Citations

Background: Patients with sickle cell disease (SCD) are at increased risk of developing bacterial infections as a result of functional asplenia. Fever, a common symptom in SCD often occurs with other sickle cell related conditions and viral infections. This poses a diagnostic challenge and early use of empiric antibiotics is recommended while awaiting cultures. The widespread administration of antibiotics to all patients with SCD with fever can result in problems such as antibiotic resistance and increased medical costs. An early and reliable biomarker is therefore needed to help distinguish between bacterial and non-bacterial causes for fever in SCD. Procalcitonin (PCT) has been shown to be elevated in bacterial but not viral infections. In SCD, few studies have looked at the role of PCT in predicting bacterial infections. Unal et al reported vaso-occlusive crisis (VOC) with or without fever did not increase PCT levels in relation to patients with no crisis and no fever. However, Rincón-López et al reported a PCT < 0.6ng/mL had a negative predictive value of 97.2% and potentially could be used to identify bacterial infection early. Methods: We retrospectively studied 122 patients with SCD who presented to the emergency department with fever from 2015-2019. Inclusion criteria were defined as patients with SCD, 17 years and older and PCT measurement on presentation to the emergency department. Exclusion criteria were defined as patients with SCD and fever who had received empiric antibiotics prior to labs being drawn in the emergency department. The cohort was divided into groups of patients with Confirmed Bacterial Infection (CBI, n=18), Suspected Bacterial Infection (SBI, n=6), Viral Infections (n=10) and Vaso-Occlusive Crises (VOC, n=88) only. CBI was defined as a positive bacterial culture (blood, body fluid, urine, respiratory or cerebrospinal fluid) or C.difficile toxin assay. Viral infections were defined as a negative bacterial culture in the presence of a virus found on PCR obtained with nasopharyngeal swab. Characteristics including genotype, age, gender, complete blood count, PCT, creatinine, total bilirubin, hydroxyurea use and length of stay were examined. Data was analyzed between the groups using descriptive statistics and accounting for unequal variances, with p-value set at 0.05 for significance. Results: Demographics and clinical characteristics are summarized in Table 1 (Figure). The mean age was 34.6 years with predominantly males (64.8%). Almost two-thirds were on hydroxyurea (62.3%). The most common genotype was HbSS (70.5%) followed by HbSC (26.2%) and HbSβ (3.3%). The mean PCT for patients with CBI was 8.99 ng/mL (range, 0.03-78.36) as compared to 0.31 ng/mL (range, 0.02-6.82) in the VOC group. The most common organisms detected were E.coli, C.difficile, Pseudomonas, Staphylococcus and Enterobacter. There was a significant difference between median PCT for patients with CBI and those with VOC (p=0.036) and between patients with CBI and viral infections (p= 0.045). Using a PCT of >0.5ng/mL resulted in 81% Sensitivity and 85% Specificity for CBI. Conclusion: In patients with SCD presenting with fever, PCT on presentation was significantly higher in those with CBI compared to VOC only or Viral Infection. Disclosures No relevant conflicts of interest to declare.

Over the past 20 years, management of patients with metastatic colorectal cancer (mCRC) has improved considerably, leading to increased overall survival and more patients eligible for third- or later-line therapy. Currently, two oral therapies are recommended in the third-line treatment of mCRC, regorafenib and trifluridine/tipiracil. Selecting the most appropriate treatment in the third-line setting poses different challenges compared with treatment selection at earlier stages. Therefore, it is important for physicians to understand and differentiate between available treatment options and to communicate the benefits and challenges of these to patients. In this narrative review, practical information on regorafenib is provided to aid physicians in their decision-making and patient communications in daily practice. We discuss the importance of appropriate patient selection and adverse events management through close patient monitoring and dose adjustments to ensure patients stay on treatment for longer and receive as much benefit as possible. We also highlight key physician–patient communication points to facilitate shared decision-making.

Abstract Background: Recent advances in radiotherapy techniques have allowed ablative doses to be safely delivered to inoperable liver tumors. In this setting, proton beam radiotherapy (PBT) provides the means to escalate radiation dose to the target volume while sparing the uninvolved liver. This study evaluated the safety and efficacy of hypofractionated PBT for liver tumors, predominantly hepatocellular carcinoma (HCC) and intrahepatic cholangiocarcinoma (ICC).Methods: We evaluated the prospective registry of the Proton Collaborative Group for patients undergoing definitive PBT for liver tumors. Demographic, clinicopathologic, toxicity, and dosimetry information were compiled.Results: To date, 63 patients have been treated at 9 institutions between 2013-2019. Thirty (48%) had HCC and 25 (40%) had ICC. The median dose and biological equivalent dose (BED) delivered was 58.05 GyE (range, 32.5-75) and 80.5 GyE (range, 53.6-100), respectively. The median mean liver BED was 13.9 GyE. Three (4.8%) patients experienced at least one grade ³3 toxicity. With median follow-up of 5.1 months (range, 0.1-40.8), the local control (LC) rate at 1 year was 91.2% for HCC and 90.9% for ICC. The 1-year LC was significantly higher (95.7%) for patients receiving BED greater than 75.2 GyE than for patients receiving BED of 75.2 GyE or lower (84.6%, p = 0.029). The overall survival rate at 1 year was 65.6% for HCC and 81.8% for ICC. Conclusions: Hypofractionated PBT results in excellent LC, sparing of the uninvolved liver, and low toxicity, even in the setting of dose-escalation. Higher dose correlates with improved LC, highlighting the importance of PBT especially in patients with recurrent or bulky disease.

Abstract Objectives To test the hypothesis that lymph node yield will vary by pathology assistant (PA) in patients undergoing radical cystectomy (RC) with pelvic lymph node dissection (PLND). Methods This is a single-institution retrospective review that included patients who underwent an RC with PLND for bladder cancer from January 1, 2007, to January 1, 2018. Predicted mean lymph node counts were generated using multivariable regression analysis. Results In a total of 430 patients who underwent RC with PLND, the median lymph node count (interquartile range) was 15.0 (11.0-21.0). The frequency of the limits of lymphadenectomy was as follows: external iliac, internal iliac, and obturator (true pelvis) (33.3%); true pelvis plus common iliac to the level of the aortic bifurcation (47.9%); and inferior mesenteric artery (18.8%). On descriptive analysis, there were differences in lymph node yield when evaluating the following variables: level of dissection, clinical stage, neoadjuvant chemotherapy, surgical approach, surgeon, pathologist, and PA (P < .05). On multivariable analysis, adjusted lymph node counts varied between surgeons, pathologists, clinical stage, and level of dissection but not by PA (P = .18). Conclusions Lymph node yield after RC varies on several known levels, including surgeon, extent of lymphadenectomy, clinical stage, and pathologist. This study found no significant variation in lymph node yield according to PA.

Abstract The coronavirus disease-2019 (COVID-19) pandemic caused by SARS-CoV-2 has exacted an enormous toll on healthcare systems worldwide. The cytokine storm that follows pulmonary infection is causally linked to respiratory compromise and mortality in the majority of patients. The sparsity of viable treatment options for this viral infection and the sequelae of pulmonary complications have fueled the quest for new therapeutic considerations. One such option, the long-forgotten idea of using low-dose radiation therapy, has recently found renewed interest in many academic centers. We outline the scientific and logistical rationale for consideration of this option and the mechanistic underpinnings of any potential therapeutic value, particularly as viewed from an immunological perspective. We also discuss the preliminary and/or published results of prospective trials examining low-dose radiation therapy for COVID-19.