Citations

OBJECTIVE Spinal stereotactic radiosurgery (SSRS) is an established treatment modality for spinal metastatic disease. A common complication of SSRS is postradiation pathologic fracture. The authors evaluated the risk of pathologic fracture in sacral SSRS. METHODS All patients receiving SSRS in 1 to 5 fractions to 1 or more sacral levels between 2011 and 2020 at participating institutions were included. Demographic, histological, anatomical, and outcome data were obtained from electronic medical records. Data were analyzed using SPSS version 28. RESULTS Of 67 total patients, 50 (74.6%) were men and 17 (25.4%) were women. The most common tumor histologies were prostate adenocarcinoma (n = 16 [23.9%]) and renal cell carcinoma (n = 12 [17.9%]). Median (range) age at treatment was 63 (8–87) years. The mean ± SD (range) number of levels treated was 1.5 ± 0.7 (1–4) levels. Mean ± SD (range) bone density at S1 was 208.0 ± 74.4 (−3.0 to 443.3) Hounsfield units (HUs). Median (range) follow-up was 16.6 (1.5–132) months, median ± SD (range) overall survival was 24 ± 21.0 (1.7–83.3) months, and the 1-year local control rate was 83.6%. Fourteen patients (20.9%) experienced fracture within the radiation field. There was no association between fracture and patient sex (p = 0.32), age (p = 0.40), S1 HU (p = 0.28), tumor location according to Denis classification (p = 0.87), presence of pain (p = 0.66), single versus multifraction radiation (p = 0.44), or number of levels treated (p = 0.52). Patients experiencing in-field progression were more likely to experience fracture (61.5% vs 10.2%, p < 0.001), and patients experiencing fracture had a higher average Spine Instability Neoplastic Score than patients without fracture (5.7 vs 4.3, p = 0.049). Only local control remained as a factor associated with sacral fracture in the multivariate analysis. Of the patients experiencing fracture, 10 (71.4%) were symptomatic and 3 of those (30.0%) underwent post-SSRS surgical intervention. CONCLUSIONS Pathologic fracture may occur after sacral SSRS in a significant number of patients and is significantly associated with failure of local control.

ABSTRACT Background Membranous nephropathy (MN) associated with phospholipase A2 receptor (PLA2R) antibodies is the most common cause of nephrotic syndrome in non-diabetic adult patients. This study investigated the relationship between clinical phenotypes and renal outcomes in this population, emphasizing the potential for phenotype-based treatment stratification. Methods We conducted a retrospective, multi-center cohort study of PLA2R-positive MN. Unsupervised cluster analysis grouped patients based on clinicopathological characteristics. Primary outcomes included complete or partial remission within 2 years of biopsy and end-stage kidney disease (ESKD) or death during follow-up. Results Among 178 patients, three distinct clusters emerged (n = 89, 70, and 19). Within 2 years of biopsy, 102 patients (57%) achieved complete or partial remission. Cluster 1, characterized by the mildest disease markers, including the lowest body mass index, serum anti-PLA2R titer, serum creatinine, proteinuria, and triglycerides, had the highest remission rate of 72%, compared with 50% in cluster 2 and 54% in cluster 3. Cluster 2 had significantly lower remission compared to cluster 1 (HR 0.64, 95% CI 0.42–0.96, P = .03); results were similar in cluster 3, albeit not statistically significant (HR 0.50, 95% CI 0.23–1.09, P = .08). Elevated anti-PLA2R levels (&gt;100 U/ml) and proteinuria (&gt;8 g/24-hour) predicted reduced remission (HR 0.56, 95% CI 0.36–0.88, P = .01; HR 0.43, 95% CI 0.26–0.73, P = .002, respectively), while high high-density lipoprotein levels were protective (HR 1.01, 95% CI 1.00–1.02, P = .048). Overall, 21 patients (12%) developed ESKD or died. ESKD-free survival differed significantly across clusters (log-rank test P = .04). Conclusions Unsupervised clustering identified distinct clinical phenotypes in PLA2R-positive MN, each associated with different renal prognoses. Phenotype-based risk stratification could enhance treatment precision, improve patient outcomes, and potentially reduce treatment-related adverse effects.

Intracerebral hemorrhage (ICH), caused by the rupture of small blood vessels, remains the least treatable subtype of stroke. The pathophysiology of ICH involves immediate mechanical compression from the hematoma, followed by secondary injuries such as cerebral edema, inflammation, and neuronal damage. Management aims to prevent hematoma expansion, enable safe and effective hematoma evacuation, and mitigate secondary injuries. Recent advancements in clinical management, including blood pressure control, hemostatic therapy, surgical and minimally invasive hematoma removal, and complication management, offer new hope. This review synthesizes these advancements, integrating insights from recent research and clinical trials, and highlights significant progress in evidence-based approaches that pave the way for precise and personalized treatment strategies. Nonetheless, further research is necessary to enhance our understanding of ICH mechanisms and develop more effective clinical interventions.

Key Points Preexisting CKD, elevated serum creatinine, and severe interstitial fibrosis and tubular atrophy were linked to poor renal prognosis in renal sarcoidosis. Steroid therapy was strongly associated with renal recovery and improved long-term outcomes in renal sarcoidosis. Early detection and management of renal involvement in sarcoidosis are critical to preventing irreversible kidney damage. Background Renal sarcoidosis (RS) is a rare but potentially severe manifestation of sarcoidosis, primarily affecting the kidneys through granulomatous interstitial nephritis and calcium metabolic disturbances. This study evaluates the clinicopathologic features and renal outcomes of biopsy-proven RS, focusing on identifying predictors of renal recovery and disease progression. Methods This retrospective study included 43 biopsy-proven RS at Mayo Clinic (2012–2024). Demographic, clinical, laboratory, and histopathologic data were analyzed. Renal recovery within 6 months was classified as complete, partial, or no recovery based on serum creatinine (sCr) changes. Long-term adverse composite outcomes included the CKD onset, CKD progression, ESKD, dialysis initiation, or death. Logistic regression and Cox proportional hazards regression were used to assess predictors of renal outcomes. Results Among the cohort, 84% exhibited interstitial nephritis, with granulomatous interstitial nephritis in 33%. Calcium phosphate deposits were found in 58% of cases. Hypercalciuria (90%) was more common than hypercalcemia (74%). Within 6 months, 86% achieved recovery (74% complete, 12% partial), while 40% experienced long-term adverse composite outcomes. Higher sCr at biopsy (≥2.4 mg/dl) and moderate-to-severe interstitial fibrosis and tubular atrophy were associated with reduced complete recovery and worse long-term outcomes, while preexisting CKD significantly increased the risk of adverse long-term outcomes. Steroid therapy significantly increased the likelihood of complete recovery and reduced the risk of adverse long-term outcomes. Conclusions Preexisting CKD, elevated sCr at biopsy, interstitial fibrosis and tubular atrophy, and steroid therapy are key predictors of renal outcomes in RS. Early diagnosis and intervention are crucial to preventing irreversible kidney damage.

PURPOSE To compare overall survival (OS) in patients with baseline metastatic gastric adenocarcinoma (GA) with and without ovarian metastasis (OM). Furthermore, within the group that had ovarian metastases, we aimed to assess whether there was a survival benefit (SB) with palliative oophorectomy (PO). PATIENTS AND METHODS This is a single-institution retrospective analysis of the clinicopathological features of women diagnosed with metastatic GA with a comparison of outcomes based on PO status. We identified 240 women with baseline metastatic GAs who were treated at MD Anderson Cancer Center between February 2003 and September 2022. Among these women, we categorized a subgroup of 102 women who had OM from their primary GA. Patients were analyzed whether they underwent PO. RESULTS Patients who developed OM were most often non-Caucasian, had peritoneal involvement, and had tumors that were both human epidermal growth factor receptor 2–negative and PD-L1–negative, with signet ring cell features and diffuse histological type. Among patients with ovarian metastases, those who had PO had an Eastern Cooperative Oncology Group = 0, more comprehensive molecular and immunohistochemical profiling, lower percentage of family history of gastroesophageal malignancies, and lower interval between diagnosis of the GA primary and the OM. PO was associated with significantly improved OS in this subgroup (hazard ratio, 0.5 [95% CI, 0.31 to 0.81]; P = .005). CONCLUSION To our knowledge, this is the largest multiethnic population study assessing SB of PO in patients with GA with OM. Additionally, it is the largest study analyzing survival in this population according to the patient's multiethnic characteristics and metastasis timing and growth patterns. PO presents as a therapeutic option for women with GAs with OM if the patient is clinically suitable for surgical resection.

Abstract Objectives/Background Post‐traumatic headache (PTH) is a common symptom following mild traumatic brain injury (mTBI). Currently, there is no identified way to accurately predict if, when, and at what pace a person will have PTH improvement. In our prior studies, we focused on predicting headache improvement at 3 months post‐mTBI. However, that approach may overlook individual differences in how headaches evolve over time. This study aimed to identify individual subgroups based on their headache trajectories and to develop machine‐learning (ML) models for early prediction of headache evolution. Methods Participants with acute PTH completed a daily electronic headache diary over 3 months, recording their headache‐related symptoms. Tensor decomposition was utilized to extract latent factors underlying the time‐varying symptoms. We applied clustering techniques on the latent factors to identify patient subgroups with varying headache improvement trajectory. Next, we developed an ML method to classify each individual into a headache trajectory subgroup as early as possible within the 3‐month interval. Results Seventy‐three individuals with acute PTH (mean age = 44.8 years, SD = 14.0; 50 females/23 males) were enrolled between 0 and 59 days post‐mTBI. Data from 54 individuals were used as the training cohort for model training, and 19 individuals were used as the test cohort for model evaluation. Tensor decomposition extracted two latent factors: one factor representing the overall state of PTH severity and disability and the other representing the improvement state of these symptoms over 3 months. Clustering identified four patient subgroups with distinct headache evolution trajectories: (1) severe symptoms without improvement, (2) severe symptoms with mild improvement, (3) milder symptoms with substantial improvement, and (4) mildest symptoms with mild improvement. The proposed ML model achieved 0.80 cross‐validation accuracy in classifying individuals with PTH into subgroups for the training cohort and 0.84 accuracy for the test cohort. Notably, the model required only the first 2 weeks of headache data to accurately identify the subgroup with the mildest headaches, 3 additional weeks to identify the subgroup with the most severe headaches and no improvement in 3 months, and 2 additional weeks to distinguish the remaining subgroups. Conclusion This study identified subgroups of individuals with acute PTH with distinct headache improvement trajectories. The proposed ML method accurately classified individuals into these subgroups using the minimally necessary early headache data for each person, including detecting the subgroup with the mildest headaches at 2 weeks. This approach could offer an estimated forecast of headache burden over time and could assist clinicians with determining treatment needs and eligibility for PTH clinical trials.

Background: Addressing social determinants of health in patient care helps hospitals better understand the non-medical factors influencing patients’ health outcomes. Objectives: The objective of this study was to evaluate the correlation between hospital characteristics, county determinants, and the systematic recording of health-related social needs among general and surgical acute care hospitals in the United States. It focused on the hospital’s routine collection of data on patients’ health-related social needs, such as transportation, housing, and food insecurity. Design: A cross-sectional retrospective study design was utilized. Methods: All hospitals that completed the American Hospital Association Annual survey (n = 2254) were included in the study. A series of multinomial logistic analyses were conducted. Results: The relative risk of hospitals routinely collecting health-related social needs data is 67% lower in for-profit hospitals and 90% higher in not-for-profit hospitals compared to government hospitals. Hospitals that are part of a system are 1.5 times more likely to routinely collect data on social needs. In addition, counties with higher household income have a statistically significant higher relative risk of hospitals collecting data on social needs, though the magnitude of the difference is small. The relative risk of hospitals collecting social needs data, but not routinely, is 2 times higher in teaching hospitals and 3 times higher among system hospitals. Conclusion: Our research strongly indicates that understanding and addressing these inherent hospital-related factors are essential for effectively integrating social determinants of health into routine healthcare data collection practices. Establishing more robust guidelines and standardization in these practices may enhance hospitals’ ability to document and utilize health-related social needs information, ultimately driving improved patient outcomes and supporting more equitable care.

e19025 Background: Recent studies suggest that patients with CLL/SLL (herein, CLL) relapsed/refractory (R/R) to both cBTKi and BCL2i (double R/R [DR]) may have poorer outcomes than the broader group of double-exposed (DE) patients. This study evaluated real-world response (rwR) and time-to-event (TTE) outcomes of a CLL DE cohort and DR subcohort in the US. Methods: This retrospective study used the nationwide Flatiron Health electronic health record-derived deidentified database to include patients with CLL treated with sequential or combination cBTKi and BCL2i in any line of therapy (LOT) on or after January 1, 2011, and a subsequent LOT (ie, index LOT) on or before November 30, 2022 (DE cohort). A subset with DR CLL (DR subcohort) was analyzed separately. Descriptive statistics were generated for demographic and clinical characteristics. Outcomes included clinician-confirmed rwR rate (rwRR) and median TTE outcomes (real-world duration of response [rwDOR], progression-free survival [rwPFS], time to next treatment [rwTTNT], and overall survival [rwOS]; Kaplan Meier, follow-up to May 31, 2023). Results: The DE cohort included 264 patients, 107 of whom were in the DR subcohort. Patients were mostly male (64%), White (75%), aged ≥65 years at first index LOT (72%) after prior cBTKi and BCL2i treatment, and treated in the community setting (71%). Approximately one-third of patients received a subsequent treatment after each index LOT. Most patients were re-treated with a cBTKi and/or BCL2i in the first index LOT (69% DE; 54% DR), and the percentage treated with chemotherapy increased with each subsequent index LOT. Confirmed rwRR was similar between DE and DR for all index LOTs (Table). More relevant are the median TTE outcomes, which were shorter for DR than DE, especially for the first index LOT, and shorter in subsequent index LOTs for both groups. Conclusions: The high percentage of patients re-treated with cBTKi and BCL2i therapies and increasing use of chemotherapy regimens with each subsequent index LOT indicate a lack of standard of care and options. Our results suggest a high unmet need in the DE CLL population, particularly in patients DR to cBTKi and BCL2i therapy, who have worse outcomes. Efficacious and durable therapy options are needed to address this unmet need. Double Exposed Index LOT Double R/R Index LOT 1st 2nd 3rd 1st 2nd 3rd N 264 90 35 107 41 12 rwRR, % (95% CI) 39(33-45) 42(32-53) 40(24-58) 36(27-45) 34(21-51) 42(16-71) Median TTE outcomes, months (95% CI) rwDOR 20.3 (13.5-32.6) 6.0(5.5-NR) 3.1(2.7-NR) 11.5 (7.9-23.5) 6.0(3.6-NR) 2.9(2.7-NR) rwPFS 8.8(7.5-10.6) 5.1(4.0-7.3) 4.3(2.9-6.3) 5.0 (4.0-7.3) 3.6(2.6-5.7) 4.7(2.7-NR) rwTTNT 13.8 (10.3-18.3) 7.9(5.7-11.3) 5.7(4.2-14.6) 8.0 (6.2-11.5) 5.9(4.4-11.4) 5.0(4.2-NR) rwOS 25.2 (22.1-37.1) 15.2(11.4-22.6) 6.6(5.7-NR) 14.7 (12.3-22.6) 11.4(5.9-NR) 6.6(5.0-NR)