Revisiting the "Weekend Effect" on Adult and Pediatric Liver and Kidney Offer Acceptance

BACKGROUND Weekends can impose resource and manpower constraints on hospitals. Studies using data from prior allocation schemas showed increased adult organ discards on weekends. We examined the impact of day of the week on adult and pediatric organ acceptance using contemporary data. MATERIAL AND METHODS Retrospective analysis of UNOS-PTR match-run data of all offers for potential kidney and liver transplant from 1/1/2016 to 7/1/2021 were examined to study the rate at which initial offers were declined depending on day of the week. Risk factors for decline were also evaluated. RESULTS Of the total initial adult/pediatric liver and kidney offers, the fewest offers occurred on Mondays and Sundays. The decline rate for adult/pediatric kidneys was highest on Saturdays and lowest on Tuesdays. The decline rate for adult livers was highest on Saturday and lowest on Wednesday. In contrast, the decline rate for pediatric livers was highest on Tuesdays and lowest on Wednesdays. Independent risk factors from multivariate analysis of the adult/pediatric kidney and liver decline rate were analyzed. The weekend offer remains an independent risk factor for adult kidney and liver offer declines, but for pediatric offers, these were not significant independent risk factors. CONCLUSIONS Although allocation systems have changed, and the availability of kidneys and livers have increased in the USA over the past 5 years, the weekend effect remains significant for adult liver and kidney offers for declines. Interestingly, the weekend effect was not seen for pediatric liver and kidney offers.

Conversion therapy for intrahepatic cholangiocarcinoma and tumor downsizing to increase resection rates: A systematic review

Intrahepatic cholangiocarcinoma (ICC) is a devastating malignant neoplasm with dismal outcomes. Several therapeutic modalities have been used with variable success to downsize these tumors for resection. Neoadjuvant therapy such as chemoembolization and radioembolization offer promising options to manage tumor burden prior to resection. A systematic review of the literature was performed with a focus on conversion therapy for ICC and tumor downsizing to increase resection rates among patients who have an initially unresectable tumor. Of 132 patients with initially unresectable ICC, we identified 27 who underwent conversion therapy with surgical resection. Adequate tumor downsizing was achieved with chemotherapy, chemoembolization, radioembolization, or combination thereof. Although negative tumor margins were possible in some patients, recurrence rates and survival outcomes were inconsistently reported. Twenty-three of 27 patients were alive at last reported follow-up. Conversion therapy for initially unresectable ICC may offer adequate tumor downsizing for resection.

Routine versus difficult cholecystectomy: using predictive analytics to assess patient outcomes

BACKGROUND

The American College of Surgeons National Surgical Quality Improvement Program^® (NSQIP) Surgical Risk. Calculator (SRC) estimates postoperative outcomes. The aim of this study was to develop and validate a specific predictive outcomes model for cholecystectomy procedures.

METHODS

Patients who underwent cholecystectomy between 2008 and 2016 and were deemed too high risk for acute care general surgery (GS) and had surgery performed by the Division of Hepatopancreatobiliary Surgery (HPB) were identified. Outcomes of the HPB cholecystectomies were matched against cholecystectomies performed by GS. New predictive models for postoperative outcomes were constructed. Area under the curve was used to assess predictive accuracy for both models and internal validation was performed using bootstrap logistic regression.

RESULTS

A total of 169/934 (18%) cholecystectomies were identified as too high risk for GS. These 169 patients were matched with 126 patients who had cholecystectomy performed by GS. For GS and HPB cholecystectomies, the proposed model demonstrated better discriminative ability compared to the SRC based on ROC curves (proposed model: 0.589-0.982; SRC: 0.570-0.836) for each of the predicted outcomes.

CONCLUSION

For patients undergoing cholecystectomy, customized models are superior for predicting individual perioperative risk and allow more accurate, patient-specific delivery of care.

Developing and validating a center-specific preoperative prediction calculator for risk of outcomes following major hepatectomy procedures

BACKGROUND

The American College of Surgeons NSQIP^® Surgical Risk Calculator (SRC) was developed to estimate postoperative outcomes. Our goal was to develop and validate an institution-specific risk calculator for patients undergoing major hepatectomy at Carolinas Medical Center (CMC).

METHODS

Outcomes generated by the SRC were recorded for 139 major hepatectomies performed at CMC (2008-2016). Novel predictive models for seven postoperative outcomes were constructed and probabilities calculated. Brier score and area under the curve (AUC) were employed to assess accuracy. Internal validation was performed using bootstrap logistic regression. Logistic regression models were constructed using bivariate and multivariate analyses.

RESULTS

Brier scores showed no significant difference in the predictive ability of the SRC and CMC model. Significant differences in the discriminative ability of the models were identified at the individual level. Both models closely predicted 30-day mortality (SRC AUC: 0.867; CMC AUC: 0.815). The CMC model was a stronger predictor of individual postoperative risk for six of seven outcomes (SRC AUC: 0.531-0.867; CMC AUC: 0.753-0.970).

CONCLUSION

Institution-specific models provide superior outcome predictions of perioperative risk for patients undergoing major hepatectomy. If properly developed and validated, institution-specific models can be used to deliver more accurate, patient-specific care.

Reliability of adverse symptom event reporting by clinicians

PURPOSE

Adverse symptom event reporting is vital as part of clinical trials and drug labeling to ensure patient safety and inform risk-benefit decision making. The purpose of this study was to assess the reliability of adverse event reporting of different clinicians for the same patient for the same visit.

METHODS

A retrospective reliability analysis was completed for a sample of 393 cancer patients (42.8% men; age 26-91, M = 62.39) from lung (n = 134), prostate (n = 113), and Ob/Gyn (n = 146) clinics. These patients were each seen by two clinicians who independently rated seven Common Terminology Criteria for Adverse Events (CTCAE) symptoms. Twenty-three percent of patients were enrolled in therapeutic clinical trials.

RESULTS

The average time between rater evaluations was 68 min. Intraclass correlation coefficients were moderate for constipation (0.50), diarrhea (0.58), dyspnea (0.69), fatigue (0.50), nausea (0.52), neuropathy (0.71), and vomiting (0.46). These values demonstrated stability over follow-up visits. Two-point differences, which would likely affect treatment decisions, were most frequently seen among symptomatic patients for constipation (18%), vomiting (15%), and nausea (8%).

CONCLUSION

Agreement between different clinicians when reporting adverse symptom events is moderate at best. Modification of approaches to adverse symptom reporting, such as patient self-reporting, should be considered.

Using confirmatory factor analysis to evaluate construct validity of the Brief Pain Inventory (BPI)

CONTEXT

The Brief Pain Inventory (BPI) is a frequently used instrument designed to assess the patient-reported outcome of pain. The majority of factor analytic studies have found a two-factor (i.e., pain intensity and pain interference) structure for this instrument; however, because the BPI was developed with an a priori hypothesis of the relationship among its items, it follows that construct validity investigations should use confirmatory factor analysis (CFA).

OBJECTIVES

The purpose of this work was to establish the construct validity of the BPI using a CFA framework and demonstrate factorial invariance using a range of demographic variables.

METHODS

A retrospective CFA was completed in a sample of individuals diagnosed with HIV/AIDS and cancer (n=364; 63% male; age 21-92 years, M=51.80). A baseline one-factor model was compared against two-factor and three-factor models (i.e., pain intensity, activity interference, and affective interference) that were developed based on the hypothetical design of the instrument.

RESULTS

Fit indices for the three-factor model were statistically superior when compared with the one-factor model and marginally better when compared with the two-factor model. This three-factor structure was found to be invariant across disease, age, and ethnicity groups.

CONCLUSION

The results of this study provide evidence to support a three-factor representation of the BPI, and the originally hypothesized two-factor structure. Such findings will begin to provide clinical trialists, pharmaceutical sponsors, and regulators with confidence in the psychometric properties of this instrument when considering its inclusion in clinical research.

Burden of Sexual Dysfunction in Women with Breast Cancer

Background: Sexual dysfunction is reported after chemotherapy and endocrine therapies, and causes a substantial burden on women with breast cancer. However, the prevalence and severity of sexual dysfunction in women undergoing therapy for both local and metastatic disease is not well defined. Improved understanding of sexual dysfunction may facilitate enhanced treatment and interventions in patients with breast cancer undergoing active treatment, and in survivors of this disease.Methods: We developed a survey that includes a previously validated questionnaire, the female sexual function index (FSFI), as well as an established measure of health-related quality of life (the EuroQol EQ-5D), and disease-specific items to characterize sexual dysfunction and its causes based on literature review and expert consultations. Anonymous administration of the surveys was conducted in outpatient clinic waiting areas of the Breast Cancer Center at Memorial Sloan-Kettering Cancer Center (MSKCC) and two community centers, under an IRB waiver of consent.Results: During November 2008 through May 2009, 509 women undergoing treatment for breast cancer of all stages were each queried once. The mean age was 51 (range 26-91). 87% reported current or past hormonal treatment, and 82% reported current or past chemotherapy (76% adjuvant; 24% for metastatic disease). Sexual dysfunction attributed to breast cancer or its treatment, defined as an FSFI score <26, was reported by 76% of respondents. Among these women, 316/386 (82%) patients considered their sexual symptoms to be bothersome, with 247/386 (64%) noting moderate or severe levels of bother (score >=5/10). Patients attributed their sexual dysfunction to chemotherapy in 318/373 (85%) of cases; to hormonal therapy in 221/298 (74%) of cases; and to surgery in 331/442 (66%) of cases. Other reported contributors to sexual dysfunction include a new diagnosis of breast cancer by 81% of respondents, anxiety by 82% of respondents, and change in relationship with a partner by 55% of respondents.Conclusion: Sexual dysfunction is prevalent in women treated for breast cancer and should be discussed with patients as a potential adverse effect of therapy. Assessment of sexual symptoms throughout treatment and beyond may facilitate the use of potential interventions such as lubricants, dilators, treatment modification, topical estrogens, and counseling. Future work includes a longitudinal prospective trial to further characterize the etiologies of these symptoms and a randomized controlled trial to evaluate interventions for sexual dysfunction.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 1056.

Pain and analgesic use in men with metastatic prostate cancer

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Background: Pain is an important endpoint in metastatic prostate cancer and was the basis for the 1996 FDA approval of mitoxantrone. Standards for pain assessment have evolved, and a 2006 draft FDA guidance provides new recommendations for patient- reported outcomes. Contemporary palliation models generally require pain reduction starting from baseline worst pain scores of ≥4/10, and progression models require a sufficient proportion of patients’ pain scores to worsen in order to assure an adequate effect size. The prevalence and distribution of pain severity at specific points in the prostate cancer disease continuum are not well defined. Consequently, it is unclear if sufficient numbers of patients are available to conduct prospective studies using pain palliation or prevention as primary endpoints. Methods: A questionnaire that includes the Brief Pain Inventory and additional pain/analgesia items was developed as a collaboration between the DOD/PCF-supported Prostate Cancer Clinical Trials Consortium (PCCTC) and FDA Study Endpoints and Labeling Design (SEALD) team. IRB waivers were obtained for anonymous administration at 5 PCCTC institutions (Sloan-Kettering, Duke, Johns Hopkins, Anderson, OHSU). Administration is ongoing. Results: Between August-December 2008, 325 men with prostate cancers representing different disease states being seen in outpatient clinics of participating centers were each queried once. Median age was 70 (range 49–87). More than half (n=175) self-reported metastatic disease, including 129 with bone metastases. Among those with bone metastases, 76 (59%) reported experiencing any level of pain in the last week; 49 (38%) reported a worst pain score ≥4/10 of which 38 (78%) used analgesics over the past week and 31 (63%) used daily analgesia. In addition, 70 of the 76 (92%) noted that their pain interfered with work, sleep, or enjoyment of life, with 25 (33%) noting severe interference. Among the 49 patients with pain scores ≥4/10, current or past docetaxel use was reported by 32 (65%), androgen deprivation therapy by 47 (96%), and 28 (57%) had been or were currently enrolled in a clinical trial. Conclusions: Pain is sufficiently prevalent in men with metastatic prostate cancer to enable prospective assessment of palliation endpoints in clinical trials.

No significant financial relationships to disclose.

Sexual dysfunction in women with breast cancer: Prevalence and severity

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Background: Sexual dysfunction (SD) is reported after chemotherapy and endocrine therapies, and causes a substantial burden on women with breast cancer. However, the prevalence and severity of SD in this population is not well defined. Improved understanding of SD may allow for enhanced treatment and interventions in patients with breast cancer undergoing active treatment, and in survivors of this disease. Methods: We developed a survey that includes a previously validated questionnaire, the female sexual function index (FSFI), and disease-specific items to characterize SD and its causes based on literature review and expert consultations. Anonymous administration of the surveys was conducted in outpatient clinic waiting areas of the M64/Breast Center Memorial Sloan-Kettering Cancer Center (MSKCC), under an IRB waiver of consent. Results: During November-December 2008, 100 women with breast cancer of any stage were each queried once. The mean age was 52 (range 26–75). 68% reported current or past hormonal treatment, and 63% reported current or past chemotherapy (84% adjuvant; 16% for metastatic disease). SD attributed to breast cancer or its treatment, defined as an FSFI score <26, was reported by 75% of respondents. Among these women, severe symptoms were noted by 38/75 (51%), and moderate by 37/75 (49%). 87/95 (92%) patients considered their sexual symptoms to be bothersome, with 59/95 (62%) noting moderate or severe levels of bother (score >=5/10). Patients attributed their SD to chemotherapy in 52/63 (83%) of cases; to hormonal therapy in 56/68 (82%) of cases; and to surgery in 68/92 (74%) of cases. Other contributors to SD were felt to include anxiety by 83% of respondents, and change in relationship with a partner by 46%. Conclusions: SD is prevalent in women treated for breast cancer and should be discussed with patients as a potential adverse effect of therapy. Assessment of sexual symptoms throughout treatment and beyond may facilitate the use of potential interventions such as lubricants, dilators, treatment modification, topical estrogens, and counseling. A longitudinal prospective trial is planned to further characterize the etiologies of these symptoms.

No significant financial relationships to disclose.

[@HOME is a new Eu-Project in Tele Home care]

@Home is a robust platform for real-time remote monitoring of patients at their home by doctors at the hospital. Health monitoring sensors, which have the capability to measure quick and easy vital parameters such as blood pressure, pulse rate, temperature, oxygen saturation (SpO2), as well as ECG 12 leads are used. Additionally, an advantage of the platform is that all the sensors are wearable and the patient is able to walk around indoors or outdoors. Moreover, the sensors are able to convey the recorded data over Bluetooth, a short-range wireless communication, to any Bluetooth enabled device such as Desktop computer or a Pocket PC.