Citations

Aims Bone marrow-derived mesenchymal stem cells obtained from bone marrow aspirate concentrate (BMAC) with platelet-rich plasma (PRP), has been used as an adjuvant to hip decompression. Early results have shown promise for hip preservation in patients with osteonecrosis (ON) of the femoral head. The purpose of the current study is to examine the mid-term outcome of this treatment in patients with precollapse corticosteroid-induced ON of the femoral head. Methods In all, 22 patients (35 hips; 11 males and 11 females) with precollapse corticosteroid-induced ON of the femoral head underwent hip decompression combined with BMAC and PRP. Mean age and BMI were 43 years (SD 12) and 31 kg/m² (SD 6), respectively, at the time of surgery. Survivorship free from femoral head collapse and total hip arthroplasty (THA) and risk factors for progression were evaluated at minimum five-years of clinical follow-up with a mean follow-up of seven years (5 to 8). Results Survivorship free from femoral head collapse and THA for any reason was 84% and 67% at seven years postoperatively, respectively. Risk factors for conversion to THA included a high preoperative modified Kerboul angle (grade 3 or 4) based on preoperative MRI (hazard ratio (HR) 3.96; p = 0.047) and corticosteroid use at the time of decompression (HR 4.15; p = 0.039). The seven-year survivorship for patients with grade 1 or 2 Kerboul angles for conversion to THA for articular collapse, and THA for any reason, were 96% and 72%, respectively, versus THA for articular collapse and THA for any reason in patients with grade 3 or 4 Kerboul angles of 40% (p = 0.003) and 40% (p = 0.032). Conclusion At seven years, hip decompression augmented with BMAC and PRP provided a 67% survivorship free from THA in patients with corticosteroid-induced ON. Ideal candidates for this procedure are patients with low preoperative Kerboul angles and can stop corticosteroid treatment prior to decompression. Cite this article: Bone Jt Open 2021;2(11):926–931.

Background: Although injectable soft-tissue fillers are frequently used for facial rejuvenation, there is a dearth of objective data evaluating the tissue-lifting effects. Current practices for efficacy evaluation include some subjectivity. This study seeks to evaluate the lifting effects of facial soft-tissue fillers in a quantifiable, objective setting. Methods: Twenty fresh hemifaces obtained from 10 Caucasian body donors (seven women and three men) with a mean age of 83.5 ± 6.8 years and a mean body mass index of 25.3 ± 4.3 kg/m2 were injected with soft-tissue fillers following a predefined treatment algorithm. Three-dimensional surface scanning procedures were performed to assess postinjection effects. Results: Injections in the medial face [i.e., forehead, medial midface, and perioral (chin and labiomandibular sulcus)] increased the local surface volume by 0.67, 0.56, and 0.87 cc and created local (but not regional) lifting effects of 1.11, 0.11, and 0.74 mm. Injections in the lateral face (temple, lateral midface, and jawline) changed the local surface volume by 0.45, 0.02, and −0.38 cc, and created local lifting effects of 0.57, 0.81, and 0.29 mm, respectively. Lateral face injections, however, created additional regional lifting effects by co-influencing neighboring lateral facial regions, which was not observed for medial face injections. Conclusions: This cadaveric study provides evidence that soft-tissue fillers, although typically classified as volumizers, can induce lifting effects of the face. Whereas temporal deep supraperiosteal injections have limited lifting effects, the combined effects of subdermal injections of the temple, lateral midface, and mandibular angle can induce lifting effects of the total lateral face. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.

Background: Various analgesic modalities have been used to improve postoperative pain in patients undergoing hip arthroscopy. Purpose: To systematically review the literature to compare the efficacy of the fascia iliaca block (FIB) with that of other analgesic modalities after hip arthroscopy in terms of postoperative pain scores and analgesic consumption. Study Design: Systematic review. Methods: A systematic review was performed by searching PubMed, the Cochrane Library, and Embase up to April 2020 to identify randomized controlled trials that compared postoperative pain and analgesic consumption in patients after hip arthroscopy with FIB versus other pain control modalities. The search phrase used was “hip arthroscopy fascia iliaca randomized.” Patients were evaluated based on postoperative pain scores and total postoperative analgesic consumption. Results: Five studies (3 level 1, 2 level 2) were identified that met inclusion criteria, including 157 patients undergoing hip arthroscopy with FIB (mean age, 38.3 years; 44.6% men) and 159 patients among the following comparison groups: lumbar plexus block (LPB), intra-articular ropivacaine (IAR), local anesthetic infiltration (LAI), saline placebo, and a no-block control group (overall mean age, 36.2 years; 36.5% men). No significant differences in pain scores were reported in the postanesthesia care unit (PACU) between the FIB and LPB (3.4 vs 2.9; P = .054), IAR (7.7 vs 7.9; P = .72), control group (no FIB: 4.1 vs 3.8; P = .76); or saline placebo (difference, –0.2 [95% CI, –1.1 to 0.7]). One study reported significantly higher pain scores at 1 hour postoperation in the FIB group compared with the LAI group (5.5 vs 3.4; P = .02). Another study reported significantly greater total analgesic consumption (in morphine equivalent dosing) in the PACU among the FIB group compared with the LPB group (20.8 vs 17.0; P = .02). No significant differences were observed in total PACU analgesic consumption between FIB and other analgesic modalities. Conclusion: In patients undergoing hip arthroscopy, the FIB does not appear to demonstrate superiority to other forms of analgesics in the immediate postoperative period. Therefore, it is not recommended as a routine form of pain control for these procedures.

Abstract Background: CINV remains a challenging chemotherapy toxicity, particularly for anthracyclines + cyclophosphamide (AC) for breast cancer. Complete response (CR), defined as no vomiting or use of rescue medication over 5 days after chemotherapy, has been the standard endpoint for successful antiemetic prophylaxis, yet duration of prophylaxis treatment failure (i.e., breakthrough CINV) is rarely assessed. Previous work demonstrated that initial cycle breakthrough CINV is associated with at least one subsequent cycle with CINV (Schwartzberg 2011), and that longer duration CINV is associated with more lost work time and impaired activity (Schwartzberg ASCO 2020). We sought to evaluate the duration of breakthrough CINV in cycle one and its association with individual patients’ repeat breakthrough CINV in subsequent cycles. Methods: Days of CINV was a prespecified endpoint in a prospective, 4-cycle CINV prophylaxis trial of combination netupitant/palonosetron (NEPA) + dexamethasone (Dex) for patients with breast cancer receiving AC; the primary endpoint was CR. Patients without CR were classified as prophylaxis treatment failure (TF) and categorized as short TF (sTF, 1-2 days) or extended TF (xTF, ≥3 days), consistent with work by Ballatori [2006] and Roeland [2019]. We analyzed patients’ sequences of CR, sTF, and xTF for cycles 1-4 and assessed likelihood of CR for cycles 2-4 based on cycle 1 TF duration, using chi-square statistics. Results: Of 402 patients in cycle 1, 303 had CR and 99 (24.6%) had TF. Duration of TF in cycle 1 was sTF for 48 patients while 51 patients had xTF. Patients with sTF in cycle 1 often experienced CR in cycle 2 (32/46 remaining patients; 69.6%) while patients with xTF in cycle 1 often had TF in cycle 2 (38/49; 77.6%). Patients had >84% likelihood of repeating their cycle 2 outcome (CR or TF) in cycles 3 and 4. Over all cycles, those with sTF in cycle 1 had CR in 75/108 later cycles (69.4%) while xTF in cycle 1 led to CR in 32/105 later cycles (29.0%), p<0.001) (see Table). Duration of later-cycle TF was typically consistent with initial cycle TF duration (p=0.046). As a predictor of later cycle TF, xTF had a positive predictive value of 0.695, with sensitivity of 0.689 and specificity of 0.701. Those with xTF in cycle 1 had 2.28 times the relative risk of later TF (CI 1.67-3.11; p<0.001) vs those with sTF. The absolute increase in risk from xTF was 40.4%. Conclusions: Although the majority of patients receiving NEPA + Dex as prophylaxis for AC in breast cancer successfully avoided breakthrough CINV, for patients with prophylaxis treatment failure, CINV duration in cycle 1 strongly predicted their future likelihood of CINV. Patients with extended (≥3 days) breakthrough CINV in cycle 1 had CINV again in over 2/3 of later cycles; conversely those with short breakthrough CINV in cycle 1 avoided CINV entirely in over 2/3 of later cycles. The markedly higher risk faced by patients with initial-cycle extended CINV is both statistically significant and clinically meaningful, due not only to its longer duration and risk-prediction but also to previously demonstrated worsening of work loss and impaired activity. Clinicians should monitor breakthrough CINV duration, seek to avoid extended CINV, and consider changing antiemetic prophylaxis when extended CINV does occur. Further study is needed to confirm this finding in other chemotherapy regimens and with other triple prophylaxis regimens. Impact of Extended CINV in Cycle 1 on CINV in Later CyclesTF1P valueInitial Cycle Result (n/total initial cycles)Total TF1 (99/402)Short TF1 (48/99)Extended TF1 (51/99)Short vs Extended TF1Later CR cycles (n, % of total later cycles)107 (50.2%)75 (69.4%)32 (29.0%)<0.0001Later TF (n, % of total later cycles)106 (49.8%)33 (30.6%)73 (71.0%)Duration of Later TF (n, % of all later TF)Later sTFLater xTFLater sTFLater xTF0.04620 (60.6%)13 (39.4%)29 (39.7%)44 (60.3%)Total later cycles (n, %)213 (100%)108 (100%)105 (100%)TF: prophylaxis Treatment Failure; TF1: TF in cycle 1; CR: Complete Response (0 days TF); CR1: CR in cycle 1; sTF: Short (1-2 days) TF; xTF: Extended (≥3 days) TF Citation Format: Rudolph M. Navari, Gary Binder, Eric J. Roeland, Alexander Molassiotis, Kathryn J. Ruddy, Thomas W. LeBlanc, Dwight D. Kloth, Silvia Sebastiani, Marco Turini, Luke M. Schmerold, Xing Liu, Lee Schwartzberg. Duration of chemotherapy-induced nausea and vomiting (CINV) as a predictor of later-cycle CINV [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr PS13-27.

Abstract Background: Although many studies have demonstrated consistent levels of effectiveness of CINV prophylaxis for the entire study population across multiple chemotherapy cycles, rarely have studies reported how each patient’s risk of subsequent CINV differs based on prior cycle breakthrough CINV with the same prophylaxis. We lack data on whether prophylaxis continues to fail in the same group of patients each cycle, or whether failure is random with each subsequent cycle. We sought to evaluate individual patients’ risk of repeat CINV in each subsequent chemotherapy cycle. Methods: In a prospective, 4-cycle CINV prophylaxis trial of oral or intravenous combination netupitant/palonosetron (NEPA) + dexamethasone (day 1) for patients with breast cancer receiving anthracycline + cyclophosphamide (AC), we defined CINV as vomiting or use of rescue medication during days 1-5 after chemotherapy. Patients without CINV were classified as complete response (CR); the rest as treatment failure (TF). We analyzed patients’ sequences of CR and TF, and compared CR or TF for cycles 2-4 based on cycle 1 outcomes, using chi-square statistics. To provide context, we performed a post-hoc similar analysis of results reported by Herrstedt et al [2005] from a clinical trial of ondansetron + aprepitant (APR) for patients with breast cancer receiving 4 cycles of AC. Results: The 402 female patients in the NEPA trial received a total of 1,299 cycles. In cycle 1, 99 (24.6%) patients experienced TF (TF1); over all 4 cycles, TF occurred 253 times (19.5%). Patients with CR in cycle 1 (CR1) had a ≥92% rate of CR in cycle 2; their rates of repeat CR were similar in each subsequent cycle. Patients with TF1 had nearly equal risk of CR or TF in cycle 2 (45:55); thereafter 85% of this TF1 subgroup repeated their cycle 2 outcome (CR or TF) in cycles 3 and 4. Over all cycles of NEPA, patients with CR1 subsequently had CR in >90% of cycles 2-4; those with TF1 subsequently had TF in 49.8% of cycles 2-4 (p<0.0001) (see Table). We separately examined Herrstedt’s evaluation of 433 patients across 1537 cycles with APR. In cycle 1, TF was seen 213 times (49.2%), with TF reported in 46.7% of cycles 1-4. We found that patients with CR1 had an 80.5% rate of CR in cycle 2 and repeat CR rates were higher in subsequent cycles. Patients with TF1 had TF in cycle 2 (TF2) at a rate of 78.4%, with 76.6% TF3 and 72.7% TF4. For APR, CR1 resulted in subsequent CR in 78.6% of cycles 2-4 while patients with TF1 again had TF in 74.8% of cycles 2-4 (p<0.0001). Patients with TF1 were more likely to later drop from the study (see Table). Notably, among those with CR1 after APR, the few patients who later had TF in any cycle, had a subsequent repeat failure rate similar to those with TF1. Conclusions: When patients receiving guideline-recommended triple antiemetic prophylaxis successfully avoided CINV in their first cycle of HEC, they had 80-95% likelihood of repeating that success in later cycles. After NEPA, those whose prophylaxis failed in cycle 1 did not face a similar high risk of repeat failure in cycle 2. The pattern of repeat failure after aprepitant was different, with a high repeat failure risk starting in cycle 2. These findings strongly suggest that consistent population average CR rates reported across cycles may mask a higher repeat failure rate for individual patients that experience cycle 1 CINV, particularly for aprepitant. Further study of this phenomenon is needed for other HEC regimens, and to confirm the lack of high repeat failure seen in cycle 2 for NEPA. Repeat CINV in Later Cycles, Based on Cycle 1 ResultsNEPAAprepitant + OndansetronInitial Cycle Result (n/total initial cycles)CR1 (303/402)TF1 (99/402)CR1 vs TF1 (P value)CR1 (220/433)TF1 (213/433)CR1 vs TF1 (P value)Subsequent CR cycles (n, % of total subseq. cycles)636 (93.0%)107 (50.2%)<0.0001464 (78.6%)124 (25.2%)<0.0001Subsequent TF cycles (n, % of total subseq. cycles)48 (7.0%)106 (49.8%)126 (21.4%)370 (74.8%)Total subsequent cycles (n, % of total subseq. cycles)684 (100%)213 (100%)590 (100%)494 (100%)Dropped vs ITT* (n, % ITT cycles)225 (24.8%)84 (28.3%)0.226370 (10.6%)145 (22.7%)<0.0001* The NEPA trial was closed when the last patient completed the first cycle, resulting in an artificially high proportion of patients that did not complete 4 cycles. Citation Format: Rudolph M Navari, Gary Binder, Alexander Molassiotis, Eric Roeland, Kathryn J. Ruddy, Thomas W. LeBlanc, Dwight D. Kloth, Silvia Sebastiani, Lina Y. Dimberg, Luke M. Schmerold, Xing Liu, Lee Schwartzberg. Chemotherapy-induced nausea and vomiting (CINV) risk after prior breakthrough CINV: Unmasking the false average [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr PS13-09.

Abstract Purpose Chemotherapy-induced nausea and vomiting (CINV) contributes to avoidable acute care, a metric now tracked in Medicare's oncology outcome measure. CINV is preventable, yet guidelines are often not followed. We sought to quantify acute care involving CINV and other avoidable toxicities after highly emetogenic chemotherapy (HEC) to identify excess risk and assess clinician adherence to antiemesis guidelines for HEC. Materials and Methods We retrospectively evaluated U.S. electronic health records (2012-2018) using Medicare's OP-35 outcome measure to identify avoidable acute care involving any of 10 toxicities, including CINV, after HEC regimens relative to non-HEC. Antiemetic guideline adherence was defined as use ofneurokinin-1 (NKl) receptor antagonists Q5 (RAs) plus 5-hydroxytryptamine type 3 RA+ dexamethasone at HEC initiation. Results Among 17,609 patients receiving HEC, acute care rates associated with HEC chemotherapy included 32% cisplatin, 31% carboplatin, and 21% anthracycline/cyclosphospharnide (AC), with 76% meeting the criteria as avoidable events. Oxaliplatin rates were 29%. Avoidable acute care occurred 1.83 times (95% confidence interval, 1.76-1.91, p < .0001) as often after HEC versus non-HEC excluding oxaliplatin; CINV-related acute care occurred 2.29 times as often. Nonadherence to antiemesis guidelines occurred in 34% and 24% of cisplatin and AC courses, respectively, because of omission of a NKl RA. Conclusions Patients treated with HEC regimens experienced high avoidable acute care use, 1.8 times the risk seen for other chemotherapy. Nonadherence to guideline-directed antiemetic prophylaxis highlights the need to ensure adherence to antiemetic guidelines, including the use of NKl RA in HEC. Implications for Practice After survival, perhaps the most important goal in oncology is limiting avoidable acute care, a goal now used by Medicare to impact cancer reimbursement. This study found that patients treated with highly emetogenic chemotherapy (HEC) regimens had high rates of avoidable acute care use, 1.8 times the risk seen for other chemotherapy. A substantial proportion of the avoidable acute care involved chemotherapy-induced nausea and vomiting. Results showed that incomplete adherence to national antiemetic guidelines for HEC regimens primarily driven by omission of upfront neurokinin-1 receptor antagonist use, suggesting that improved adherence can meaningfully resolve this gap in quality and cost of care.

Background: Mitral valve-in-valve (ViV) and valve-in-ring (ViR) are alternatives to surgical reoperation in patients with recurrent mitral valve failure after previous surgical valve repair or replacement. Our aim was to perform a large-scale analysis examining midterm outcomes after mitral ViV and ViR. Methods: Patients undergoing mitral ViV and ViR were enrolled in the Valve-in-Valve International Data Registry. Cases were performed between March 2006 and March 2020. Clinical endpoints are reported according to the Mitral Valve Academic Research Consortium (MVARC) definitions. Significant residual mitral stenosis (MS) was defined as mean gradient ≥10 mm Hg and significant residual mitral regurgitation (MR) as ≥ moderate. Results: A total of 1079 patients (857 ViV, 222 ViR; mean age 73.5±12.5 years; 40.8% male) from 90 centers were included. Median STS-PROM score 8.6%; median clinical follow-up 492 days (interquartile range, 76–996); median echocardiographic follow-up for patients that survived 1 year was 772.5 days (interquartile range, 510–1211.75). Four-year Kaplan-Meier survival rate was 62.5% in ViV versus 49.5% for ViR ( P <0.001). Mean gradient across the mitral valve postprocedure was 5.7±2.8 mm Hg (≥5 mm Hg; 61.4% of patients). Significant residual MS occurred in 8.2% of the ViV and 12.0% of the ViR patients ( P =0.09). Significant residual MR was more common in ViR patients (16.6% versus 3.1%; P <0.001) and was associated with lower survival at 4 years (35.1% versus 61.6%; P =0.02). The rates of Mitral Valve Academic Research Consortium–defined device success were low for both procedures (39.4% total; 32.0% ViR versus 41.3% ViV; P =0.01), mostly related to having postprocedural mean gradient ≥5 mm Hg. Correlates for residual MS were smaller true internal diameter, younger age, and larger body mass index. The only correlate for residual MR was ViR. Significant residual MS (subhazard ratio, 4.67; 95% CI, 1.74–12.56; P =0.002) and significant residual MR (subhazard ratio, 7.88; 95% CI, 2.88–21.53; P <0.001) were both independently associated with repeat mitral valve replacement. Conclusions: Significant residual MS and/or MR were not infrequent after mitral ViV and ViR procedures and were both associated with a need for repeat valve replacement. Strategies to improve postprocedural hemodynamics in mitral ViV and ViR should be further explored.