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Neurology ◽  
2022 ◽  
pp. 10.1212/WNL.0000000000013316
Author(s):  
Merelijne Anthoesa Verschoof ◽  
Adrien E. Groot ◽  
Sebastiaan F.T.M. de Bruijn ◽  
Bob Roozenbeek ◽  
H. Bart van der Worp ◽  
...  

Objective:To explore clinical and safety outcomes of patients with acute ischemic stroke (AIS) and active cancer after endovascular treatment (EVT).Methods:Using data from the MR CLEAN Registry, we compared patients with active cancer (defined as cancer diagnosed within 12 months prior to stroke, metastatic disease, or current cancer treatment) to patients without cancer. Outcomes were 90-day modified Rankin Scale (mRS) score, mortality, successful reperfusion (eTICI scores≥2b), symptomatic intracranial hemorrhage (sICH), and recurrent stroke. Subgroup analyses were performed in patients with a pre-stroke mRS score of 0 or 1 and according to treatment setting (curative or palliative). Analyses were adjusted for prognostic variables.Results:Of 2583 patients who underwent EVT, 124 (4.8%) had active cancer. They more often had pre-stroke disability (mRS≥2: 34.1% vs. 16.6%). The treatment setting was palliative in 25.3% of the patients. There was a shift towards worse functional outcome at 90 days in patients with active cancer (adjusted common OR 2.2, 95% CI 1.5-3.2). At 90 days, patients with active cancer were less often independent (mRS 0-2: 22.6% vs. 42.0%, aOR 0.5, 95% CI 0.3-0.8), and more often dead (52.2% vs. 26.5%, aOR 3.2, 95% CI 2.1-4.9). Successful reperfusion (67.8% vs. 60.5%, aOR 1.4, 95% CI 1.0-2.1) and sICH rates (6.5% vs. 5.9%, aOR 1.1, 95 %CI 0.5-2.3) did not differ. Recurrent stroke within 90 days was more common in patients with active cancer (4.0% vs. 1.3%, aOR 3.1, 95% CI 1.2-8.1). The sensitivity analysis of patients with a pre-stroke mRS of 0 or 1 showed that patients with active cancer still had a worse outcome at 90 days (acOR 1.9, 95% CI 1.2-3.0). Patients with active cancer in a palliative treatment setting regained functional independence less often compared to patients in a curative setting (18.2% vs. 32.1%) and mortality was also higher (81.8% vs. 39.3%).Conclusions:Despite similar technical success, patients with active cancer had significantly worse outcomes after EVT for AIS. Moreover, they had an increased risk of recurrent stroke. Nevertheless, about a quarter of the patients regained functional independence and the risk of other complications, most notably sICH, was not increased.Classification of Evidence:This study provides Class I evidence that patients with active cancer undergoing EVT for AIS have worse functional outcomes at 90 days compared to those without active cancer.


BMJ Open ◽  
2021 ◽  
Vol 11 (12) ◽  
pp. e056284
Author(s):  
Nick Jovanoski ◽  
Xin Chen ◽  
Ursula Becker ◽  
Kelly Zalocusky ◽  
Devika Chawla ◽  
...  

ObjectiveTo identify potential risk factors for adverse long-term outcomes (LTOs) associated with COVID-19, using a large electronic health record (EHR) database.DesignRetrospective cohort study. Patients with COVID-19 were assigned into subcohorts according to most intensive treatment setting experienced. Newly diagnosed conditions were classified as respiratory, cardiovascular or mental health LTOs at >30–≤90 or >90–≤180 days after COVID-19 diagnosis or hospital discharge. Multivariate regression analysis was performed to identify any association of treatment setting (as a proxy for disease severity) with LTO incidence.SettingOptum deidentified COVID-19 EHR dataset drawn from hospitals and clinics across the USA.ParticipantsIndividuals diagnosed with COVID-19 (N=57 748) from 20 February to 4 July 2020.Main outcomesIncidence of new clinical conditions after COVID-19 diagnosis or hospital discharge and the association of treatment setting (as a proxy for disease severity) with their risk of occurrence.ResultsPatients were assigned into one of six subcohorts: outpatient (n=22 788), emergency room (ER) with same-day COVID-19 diagnosis (n=11 633), ER with COVID-19 diagnosis≤21 days before ER visit (n=2877), hospitalisation without intensive care unit (ICU; n=16 653), ICU without ventilation (n=1837) and ICU with ventilation (n=1960). Respiratory LTOs were more common than cardiovascular or mental health LTOs across subcohorts and LTO incidence was higher in hospitalised versus non-hospitalised subcohorts. Patients with the most severe disease were at increased risk of respiratory (risk ratio (RR) 1.86, 95% CI 1.56 to 2.21), cardiovascular (RR 2.65, 95% CI 1.49 to 4.43) and mental health outcomes (RR 1.52, 95% CI 1.20 to 1.91) up to 6 months after hospital discharge compared with outpatients.ConclusionsPatients with severe COVID-19 had increased risk of new clinical conditions up to 6 months after hospital discharge. The extent that treatment setting (eg, ICU) contributed to these conditions is unknown, but strategies to prevent COVID-19 progression may nonetheless minimise their occurrence.


2021 ◽  
Vol 23 (Supplement_6) ◽  
pp. vi134-vi134
Author(s):  
Jacob Ellison ◽  
Francesco Caliva ◽  
Pablo Damasceno ◽  
Tracy Luks ◽  
Marisa LaFontaine ◽  
...  

Abstract Although current advances for automated glioma lesion segmentation and volumetric measurements using deep learning have yielded high performance on newly-diagnosed patients, response assessment in neuro-oncology still relies on manually-drawn, cross-sectional areas of the tumor because these models do not generalize to patients in the post-treatment setting, where they are most needed in the clinic. Surgical resections, adjuvant treatment, or disease progression can alter the characteristics of these lesions on T2-weighted imaging, causing measures of segmentation accuracy, typically measured by Dice coefficients of overlap (DCs), to drop by ~15%. To improve the generalizability of T2-lesion segmentation to patients with glioma post-treatment, we evaluated the effects of: 1) training with different proportions of newly-diagnosed and treated gliomas, 2) applying transfer learning from pre- to post-treatment domains, and 3) incorporating a loss term that spatially weights the lesion boundaries with greater emphasis in training. Using 425 patients (208 newly-diagnosed, 217 post-Tx, with 25 treated patients withheld as a test set) and a top-performing model previously trained on newly-diagnosed gliomas, we found that DCs increased by 10% (to 0.84) then plateaued after including ~25% of post-treatment patients in training. Transfer learning (pre-training on newly-diagnosed and finetuning with post-treatment data) significantly improved Hausdorf distances (HDs), a measure more sensitive to changes at the lesion boundaries, by 17% after including 26% post-treatment images in training, while DCs remained similar. Although modifying our loss functions with boundary-weighted penalizations resulted in comparable DCs to using standard DC loss, HD measures were further reduced by 26%, suggesting that HDs may be a more sensitive metric to subtle changes in segmentation accuracy than DCs. Current work is evaluating their utility in providing accurate volumes for real-time response assessment in the clinic using workflows that have recently been deployed on our clinical PACs system.


Author(s):  
Kyoko Tanaka ◽  
Hitoshi Makino ◽  
Kazuaki Nakamura ◽  
Akio Nakamura ◽  
Maoko Hayakawa ◽  
...  

AbstractThe study on robot-assisted therapy in a pediatric field has not been applied sufficiently in clinical settings. The purpose of this pilot study is to explore the potential therapeutic effects of a group robot intervention (GRI), using dog-like social robot (SR) ‘aibo’ in pediatric ward. GRI by aibo was conducted for those children with chronic illness (127 in total) who are hospitalized in National Centre for Child Health and Development (NCCHD), and their caregivers (116 in total), from March to April 2018. The observer made structured behavioural observation records, based on which qualitative research on the features of their words and conducts, were carried out. As a result, first, during the GRI, about 2/3 of total expression by children were positive, while about 1/4 were negative or inappropriate. On the other hand, as seen in the ‘change’ group, those children who had originally responded with negative expression eventually came to express positive expression, while getting involved in a ternary relationship or participating in a session more than once. Secondly, as for the expression from the caregivers during the GRI, active expressions such as ‘participation’ and ‘exploration’ accounted for the 2/3, while 1/3 turned out to be rather placid expressions such as ‘watch over’ or ‘encourage.’Conclusion: There has not been any precedent study on the features of words and conducts expressed by patients and their caregivers during the GRI by aibo. The outcome suggests that aibo could possibly be used as a tool for group robot-assisted therapy in the pediatric treatment setting. What is Known:• The study on robot-assisted therapy in a pediatric field has only just begun.• Though many kinds of social robot have been reportedly used so far, none has yet to be applied in clinical settings What is New:• Our study revealed the features of words and behaviour expressed by the patients and their caregivers, when dog-like social robot ‘aibo’ was used for a group robot intervention in the pediatric ward.• The outcome suggests that aibo could possibly be used as a tool for group robot-assisted therapy in the pediatric treatment setting.


BMJ Open ◽  
2021 ◽  
Vol 11 (10) ◽  
pp. e049009
Author(s):  
Deborah Marshall ◽  
Melissa D Aldridge ◽  
Kavita Dharmarajan

ObjectivesThe Centers for Medicare & Medicaid Services’ newly enacted Radiation Oncology Model (‘RO Model’) was designed to test the cost-saving potential of prospective episode-based payments for radiation treatment for 17 cancer diagnoses by encouraging high-value care and more efficient care delivery. For bone metastases, evidence supports the use of higher-value, shorter courses of radiation (≤10 fractions). Our goal was to determine the prevalence of short radiation courses (≤10 fractions) for bone metastases and the setting, treatment and patient characteristics associated with such courses and their expenditures.DesignUsing the RO Model episode file, we evaluated receipt of ≤10 fractions of radiotherapy for bone metastases and expenditures by treatment setting for Medicare fee-for-service beneficiaries during calendar years 2015–2017.Using unadjusted and adjusted regression models, we determined predictors of receipt of ≤10 fractions and expenditures. Multivariable models adjusted for treatment and patient characteristics.ResultsThere were 48 810 episodes for bone metastases during the period. A majority of episodes for ≤10 fractions occurred in hospital-outpatient settings (62.8% (N=22 715)). After adjusting for treatment and patient factors, hospital-outpatient treatment setting remained a significant predictor of receiving ≤10 fractions (adjusted OR 2.03 (95% CI 1.95, 2.12; p<0.001) vs free-standing). The greatest adjusted contributors to total expenditures were number of fractions (US$−3424 (95% CI US$−3412 to US$−3435) for ≤10 fractions vs >10; p<0.001) and treatment type (including US$7716 (95% CI US$7424 to US$8018) for intensity modulated radiation therapy vs conventional external beam; p<0.001).ConclusionsA measurable performance gap exists for delivery of higher-value bone metastases radiotherapy under an episode-based model, associated with increased expenditures. The RO Model may succeed in improving the value of bone metastases radiation. Increasing the capacity of free-standing centres to implement palliative-focused services may improve the ability of these practices to succeed under the RO Model.


2021 ◽  
Vol 3 (Supplement_3) ◽  
pp. iii13-iii13
Author(s):  
David Reinecke ◽  
Stephanie T Jünger ◽  
Martin Kocher ◽  
Maximilian Ruge ◽  
Daniel Ruess ◽  
...  

Abstract Background and Purpose While data reporting the number of brain metastasis as a prognostic factor for patients with NSCLC, we analyzed whether the prognostic importance of the mere count of brain metastasis in a modern, multimodal treatment setting. Patients and Methods We retrospectively analyzed patients treated for BM from non-small lung cancer between 2010 and 2020. Demographics, baseline characteristics, and tumor-associated parameters were retrieved from an electronic database. Prognostic factors for local cerebral control and survival were identified using the log-rank test and Cox regression analysis. Results We included 343 consecutive patients (male n=187, female n=156; median age 61 years). Histological subtypes were adenocarcinoma (n=283), squamous-cell carcinoma (n=42) and neuroendocrine carcinoma (n=18). The median number of BM was one (range 1–20). Single (n = 189), oligo (n=110) and multiple BM (n=44) showed in total a median follow up of 10 months (minimum 1, maximum 142). Treatment comprised surgical resection (n=218) with radiotherapy, stereotactic radiosurgery (n=125) and adjuvant systemic therapy (n=203). The median local cerebral control was 11 months (95%CI 8.5 – 13.5) and the median overall survival was 16 months (95%CI 12.8 – 19.2). The number of BM did not influence local control and overall survival rates (p = 0.234 and p = 0.210, respectively). Controlled systemic disease (HR 0.42; 95% CI 0.2284–0.633; p&lt;0.0001), clinical status (Karnofsky Performance Score &gt; 70; HR 0.41; 95% CI 0.265–0.661; p&lt;0.0001) and adjuvant systemic therapy (HR 0.38; 95% CI 0.279–0.530; p&lt;0.0001) were independent prognostic factors for survival. Conclusions The mere number of brain metastases is not a prognostic factor for survival and local cerebral control in a multimodal treatment setting.


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