Defining low-risk lesions in early-stage esophageal adenocarcinoma

OBJECTIVE

As endoscopic approaches become more widely used to treat early-stage esophageal cancer, reliably identifying patients with less-aggressive tumors is paramount. We sought to identify risk factors for recurrence in patients with completely resected T1 esophageal adenocarcinoma.

METHODS

We retrospectively analyzed a single-institutional database for all patients with completely resected pathologic T1 esophageal adenocarcinoma (1996-2016). Risk factors for recurrence were identified using competing-risk regression methods. Risk stratification was performed on the basis of known preoperative clinicopathologic factors; this model's discriminative power for overall survival was evaluated using a Cox proportional hazards model.

RESULTS

Of 243 patients, 32 experienced recurrence. At a median follow-up among survivors of 4 years (range, 0.05-19 years), the 5-year cumulative incidence of recurrence was 15%, and median time to recurrence was 2 years (range, 0.26-6.13 years). On univariable analysis, submucosal invasion, N1 disease, poor differentiation, tumor length, lymphovascular invasion, and multicentricity were significantly associated with recurrence. On multivariable analysis, N1 disease (hazard ratio, 2.93; 95% confidence interval, 1.17-7.34; P = .022) and tumor length (hazard ratio, 1.44; 95% confidence interval, 1.12-1.86; P = .004) were independently associated with recurrence. Risk stratification showed that patients without lymphovascular invasion and a with median tumor length of 0.8 cm (range, 0.10-1.70 cm) had a <10% risk of recurrence and improved survival.

CONCLUSIONS

Pathologic T1 tumors have a 5-year cumulative incidence of recurrence of 15%. Nodal involvement and tumor length were independent risk factors for recurrence, whereas tumors <2 cm in length without lymphovascular invasion were associated with a low risk of recurrence.

Outcomes of transcatheter vs. isolated surgical aortic valve replacement in mediastinal radiation-associated severe aortic stenosis

Introduction

Mediastinal radiation can lead to long-term cardiac sequelae, including aortic valve disease. Surgical aortic valve replacement (SAVR) is associated with poor outcomes in this population. Transcatheter aortic valve replacement (TAVR) now provides an alternative treatment strategy that may improve outcomes.

Purpose

To compare 30-day outcomes after TAVR vs. isolated SAVR for radiation-associated severe symptomatic aortic stenosis using the Society of Thoracic Surgery (STS) National Adult Cardiac Surgery Database.

Methods

We evaluated 1,668 TAVR and 2,611 isolated SAVR patients enrolled in the STS national database from July 2011 through December 2018. A propensity score for TAVR vs. SAVR was derived using a non-parsimonious logistic regression model that included 29 pre-operative variables and was used to generate a 1:1 matched cohort (NTotal=1,560). 30-day outcomes in TAVR vs. SAVR patients were compared in the matched cohort using conditional logistic regression. We also tested for temporal trends in 30-day mortality separately for TAVR and SAVR in the matched cohort, adjusted for potential confounders, to see if outcomes varied across the study period.

Results

In the propensity-matched cohort, baseline demographics, comorbidities and preoperative characteristics were balanced between the TAVR and SAVR groups. The mean age was 73.3 years and 75% were females in each group. In the propensity-matched cohort, TAVR was associated with significantly reduced 30-day all-cause [OR=0.50 (0.30–0.84), p=0.01] and cardiovascular mortality as compared to SAVR [OR=0.33 (0.14–0.78), p=0.01]. Similarly, post-operative complications occurred less in the TAVR group except for stroke/transient ischemic attack (TIA) [OR=3.17 (1.27–7.93), p=0.01] and pacemaker implantation [OR=1.71 (1.21–2.44), p=0.003] which were significantly higher with TAVR (Figure 1A). While, 30-day mortality associated with both procedures improved over the course of the study, the trend was only statistically significant in the TAVR group following adjustment for potential confounders. TAVR was consistently associated with better survival than SAVR in the matched cohort across the study period (Figure 1B).

Conclusion

Our findings suggest that TAVR is a safe alternative to SAVR for radiation-associated severe symptomatic aortic stenosis and is associated with lower 30-day mortality and post-operative complications. The risk of stroke/TIA and pacemaker implantation is higher with TAVR and should be considered when choosing therapy. Additional prospective studies to validate our findings and evaluate long-term outcomes are needed to further guide clinical decision making in this population.

Figure 1

Funding Acknowledgement

Type of funding source: Private grant(s) and/or Sponsorship. Main funding source(s): Funding to support acquisition of the data from the Society of Thoracic Surgery was obtained from discretionary funds available to Dr. Anju Nohria from the Cardiovascular Medicine Division.

Fixed-dose combination in management of type 2 diabetes mellitus: Expert opinion from an international panel

Type 2 diabetes mellitus (T2DM) is a progressive disease with multifactorial etiology. The first-line therapy includes monotherapy (with metformin), which often fails to provide effective glycemic control, necessitating the addition of add-on therapy. In this regard, multiple single-dose agents formulated as a single-dose form called fixed-dose combinations (FDCs) have been evaluated for their safety, efficacy, and tolerability. The primary objective of this review is to develop practice-based expert group opinion on the current status and the causes of concern regarding the irrational use of FDCs, in Indian settings. After due discussions, the expert group analyzed the results from several clinical evidence in which various fixed combinations were used in T2DM management. The panel opined that FDCs (double or triple) improve patient adherence, reduce cost, and provide effective glycemic control and, thereby, play an important role in the management of T2DM. The expert group strongly recommended that the irrational metformin FDC's, banned by Indian government, should be stopped and could be achieved through active participation from the government, regulatory bodies, and health ministry, and through continuous education of primary care physicians and pharmacists. In T2DM management, FDCs play a crucial role in achieving glycemic targets effectively. However, understanding the difference between rational and irrational FDC combinations is necessary from the safety, efficacy, and tolerability perspective. In this regard, primary care physicians will have to use a multistep approach so that they can take informed decisions.

Characterizing street-connected children and youths' social and health inequities in Kenya: a qualitative study

BACKGROUND

Street-connected children and youth (SCY) in Kenya disproportionately experience preventable morbidities and premature mortality. We theorize these health inequities are socially produced and result from systemic discrimination and a lack of human rights attainment. Therefore, we sought to identify and understand how SCY's social and health inequities in Kenya are produced, maintained, and shaped by structural and social determinants of health using the WHO conceptual framework on social determinants of health (SDH) and the Convention on the Rights of the Child (CRC) General Comment no. 17.

METHODS

This qualitative study was conducted from May 2017 to September 2018 using multiple methods including focus group discussions, in-depth interviews, archival review of newspaper articles, and analysis of a government policy document. We purposively sampled 100 participants including community leaders, government officials, vendors, police officers, general community residents, parents of SCY, and stakeholders in 5 counties across Kenya to participate in focus group discussions and in-depth interviews. We conducted a thematic analysis situated in the conceptual framework on SDH and the CRC.

RESULTS

Our findings indicate that SCY's social and health disparities arise as a result of structural and social determinants stemming from a socioeconomic and political environment that produces systemic discrimination, breaches human rights, and influences their unequal socioeconomic position in society. These social determinants influence SCY's intermediary determinants of health resulting in a lack of basic material needs, being precariously housed or homeless, engaging in substance use and misuse, and experiencing several psychosocial stressors, all of which shape health outcomes and equity for this population.

CONCLUSIONS

SCY in Kenya experience social and health inequities that are avoidable and unjust. These social and health disparities arise as a result of structural and social determinants of health inequities stemming from the socioeconomic and political context in Kenya that produces systemic discrimination and influences SCYs' unequal socioeconomic position in society. Remedial action to reverse human rights contraventions and to advance health equity through action on SDH for SCY in Kenya is urgently needed.

Computed tomographic indications for occult skull fractures in paediatric head trauma diagnosed at the time of wound closure under general anaesthesia

Children with head injuries commonly present to the emergency department with forehead lacerations, and are frequently referred to the oral and maxillofacial team. Assessing the Glasgow coma scale (GCS) and neurological status of these patients is particularly challenging and there remains marked ambiguity regarding the use of computed tomographic (CT) imaging in children who have no obvious signs of traumatic brain injury. We present a case series of three patients who presented to our unit with forehead lacerations following a fall. All had a normal GCS, no obvious neurological signs, and all were listed for wound closure under general anaesthesia. Intraoperatively they were found to have underlying skull fractures that necessitated emergency CT whilst under general anaesthesia. Retrospective analysis was performed. Current guidelines and the literature were reviewed to identify factors that may help to identify occult skull fractures in the context of paediatric head trauma. Despite the subsequent discovery of skull fractures under general anaesthesia, none of our patients would have satisfied the present absolute indications for CT in the current guidelines. A number of helpful factors are not common in the UK guidelines but are present in others, including the presence of an appreciable haematoma and lacerations greater than 5 cm, amongst others. The assessment of paediatric patients with head trauma often remains a challenge when assessing for features such as headache, focal neurology, and amnesia. A high index of suspicion, formal examination under anaesthesia, and communication with the radiology department, are imperative if we are to avoid missing an occult injury that could potentially result in brain injury.

Dissemination of Information About Climate Change by State and Local Public Health Departments: United States, 2019-2020

Objectives. To determine if and how state and local public health departments present information about climate change on their Web sites, their most public-facing platform.Methods. We collected data from every functioning state (n = 50), county (n = 2090), and city (n = 585) public health department Web site in the United States in 2019 and 2020. We analyzed data for presence and type of climate-related content and to determine whether there existed clear ways to find climate change information. We analyzed Web sites providing original content about climate change for explanatory or attributional language.Results. Fewer than half (40%) of state health department Web sites, and only 1.6% of county and 3.9% of city Web sites, provided clear ways to find climate change information, whether through provision of original content or links to external agencies' Web sites. Among Web sites providing original content, 48% provided no explanation of climate change causes.Conclusions. National and global public health associations have identified climate change as a public health emergency, but most state and local public health departments are not delivering that message. These departments must be better supported to facilitate dissemination of reliable, scientific information about climate change and its effects on health.

Unravelling the utility of modern sulfonylureas from cardiovascular outcome trials and landmark trials: expert opinion from an international panel

AIM

The primary objective of this review is to develop practice-based expert group opinions on the cardiovascular (CV) safety and utility of modern sulfonylureas (SUs) in cardiovascular outcome trials (CVOTs).

BACKGROUND

The United States Food and Drug Administration issued new guidance to the pharmaceutical industry in 2008 regarding the development of new antihyperglycemic drugs. The guidance expanded the scope for the approval of novel antihyperglycemic drugs by mandating CVOTs for safety. A few long-term CVOTs on dipeptidyl peptidase 4 inhibitors, glucagon-like peptide 1 receptor agonists, and sodium-glucose cotransporter 2 inhibitors have been completed, while others are ongoing. SUs, which constitute one of the key antihyperglycemic agents used for the management of type 2 diabetes mellitus (T2DM), have been used as comparator agents in several CVOTs. However, the need for CVOTs on modern SUs remains debatable. In this context, a multinational group of endocrinologists convened for a meeting and discussed the need for CVOTs of modern SUs to evaluate their utility in the management of patients with T2DM. At the meeting, CVOTs of modern SUs conducted to date and the hypotheses derived from the results of these trials were discussed.

REVIEW RESULTS

The expert group analyzed the key trials emphasizing the CV safety of modern SUs and also reviewed the results of various CVOTs in which modern SUs were used as comparators. Based on literature evidence and individual clinical insights, the expert group opined that modern SUs are cardiosafe and that since they have been used as comparators in other CVOTs, CVOTs of SUs are not required.

CONCLUSION

Modern SUs can be considered a cardiosafe option for the management of patients with diabetes mellitus and CV disease; thus CVOTs among individuals with T2DM are not required.

Genitourinary cancer management during a severe pandemic: Utility of rapid communication tools and evidence-based guidelines

OBJECTIVES

To determine the usefulness of social media for rapid communication with experts to discuss strategies for prioritization and safety of deferred treatment for urologic malignancies during COVID-19 pandemic, and to determine whether the discourse and recommendations made through discussions on social media (Twitter) were consistent with the current peer-reviewed literature regarding the safety of delayed treatment.

METHODS

We reviewed and compiled the responses to our questions on Twitter regarding the management and safety of deferred treatment in the setting of COVID-19 related constraints on non-urgent care. We chronicled the guidance published on this subject by various health authorities and professional organizations. Further, we analyzed peerreviewed literature on the safety of deferred treatment (surgery or systemic therapy) to make made evidence-based recommendations.

RESULTS

Due to the rapidly changing information about epidemiology and infectious characteristics of COVID-19, the health authorities and professional societies guidance required frequent revisions which by design take days or weeks to produce. Several active discussions on Twitter provided real-time updates on the changing landscape of the restrictions being placed on non-urgent care. For separate discussion threads on prostate cancer and bladder cancer, dozens of specialists with expertise in treating urologic cancers could be engaged in providing their expert opinions as well as share evidence to support their recommendations. Our analysis of published studies addressing the safety and extent to which delayed cancer care does not compromise oncological outcome revealed that most prostate cancer care and certain aspects of the bladder and kidney cancer care can be safely deferred for 2-6 months. Urothelial bladder cancer and advanced kidney cancer require a higher priority for timely surgical care. We did not find evidence to support the idea of using nonsurgical therapies, such as hormone therapy for prostate cancer or chemotherapy for bladder cancer for safer deferment of previously planned surgery. We noted that the comments and recommendations made by the participants in the Twitter discussions were generally consistent with our evidence-based recommendations for safely postponing cancer care for certain types of urologic cancers.

CONCLUSION

The use of social media platforms, such as Twitter, where the comments and recommendations are subject to review and critique by other specialists is not only feasible but quite useful in addressing the situations requiring urgent resolution, often supported by published evidence. In circumstances such as natural disasters, this may be a preferable approach than the traditional expert panels due to its ability to harness the collective intellect to available experts to provide responses and solutions in real-time. These real-time communications via Twitter provided sound guidance which was readily available to the public and participants, and was generally in concordance with the peerreviewed data on safety of deferred treatment.