Citations

Abstract Objective To provide a comprehensive assessment of various fractionation schemes in radiation therapy for breast cancer, with a focus on side effects, cosmesis, quality of life, risks of recurrence, and survival outcomes. Design Systematic review and meta-analysis. Data sources Ovid MEDLINE, Embase, and Cochrane Central Register of Controlled Trials (from inception to 23 October 2023). Study selection Included studies were randomised controlled trials focusing on conventional fractionation (CF; daily fractions of 1.8-2 Gy, reaching a total dose of 50-50.4 Gy over 5-6 weeks), moderate hypofractionation (MHF; fraction sizes of 2.65-3.3 Gy for 13-16 fractions over 3-5 weeks), and/or ultra-hypofractionation (UHF; schedule of only 5 fractions). Data extraction Two independent investigators screened studies and extracted data. Risk of bias and quality of evidence were assessed using the Cochrane Collaboration’s tool and the GRADE (Grading of Recommendations, Assessment, Development, and Evaluations) approach, respectively. Data synthesis Pooled risk ratios (RRs) and hazard ratios (HRs) with 95% confidence intervals (CIs) were calculated using a random effects model. Heterogeneity was analysed using Cochran’s Q test and I 2 statistic. Network meta-analysis was used to integrate all available evidence. Main outcome measures The pre-specified primary outcome was grade ≥2 acute radiation dermatitis and late radiation therapy related side effects; secondary outcomes included cosmesis, quality of life, recurrence, and survival metrics. Results From 1754 studies, 59 articles representing 35 trials (20 237 patients) were assessed; 21.6% of outcomes showed low risk of bias, whereas 78.4% had some concerns or high risk, particularly in outcome measurement (47.4%). The RR for grade ≥2 acute radiation dermatitis for MHF compared with CF was 0.54 (95% CI 0.49 to 0.61; P<0.001) and 0.68 (0.49 to 0.93; P=0.02) following breast conserving therapy and mastectomy, respectively. Hyperpigmentation and grade ≥2 breast shrinkage were less frequent after MHF than after CF, with RRs of 0.77 (0.62 to 0.95; P=0.02) and 0.92 (0.85 to 0.99; P=0.03), respectively, in the combined breast conserving therapy and mastectomy population. However, in the breast conserving therapy only trials, these differences in hyperpigmentation (RR 0.79, 0.60 to 1.03; P=0.08) and breast shrinkage (0.94, 0.83 to 1.07; P=0.35) were not statistically significant. The RR for grade ≥2 acute radiation dermatitis for UHF compared with MHF was 0.85 (0.47 to 1.55; P=0.60) for breast conserving therapy and mastectomy patients combined. MHF was associated with improved cosmesis and quality of life compared with CF, whereas data on UHF were less conclusive. Survival and recurrence outcomes were similar between UHF, MHF, and CF. Conclusions MHF shows improved safety profile, cosmesis, and quality of life compared with CF while maintaining equivalent oncological outcomes. Fewer randomised controlled trials have compared UHF with other fractionation schedules, but its safety and oncological effectiveness seem to be similar with short term follow-up. Given the advantages of reduced treatment time, enhanced convenience for patients, and potential cost effectiveness, MHF and UHF should be considered as preferred options over CF in appropriate clinical settings, with further research needed to solidify these findings. Systematic review registration PROSPERO CRD42023460249.

Importance Numerous studies show that early palliative care improves quality of life and other key outcomes in patients with advanced cancer and their caregivers, although most lack access to this evidence-based model of care. Objective To evaluate whether delivering early palliative care via secure video vs in-person visits has an equivalent effect on quality of life in patients with advanced non–small cell lung cancer (NSCLC). Design, Setting, and Participants Randomized, multisite, comparative effectiveness trial from June 14, 2018, to May 4, 2023, at 22 US cancer centers among 1250 patients within 12 weeks of diagnosis of advanced NSCLC and 548 caregivers. Intervention Participants were randomized to meet with a specialty-trained palliative care clinician every 4 weeks either via video visit or in person in the outpatient clinic from the time of enrollment and throughout the course of disease. The video visit group had an initial in-person visit to establish rapport, followed by subsequent virtual visits. Main Outcomes and Measures Equivalence of the effect of video visit vs in-person early palliative care on quality of life at week 24 per the Functional Assessment of Cancer Therapy-Lung questionnaire (equivalence margin of ±4 points; score range: 0-136, with higher scores indicating better quality of life). Participants completed study questionnaires at enrollment and at weeks 12, 24, 36, and 48. Results By 24 weeks, participants (mean age, 65.5 years; 54.0% women; 82.7% White) had a mean of 4.7 (video) and 4.9 (in-person) early palliative care encounters. Patient-reported quality-of-life scores were equivalent between groups (video mean, 99.7 vs in-person mean, 97.7; difference, 2.0 [90% CI, 0.1-3.9]; P = .04 for equivalence). Rate of caregiver participation in visits was lower for video vs in-person early palliative care (36.6% vs 49.7%; P &amp;lt; .001). Study groups did not differ in caregiver quality of life, patient coping, or patient and caregiver satisfaction with care, mood symptoms, or prognostic perceptions. Conclusions and Relevance The delivery of early palliative care virtually vs in person demonstrated equivalent effects on quality of life in patients with advanced NSCLC, underscoring the considerable potential for improving access to this evidence-based care model through telehealth delivery. Trial Registration ClinicalTrials.gov Identifier: NCT03375489

Abstract Recent introduction of 2 different lymphoma classifications has raised concerns about consistency in diagnosis, management, and clinical trial enrollment. Data from a large cohort reflecting real-world clinical practice suggest that differences between the classifications will affect &lt;1% of non-Hodgkin lymphomas.

Abstract Background and Objectives Social isolation is commonly experienced by older people and is associated with adverse health outcomes. Little is known about the influence of social isolation on the risk of acute care utilization among people living with mild cognitive impairment (MCI) or dementia. Our objective was to investigate the impact of social isolation on the risk of death, hospitalization, and emergency department (ED) use among people living with MCI or dementia who are followed in our Community Internal Medicine practice at Mayo Clinic, Rochester, Minnesota. Research Design and Methods We included people living with MCI or dementia, 55 years and older, who had a clinic visit between June 1, 2019, and June 30, 2021, and who had completed questions about social connections. The risk of death, hospitalization, and ED use was examined by levels of social connection (socially isolated, moderately isolated, moderately integrated, or socially integrated). Results Of 2,320 people included (1,010 with MCI and 1,310 with dementia), 455 (19.6%) were classified as socially isolated and 591 (25.5%) were moderately isolated. Compared with those who were socially integrated, people who were socially isolated were at higher risk of death, hospitalization, and ED visits (p &lt; .001). Discussion and Implications Social isolation is associated with an increased risk of acute health care utilization and death in people living with MCI or dementia. Interventions to address social isolation in this population are needed.

AbstractBackgroundTrauma remains the leading cause of pediatric mortality in the United States. Although use of massive transfusion protocols (MTPs) in this population is widespread, optimal pediatric resuscitation is not well established. We sought to assess contemporary pediatric MTP practice in the United States.Study Design and MethodsA web‐based survey was designed by the Association for the Advancement of Blood & Biotherapies (AABB) Pediatric Transfusion Medicine Subsection and distributed to select American College of Surgeons (ACS) Level I Verified pediatric trauma centers. The survey assessed current MTP policy, implementation, and recent changes in practice.ResultsResponse rate was 55% (22/40). Almost half of the respondents were from the South. The median RBC:plasma ratio was 1 (interquartile range 1–1.5). Protocolized fibrinogen supplementation was common while integration of antifibrinolytic therapy into MTPs was infrequent. Viscoelastic testing (VET) was available at most sites, 71% (15/21, one site did not respond), and was generally utilized on an ad‐hoc basis. Roughly, a third of sites had changed their MTP in the past 3 years due to blood supply issues, and about a third reported having group O Whole Blood on‐site.ConclusionMTP practice is similar throughout the United States. Though fibrinogen supplementation is common—other emerging interventions such as antifibrinolytic therapy or utilization of routine viscoelastic testing—are not widespread. Pediatric transfusion medicine experts must continue to follow practice change, as contemporary large trials begin to characterize new supportive modalities to optimize resuscitation in pediatric trauma patients.

BACKGROUND: There has been a shift in the treatment of fistula-in-ano toward a focus on the preservation of continence while simultaneously eradicating the disease. The utilization of radially emitting diode laser catheters to ablate fistula tracks has been described since 2011, with heterogenous studies publishing success rates ranging from 20% to 89%. OBJECTIVE: Present the authors’ experience managing solitary transsphincteric fistulas of cryptoglandular origin with a radially emitting diode laser. DESIGN: Prospective nonrandomized single center trial with 12-month follow-up. SETTINGS: Quaternary referral academic health care center. PATIENTS: Forty-six adults with transsphincteric fistula-in-ano. INTERVENTIONS: All patients underwent radially emitting diode laser closure of fistula-in-ano. MAIN OUTCOME MEASURES: Clinical healing and fistula recurrence. RESULTS: Forty-six patients with a median age of 48 years (range, 26–85) underwent diode laser closure. Most were men (n = 28; 60%). Twenty-four patients (52%) had previous fistula repairs with a median of 1.5 (range, 1–7) repairs per patient. All were followed for 12 months. Successful closure after 1 laser treatment occurred in 43% of patients. Thirteen of 26 failure cases (50%) were able to undergo a delayed fistulotomy secondary to an anatomic change with the fistula becoming more superficial, moving out of the internal sphincter muscle after laser ablation, all of which healed. No patients experienced new or worsening (preexisting) fecal incontinence. Two patients (8%) continued treatment for abscesses/fistula branching. One patient (3%) experienced migration of the fistula from the base of the left labia to the introitus of the vagina and 1 experienced recurrence and worsening of their disease process with subsequent involvement of the coccyx (previous deep postanal space abscess). LIMITATIONS: Limitations to our study include its nonrandomized prospective nature, single center and surgeon experience, and small patient sample size. CONCLUSIONS: Radially emitting diode laser closure is a continence-preserving option to consider when treating transsphincteric fistula-in-ano. When the procedure fails, it does not fail poorly (open wounds, retracted flaps, incontinence, etc) and can be repeated. Complications can include abscess formation and fistula migration to adjacent anatomic locations (vagina). Even if unsuccessful, after treatment, the fistula can anatomically migrate distally, becoming more superficial and thus providing the opportunity to proceed with a delayed fistulotomy. See Video Abstract. CIERRE DE FÍSTULA ANAL TRANSESFINTÉRICA CON LÁSER DE DIODO DE EMISIÓN RADIAL ANTECEDENTES: Ha habido un cambio en el tratamiento de la fístula anal hacia un enfoque en la preservación de la continencia y al mismo tiempo en la erradicación de la enfermedad. La utilización de catéteres láser de diodo de emisión radial para extirpar los trayectos de las fístulas se describe desde el 2011 y estudios heterogéneos publican tasas de éxito que oscilan entre el 20 y el 89%. OBJETIVO: Presentar nuestra experiencia en el manejo de fístulas transesfinterianas solitarias de origen criptoglandular con láser de diodo de emisión radial. DISEÑO: Ensayo prospectivo, no aleatorizado, unicéntrico, con seguimiento de 12 meses. LUGARES: Centro de salud académico de referencia Cuaternario. PACIENTES: Cuarenta y seis adultos con fístula anal transesfintérica. INTERVENCIONES: Todos se sometieron a cierre de fístula anal con láser de diodo de emisión radial. MEDIDAS PRINCIPALES DEL RESULTADO: Curación clínica y recurrencia de la fístula. RESULTADOS: Cuarenta y seis pacientes con una mediana de edad de 48 años (rango, 26-85) se sometieron a cierre con láser de diodo. La mayoría eran hombres (n=28/60%). Veinticuatro (52%) habían tenido reparaciones previas de fístulas con una mediana de 1,5 (rango, 1-7) reparaciones por paciente. Todos fueron seguidos durante 12 meses. El cierre exitoso después de un tratamiento con láser se produjo en el 43%. Trece de 26 fracasos (50%) pudieron someterse a una fistulotomía tardía debido a un cambio anatómico en el que la fístula se volvió más superficial y salió del músculo del esfínter interno después de la ablación con láser, y todas sanaron. Ningún paciente experimentó incontinencia fecal nueva o que empeoró (preexistente). Dos (8%) continuaron tratamiento por abscesos/ramificación de fístulas. Una (3%) experimentó migración de la fístula desde la base de los labios izquierdos hasta el introito de la vagina y 1 experimentó recurrencia y empeoramiento de su proceso patológico con posterior afectación del cóccix (absceso previo en el espacio postanal profundo). LIMITACIONES: Las limitaciones de nuestro estudio incluyen su naturaleza prospectiva no aleatoria, la experiencia de un solo centro y del cirujano y el tamaño pequeño de la muestra de pacientes. CONCLUSIONES: El cierre con láser de diodo de emisión radial es una opción para preservar la continencia a considerar cuando se trata la fístula en el ano transesfintérica. Cuando el procedimiento fracasa, no fracasa mal (heridas abiertas, colgajos retraídos, incontinencia, etc.), y puede repetirse. Las complicaciones pueden incluir formación de abscesos y migración de fístulas a ubicaciones anatómicas adyacentes (vagina). Incluso si no tiene éxito, después del tratamiento la fístula puede migrar anatómicamente distal volviéndose más superficial y brindando así la oportunidad de proceder con una fistulotomía retrasada. (Traducción—Yesenia Rojas-Khalil)

The NCCN Guidelines for Colorectal Cancer (CRC) Screening describe various colorectal screening modalities as well as recommended screening schedules for patients at average or increased risk of developing sporadic CRC. They are intended to aid physicians with clinical decision-making regarding CRC screening for patients without defined genetic syndromes. These NCCN Guidelines Insights focus on select recent updates to the NCCN Guidelines, including a section on primary and secondary CRC prevention, and provide context for the panel’s recommendations regarding the age at which to initiate screening in average-risk individuals and those with increased risk based on personal history of childhood, adolescent, and young adult cancer.