Citations

Abstract Background The treatment of locally advanced rectal cancer now includes “watch-and-wait” (WW) management for patients who exhibit a clinical complete response (cCR) to total neoadjuvant therapy (TNT). We assessed patients’ knowledge and preferences regarding WW with the goal of incorporating patient input into clinical trial design. Methods Rectal cancer patients in advocacy groups (COLONTOWN/Rectalburgh and Fight CRC) were surveyed regarding perceptions about treatment strategies, tolerable risks of treatment failure, and preferences on clinical trial design. Surveys were initially distributed in 2019, with the shift toward WW prompting re-survey of select questions in 2023. Results All respondents preferred enrollment in trials that incorporated patient input. Most respondents (76%) preferred treatment that incorporated chemotherapy escalation over radiation escalation. Furthermore, when presented with a hypothetical patient who developed a cCR after chemoradiation (without the option for WW), 58% of patients chose surgical treatment (with 100% risk of permanent ostomy and 80% chance of cure) over omission of surgery (with <80% chance of cure). In contrast, when the hypothetical patient developed a cCR after TNT (with an option for WW), 82% of patients opted for selective WW over surgery. Conclusions This work successfully integrated patient advocacy groups as a resource for obtaining patient input. Surveys revealed patients had a strong preference for chemotherapy escalation, for selective WW when offered, and for incorporation of input into future clinical trial design. These findings describe how well-informed patients approach complex medical decision-making and serve as a starting point for future studies seeking to incorporate patient voices.

Telesurgery has the potential to overcome geographical barriers in surgical care, encouraging its deployment in areas with sparse surgical expertise. Despite successful in-human experiments and substantial technological progress, the adoption of telesurgery remains slow. In this Review, we analyze the reasons for this slow adoption. First, we identify various contexts for telesurgery and highlight the vastly different requirements for their realization. We then discuss why procedures with high urgency and skill sparsity are particularly suitable for telesurgery. Last, we summarize key research areas essential for further progress. The goal of this Review is to provide the reader with a comprehensive analysis of the current state of telesurgery research and to provide guidance for faster adoption of this exciting technology.

Background: Arteriovenous malformations (AVMs) are complex vascular anomalies with a high risk of hemorrhage and neurological deficits, especially when located in eloquent brain regions. The eloquence of an AVM location is a critical factor in the treatment planning, influencing both the risk of complications and long-term functional outcomes. This study aims to compare outcomes between eloquent and non-eloquent AVMs. Methods: This multicenter, retrospective study utilized data from the Multicenter International Study for Treatment of Brain AVMs (MISTA) consortium. Patients with eloquent and non-eloquent AVMs were compared on baseline characteristics, angiographic outcomes, and functional outcomes using the modified Rankin Scale (mRS). Propensity score weighting (IPTW) was applied to adjust for confounding variables. Results: The study included 1013 patients, with 498 (49.2%) AVMs located in eloquent regions and 515 (50.8%) in non-eloquent regions. In unadjusted analysis, eloquent AVMs had lower complete obliteration rates (67.6% vs 79.5%, OR: 0.53, 95% CI: 0.39–0.72, p < 0.001) and higher complication rates (24.5% vs 19.0%, OR: 1.38, 95% CI: 1.02–1.86, p = 0.03) compared to non-eloquent AVMs. After IPTW adjustment, eloquent AVMs continued to show significantly higher odds of overall complications (OR: 1.68, 95% CI: 1.12–2.52, p = 0.01) and symptomatic complications (OR: 1.77, 95% CI: 1.12–2.80, p = 0.01). Secondary analysis within the eloquent group indicated that embolization was linked to an elevated risk of complications. Surgery and radiosurgery showed comparable functional outcomes at last follow-up and complications rates with higher complete obliteration rates in surgery. Conclusion: AVMs in eloquent brain areas present higher risks of complications and lower obliteration rates, emphasizing the need for cautious, individualized treatment planning. Within the eloquent group, embolization increased the risk of complications, while surgery and radiosurgery showed comparable functional outcomes at last follow-up and complication rates with higher complete obliteration rates in surgery. These findings highlight the importance of location in AVM management and support further research focusing on comparing treatment strategies for AVMs in eloquent brain areas.

AbstractCases of myelin oligodendrocyte glycoprotein (MOG) antibody‐associated disease (MOGAD) co‐occurring with neoplasms have been reported. In this international, retrospective cohort study in South Korea and the USA, 16 of 445 (3.6%) patients with MOGAD had concurrent neoplasm within 2 years of MOGAD onset, resulting in a standardized incidence ratio for neoplasm of 3.10 (95% confidence interval [CI], 1.77–4.81; P < 0.001) when compared to the age‐ and country‐adjusted incidence of neoplasm in the general population. However, none of the nine tumor tissues obtained demonstrated MOG immunostaining. The slightly increased frequency without immunohistopathological evidence suggest with true paraneoplastic MOGAD is extremely rare.

ABSTRACTBackgroundThe factors contributing to sustained ventricular arrhythmias (VAs) >30 days after left ventricular assist device (LVAD) implantation are not well‐established.ObjectivesThis study aimed to predict the factors associated with late sustained VAs after LVAD implantation and develop a predictive score to identify patients with an increased risk of late sustained VAs after the procedure.MethodsWe performed a retrospective cohort study on a training cohort of 623 patients and a validation cohort of 157 patients who underwent LVAD implantation at the Mayo Clinic (Rochester, Phoenix, and Jacksonville) from January 1, 2000, to December 30, 2020. Late sustained VAs were defined as ventricular tachycardia (VT) and ventricular fibrillation (VF) occurring >30 days after the LVAD procedure. Detailed chart reviews of the electronic health records within the Mayo Clinic and outside medical records were performed.ResultsA total of 780 patients were included in our study. Late sustained VAs occurred in 30% (n = 232) of the patients. The significant factors associated with late sustained VAs after LVAD were the history of VAs prior to LVAD (34.1% vs. 23.0%, p < 0.01), implantable cardiac defibrillator (ICD) (87.9% vs. 77.6%, p < 0.01) or cardiac resynchronization therapy (CRT) in situ (43.5% vs. 33.6%, p = 0.008), VT ablation prior to LVAD (5.2% vs. 1.8%, p = 0.010), use of amiodarone (49.1% vs. 38.7%, p = 0.007), use of mexiletine (15.5% vs. 5.7%, p < 0.01), and higher left ventricular end‐diastolic diameter (LVEDD) on echocardiography prior to LVAD implantation (71.4 vs. 68.7 mm, p = 0.002). During follow‐up, the patients who developed late sustained VAs after LVAD had lower survival than those who did not (HR = 1.96, 95% CI:156–2.4, p < 0.001). The average time from LVAD to orthotopic heart transplant was longer among late sustained VAs patients (23 vs. 14 months, p < 0.01). The “VIN” risk score was created to identify four risk groups: low (scores 0), intermediate (score 1), high (score 2), and very high (score 3). The rates of late VA's in the training cohort at 1 year were 9.5%, 14%, 18%, and 25% which was almost similar to the risk of late VA's at validation cohort 10%, 12%, 20%, and 63%, respectively.ConclusionsLate sustained VAs occurred in 30% of the patients who received LVAD and were associated with lower survival. The VIN risk score was developed and validated to stratify patients into low, intermediate, high, and very high risk of late sustained VAs.

OBJECTIVE The definitive influence of prestroke disability on outcomes in patients with a low Alberta Stroke Program Early CT Score (ASPECTS) treated with endovascular thrombectomy (EVT) for acute ischemic stroke (AIS) due to large-vessel occlusion (LVO) remains unknown. This study aimed to investigate the impact of prestroke disability on outcomes in this specific population. METHODS Data from 32 international centers for AIS-LVO patients with a low ASPECTS who underwent EVT between January 2013 and December 2022 were analyzed retrospectively. Low ASPECTS and prestroke disability were defined as ASPECTS values of 2–5 and prestroke modified Rankin Scale (mRS) score ≥ 2. The primary outcome was a return to the prestroke mRS score at 90 days. Secondary outcomes were independent ambulation (mRS scores of 0–3) or a return to the prestroke mRS score at 90 days, good functional outcome (mRS scores of 0–2) or a return to the prestroke mRS score at 90 days, successful recanalization, and 90-day mortality. Safety outcomes were any intracranial hemorrhage or symptomatic intracranial hemorrhage. A symptomatic intracranial hemorrhage was defined as an intracranial hemorrhage with an associated worsening of ≥ 4 points in the National Institutes of Health Stroke Scale score. Outcomes were compared between patients with and without prestroke disability. RESULTS Of 293 patients, 50 (17.1%) had a prestroke disability. Of 50 patients, 20 (40.0%), 24 (48.0%), and 6 (12.0%) had prestroke mRS scores of 2, 3, and 4, respectively. The primary outcome showed no significant difference between the two groups. Compared with patients without prestroke disability, those with prestroke disability had a significantly smaller proportion of independent ambulation or return to prestroke mRS score (adjusted OR 0.13, 95% CI 0.03–0.53) and good functional outcome or return to prestroke mRS score (adjusted OR 0.21, 95% CI 0.05–0.91). Other secondary and safety outcomes showed no significant difference between the two groups. CONCLUSIONS The present study indicated that prestroke disability was not associated with a return to the prestroke mRS score at 90 days or intracranial hemorrhage. Physicians should not routinely exclude AIS-LVO patients with a low ASPECTS who have prestroke disability from EVT based on prestroke disability alone.

Background The contact aspiration (CA) technique is often used to perform endovascular thrombectomy (EVT) for acute ischemic stroke (AIS); however, rescue strategies are necessary if CA fails to achieve recanalization. This study investigates the outcomes of incorporating stent retriever (SR) thrombectomy in the rescue strategy following failed CA. Methods EVT patients with failed CA attempts were identified from a large multicenter registry and stratified by rescue technique: CA alone or incorporating SR in the rescue strategy. Outcomes included successful recanalization, 90-day functional outcomes (defined by the modified Rankin Scale (mRS) score), symptomatic intracranial hemorrhage (sICH), and 90-day mortality. Results Among 1885 patients with failed CA attempts, conversion to SR was associated with higher recanalization rates (85.2% vs 80.6%; p=0.03), higher rates of second-pass recanalization (31.2% vs 23.4%; p<0.001), and better 90-day outcomes (mRS 0–2: 35.2% vs 29.9%; p=0.04) when compared with repeated CA attempts. Trevo SRs showed higher odds of successful recanalization (adjusted odds ratio (aOR)=1.9; p=0.02), second-pass recanalization (aOR=1.7; p=0.01), and reduced odds of sICH (aOR=0.3; p=0.02). EmboTrap SRs were associated with higher odds of 90-day mortality (aOR=2.6; p=0.004) and sICH (aOR=2.9; p=0.04) and lower odds of recanalization (aOR=0.5; p=0.03). Conclusions Incorporating SR in the rescue strategy after a failed CA improves recanalization rates and functional outcomes. Trevo SRs demonstrated superior efficacy and safety when incorporated into the rescue strategy.

Abstract Background Recurrent Clostridioides difficile infection (rCDI) is common, with a prior CDI linked to a risk of up to 65% for subsequent recurrences. Fecal microbiota, live-jslm (RBL) is the first microbiota-based product approved in the US for the prevention of rCDI in adult patients following antibiotic treatment for rCDI. This study reports the characteristics and outcomes of patients with rCDI who were administered RBL in a real-world setting. Methods Adult patients with rCDI who received RBL either at home or a clinic from healthcare professionals affiliated with a home-care provider network were included. Patients were required to have at least 8 weeks of follow-up after RBL administration, with CDI recurrence status assessed at week 8. Patient demographics, clinical characteristics, administration setting, prior medication use, and prior healthcare resource utilization were collected. The primary outcome was CDI recurrence within 8 weeks post-RBL administration. All variables were summarized descriptively using median and interquartile range (IQR) for continuous outcomes and count and percentage for categorical variables. Results Between July 2023 and March 2024, 136 patients with rCDI received RBL, of whom 73 had at least 8-week follow up and reported CDI recurrence status at week 8. Patients had a median age of 63.0 years (IQR = 47.0, 76.0), 68.5% were female, most (74.0%) had ≥ 3 prior CDI recurrences, 5.5% had received fecal microbiota transplant, and 9.6% had received bezlotoxumab (Table). One third of patients (32.9%) had previously been hospitalized and 38.4% had prior emergency room visits due to CDI. Most patients were previously treated with antibiotics for rCDI: 39.7% with vancomycin only, 11.0% with fidaxomicin only, and 43.8% with both vancomycin and fidaxomicin. All patients, except for 4 with missing data, received RBL 24-72 hours post-antibiotics. Most patients (83.6%) received RBL at home. At week 8, the overall treatment success rate (no CDI recurrence) was 87.7% (87.3% [62/71] in RBL-naïve; 100% [2/2] in previously RBL-treated). Conclusion RBL was effective in preventing recurrence of CDI at 8 weeks in a real-world setting, where most patients received RBL at home. These results suggest that RBL is effective in managing rCDI, including in a home care setting. Disclosures Sahil Khanna, MBBS, MS, Ferring Pharmaceuticals, Inc.: Grant/Research Support|Finch: Grant/Research Support|Immuron: Advisor/Consultant|Niche: Advisor/Consultant|Pfizer: Grant/Research Support|Probio Tech, LLC: Advisor/Consultant|Seres Therapeutics: Grant/Research Support|Takeda: Advisor/Consultant|Vedanta: Grant/Research Support Sanghyuk Seo, PharmD, MS, Ferring Pharmaceuticals, Inc.: Employee Min Yang, MD, PhD, Analysis Group, Inc.: I am an employee of Analysis Group, Inc., which has received consulting fees from Ferring for the conduct of this study. Viviana García-Horton, PhD, Analysis Group, Inc.: I am an employee of Analysis Group, Inc., which has received consulting fees from Ferring for the conduct of this study. Yipeng Gao, PhD, Analysis Group, Inc.: I am an employee of Analysis Group, Inc., which has received consulting fees from Ferring for the conduct of this study. Hannah Kim, PhD, Analysis Group, Inc.: I am an employee of Analysis Group, Inc., which has received consulting fees from Ferring for the conduct of this study. Loren Ormenaj, n/a, Analysis Group, Inc.: I am an employee of Analysis Group, Inc., which has receivedconsulting fees from Ferring for the conduct of this study. Amy Guo, PhD, Ferring Pharmaceuticals, Inc.: Employee

Abstract Background Morbidity from bacteremia may be exacerbated by inadequate initial antibiotic therapy. This concern however may lead to hesitance to de-escalate while awaiting pathogen identification and susceptibility results. We performed a randomized controlled trial evaluating the impact of a strategy for rapid pathogen and resistance detection directly from positive blood culture bottles (BCBs) using a rapid multiplex PCR (rmPCR) complemented with a rapid phenotypic screen (RPS) for extended-spectrum beta-lactamases and carbapenemases in a setting with moderate to high levels of antimicrobial resistance where routine direct-from-BCB disk diffusion susceptibility testing was in place Methods Patients with positive BCBs were randomized to 2 arms: 1) Standard BCB processing (including direct from BCB disk diffusion susceptibility testing - control, n=419) with antimicrobial stewardship (AS); or 2) rmPCR/RPS with AS (rmPCR/RPS, n=425). The primary outcome was time from positive blood culture result to prescription of an effective or optimal antibiotic regimen. An effective antibiotic regimen was defined as one active against the detected pathogen(s); an optimal antibiotic regimen was defined as an effective regimen which was also the most narrow spectrum and targeted one, as recommended by institutional guidelines. Mortality was analyzed as a secondary outcome. Results True bacteremia was identified in 658 patients (n=329 in both arms); 597 were monomicrobial (405 with aerobic or facultative anaerobic Gram negatives rods [AGNR]) and 61 polymicrobial (41 harboring AGNR). Time from BCB Gram stain to prescription of an effective antibiotic was 9.9 versus 3.2 hours in the control and rmPCR/RPS groups, respectively (p=0.58) and time from Gram stain to prescription of an optimal antibiotic regimen was 41.6 versus 29.4 hours in the two groups, respectively (p &lt; 0.001). 14-day mortality was 7.6% versus 4.3% (p = 0.069) and 30-day mortality was 11.2% versus 8.8% (p=0.30) in the two groups, respectively. Conclusion Compared to control methods which included direct-from-BCB disk diffusion susceptibility testing, an intervention comprising rmPCR/RPS with AS applied to positive blood cultures improved time to optimal therapy but not time to effective therapy or mortality. Disclosures Shawn Vasoo, MBBS, MRCP, D(ABP), D(ABIM) (Inf Dis), FRCPath, bioMerieux: In-kind, for this study|Rosco Diagnostica: In-kind, for this study Robin Patel, MD, a patent on Bordetella pertussis/parapertussis PCR issued, a patent on a device/method for sonication with royalties paid by Samsung to Mayo Clinic, a: See above|MicuRx Pharmaceuticals and BIOFIRE: Grant/Research Support|PhAST, Day Zero Diagnostics, Abbott Laboratories, Sysmex, DEEPULL DIAGNOSTICS, S.L., Netflix, Oxford Nanopore Technologies and CARB-X: Advisor/Consultant|Up-to-Date and the Infectious Diseases Board Review Course.: Honoraria Paul Tambyah, MBBS (S'pore), Diplomate, American Board of Internal Medicine and Infectious Diseases, Moderna: Grant/Research Support|Sanofi-Pasteur: Grant/Research Support