Citations

Case: A 49-year-old right-hand-dominant man sustained an auger-related injury that resulted in open dislocation at the left wrist and palm, with complete amputation of the distal aspect of the forearm and the hand. The injury at the elbow included instability with an ulnar coronoid fracture, posterior dislocation of the ulna, and posterolateral dislocation of the radius. To restore stability of the forearm stump and elbow, we performed a complete resection of the radius, open reduction and internal fixation of the coronoid tip, a repair of the lateral collateral ligament, and transfer of the distal biceps tendon to the coronoid. Conclusion: The procedure stabilized the elbow, allowing for early mobilization. The patient was eventually fitted with a prosthesis that allowed him to return to full-time manual labor in a rural setting.

74 Background: U.S. National Antiemetic Guidelines recommend upfront triple prophylaxis (NK1 receptor antagonist (RA) + 5HT3 RA + dexamethasone) for patients receiving highly emetogenic chemotherapy (HEC), including carboplatin AUC ≥ 4 per 2017 guidelines. While existing data show gaps in guideline compliance, variation between individual physicians is less studied, and a realistic target compliance rate remains unknown. Methods: In a large electronic health record database (IBM Explorys), we identified HEC courses of therapy initiated from 2012 to 2017. Guideline compliance was defined as triple prophylaxis at chemotherapy initiation. Patient courses for ≥ 7 day cycles of cisplatin or anthracycline + cyclophosphamide (AC), or carboplatin (≥ 14 day cycles as a proxy for AUC ≥ 4) were ascribed to oncologists based on encounter frequency. We then ranked physicians treating ≥ 5 HEC courses and evaluated guideline compliance and individual physician variation. Results: In total, 10,074 HEC courses were identified and attributed to 451 unique physicians. Overall antiemetic guideline compliance with cisplatin and AC averaged 68% and 81% respectively. When ranked by compliance, the top 20% of physicians were 2.5 - 1.5 times as compliant as the bottom 20% (cisplatin 100% vs 40%; AC 100% vs 67%). For cisplatin, 32% of physicians had > 90% compliance; the remaining 68% were evenly distributed from 0 - 90%. For AC, 56% of physicians had > 90% compliance, and another 14% had 80 - 90%; the remaining 30% were evenly distributed. For carboplatin, 62% of physicians had ≤ 10% compliance, and another 17% had 11 - 20%; however, the majority of these data preceded guideline inclusion of carboplatin AUC ≥ 4 as HEC. Rates were independent of course volume per physician. Conclusions: Considerable physician-level variation exists in triple antiemetic prophylaxis guideline adherence for HEC. Hundreds of physicians had > 90% compliance with guidelines, suggesting 90% is a realistic target. However, the majority exhibited substantial gaps in NK1 RA use in HEC, placing patients unnecessarily at risk for CINV. Interventions are needed to bolster triple antiemetic prophylaxis in HEC, perhaps especially for carboplatin.

112 Background: Reducing hospitalizations for chemotherapy-related toxicities represents an opportunity to improve both the quality and cost of cancer treatment. Nausea and vomiting (NV) account for almost 10% of “avoidable” toxicity-related post-chemotherapy hospitalizations (2016 Medicare data). We sought to evaluate the event cost of NV-related hospitalizations among patients with cancer from a US payer perspective. Methods: From a large US claims database (Truven MarketScan), we identified hospitalizations with NV as the primary diagnosis and cancer as a secondary diagnosis (01/2011-06/2017). This method increases specificity for NV as the principal hospitalization factor, while underreporting the prevalence of NV as a contributory factor. To determine event costs, we evaluated hospital and other reimbursement during the hospitalization. To explore subgroup differences, we stratified results by tumor type, payer type, admission route, receipt of highly emetogenic chemotherapy (HEC; 2017 definition includes carboplatin AUC ≥4) and antiemetic prophylaxis. We adjusted all costs to 2017 US dollars. Results: Among 918,192 hospitalizations involving cancer, we identified 80,995 with both NV and a cancer diagnosis code. Of these, 5,293 had NV as the primary diagnosis and 62 lacked cost data. Patients (mean age = 57.7±16.2) were 67% female. Median hospital length of stay was 4 days and mean cost per hospitalization was $15,085. Non-Medicare admissions (82%) had a higher mean cost vs. Medicare ($15,737 vs. $12,111, p < 0.01). We found < $1,000 difference between the highest and lowest cost per hospitalization among the 6 most common tumor types. We found the 65% of patients with a chemotherapy claim ≤30 days prior to hospitalization had costs of $13,882 per event. Among the 45% of chemotherapies that were HEC, > 50% lacked an NK1 receptor antagonist as prophylaxis. Conclusions: The average cost of NV-related hospitalizations among patients with cancer exceeds $15,000 per event, highlighting the need to effectively address this symptom. Roughly half the hospitalizations involved HEC, with over half of those patients not receiving guideline-based antiemetic prophylaxis.

Abstract Background: There have been few studies of sufficient size to address the relationship between glioma risk and the use of aspirin or NSAIDs, and results have been conflicting. The purpose of this study was to examine the associations between glioma and aspirin/NSAID use, and to aggregate these findings with prior published studies using meta-analysis. Methods: The Glioma International Case-Control Study (GICC) consists of 4,533 glioma cases and 4,171 controls recruited from 2010 to 2013. Interviews were conducted using a standardized questionnaire to obtain information on aspirin/NSAID use. We examined history of regular use for ≥6 months and duration-response. Restricted maximum likelihood meta-regression models were used to aggregate site-specific estimates, and to combine GICC estimates with previously published studies. Results: A history of daily aspirin use for ≥6 months was associated with a 38% lower glioma risk, compared with not having a history of daily use [adjusted meta-OR = 0.62; 95% confidence interval (CI), 0.54–0.70]. There was a significant duration-response trend (P = 1.67 × 10−17), with lower ORs for increasing duration of aspirin use. Duration-response trends were not observed for NSAID use. In the meta-analysis aggregating GICC data with five previous studies, there was a marginally significant association between use of aspirin and glioma (mOR = 0.84; 95% CI, 0.70–1.02), but no association for NSAID use. Conclusions: Our study suggests that aspirin may be associated with a reduced risk of glioma. Impact: These results imply that aspirin use may be associated with decreased glioma risk. Further research examining the association between aspirin use and glioma risk is warranted.

ABSTRACT The last decade has seen a sharp increase in the number of scientific publications describing physiological and pathological functions of extracellular vesicles (EVs), a collective term covering various subtypes of cell‐released, membranous structures, called exosomes, microvesicles, microparticles, ectosomes, oncosomes, apoptotic bodies, and many other names. However, specific issues arise when working with these entities, whose size and amount often make them difficult to obtain as relatively pure preparations, and to characterize properly. The International Society for Extracellular Vesicles (ISEV) proposed Minimal Information for Studies of Extracellular Vesicles (“MISEV”) guidelines for the field in 2014. We now update these “MISEV2014” guidelines based on evolution of the collective knowledge in the last four years. An important point to consider is that ascribing a specific function to EVs in general, or to subtypes of EVs, requires reporting of specific information beyond mere description of function in a crude, potentially contaminated, and heterogeneous preparation. For example, claims that exosomes are endowed with exquisite and specific activities remain difficult to support experimentally, given our still limited knowledge of their specific molecular machineries of biogenesis and release, as compared with other biophysically similar EVs. The MISEV2018 guidelines include tables and outlines of suggested protocols and steps to follow to document specific EV‐associated functional activities. Finally, a checklist is provided with summaries of key points.

The 24th Joint Annual Congress of the International Liver Transplantation Society in association with European Liver and Intestine Transplant Association and Liver Intensive Care Group of Europe was held in Lisbon, Portugal from May 23 to 26, 2018. More than 1200 participants from over 60 countries including surgeons, hepatologists, anesthesiologists and critical care intensivists, radiologists, pathologists, organ procurement personnel, and research scientists came together with the common aim of improving care and outcomes for liver transplant recipients. Over 600 scientific abstracts were presented. The principal themes were living donation, use of marginal liver donors, machine preservation, disease-specific immunosuppressive regimen, malignancies, and advances in pediatric liver transplantation and liver transplant anesthesia. This report presents excerpts from invited lectures and select abstracts from scientific sessions, which add to current knowledge, and will drive clinical practice and future research.