multiple visceral anomalies and multiple repeat surgeries are main anaesthetic challenges. Here we report a case of seven month old child with Apert syndrome who was posted for posterior sagittal anorectoplasty.