Abstract
BACKGROUND
Maximizing extent of resection (EOR) improves outcomes in adults with World Health Organization (WHO) grade II low-grade gliomas (LGG). However, recent studies demonstrate that ...LGGs bearing a mutation in the isocitrate dehydrogenase 1 (IDH1) gene are a distinct molecular and clinical entity. It remains unclear whether maximizing EOR confers an equivalent clinical benefit in IDH mutated (mtIDH) and IDH wild-type (wtIDH) LGGs.
OBJECTIVE
To assess the impact of EOR on malignant progression-free survival (MPFS) and overall survival (OS) in mtIDH and wtIDH LGGs.
METHODS
We performed a retrospective review of 74 patients with WHO grade II gliomas and known IDH mutational status undergoing resection at a single institution. EOR was assessed with quantitative 3-dimensional volumetric analysis. The effect of predictor variables on MPFS and OS was analyzed with Cox regression models and the Kaplan–Meier method.
RESULTS
Fifty-two (70%) mtIDH patients and 22 (30%) wtIDH patients were included. Median preoperative tumor volume was 37.4 cm3; median EOR of 57.6% was achieved. Univariate Cox regression analysis confirmed EOR as a prognostic factor for the entire cohort. However, stratifying by IDH status demonstrates that greater EOR independently prolonged MPFS and OS for wtIDH patients (hazard ratio HR = 0.002 95% confidence interval {CI} 0.000-0.074 and HR = 0.001 95% CI 0.00-0.108, respectively), but not for mtIDH patients (HR = 0.84 95% CI 0.17-4.13 and HR = 2.99 95% CI 0.15-61.66, respectively).
CONCLUSION
Increasing EOR confers oncologic and survival benefits in IDH1 wtLGGs, but the impact on IDH1 mtLGGs requires further study.
Given the growing incidence of infective endocarditis (IE), understanding the risks and benefits of valvular surgery is critical. This decision is particularly complex for the 1 in 10 cases ...complicated by intracranial hemorrhage (ICH). While guideline recommendations currently favor early surgery in general, delayed intervention of at least 4 weeks is still recommended for patients with ICH. To date, there are no randomized controlled trials that inform management of patients with an indication for surgery but concomitant ICH, and even reported observational data are rare. This paper reviews the current literature on timing of surgery with a specific focus on cases of ICH. It emphasizes a growing body of literature challenging the current paradigm that surgery within 4 weeks is associated with neurologic deterioration and high mortality rates by demonstrating favorable outcomes for patients with pre-operative ICH who undergo early valvular surgery. Based on these data, we propose a practical management algorithm to facilitate decisions on surgical timing in these complicated cases. Since more rigorous evidence may never be available, clinicians should make patient-specific surgical timing decisions that attempt to balance the competing risks of neurologic versus cardiac complications.
Consumer wearable devices with health and wellness features are increasingly common and may enhance disease detection and management. Yet studies informing relationships between wearable device use, ...attitudes toward device data, and comprehensive clinical profiles are lacking.
WATCH-IT (Wearable Activity Tracking for Comprehensive Healthcare-Integrated Technology) studied adults receiving longitudinal primary or ambulatory cardiovascular care in the Mass General Brigham health care system from January 2010 to July 2021. Participants completed a 20-question electronic survey about perceptions and use of consumer wearable devices, with responses linked to electronic health records. Multivariable logistic regression was used to identify factors associated with device use. Among 214 992 individuals receiving longitudinal primary or cardiovascular care with an active electronic portal, 11 121 responded (5.2%). Most respondents (55.8%) currently used a wearable device, and most nonusers (95.3%) would use a wearable if provided at no cost. Although most users (70.2%) had not shared device data with their doctor previously, most believed it would be very (20.4%) or moderately (34.4%) important to share device-related health information with providers. In multivariable models, older age (odds ratio OR, 0.80 per 10-year increase 95% CI, 0.77-0.82), male sex (OR, 0.87 95% CI, 0.80-0.95), and heart failure (OR, 0.75 95% CI, 0.63-0.89) were associated with lower odds of wearable device use, whereas higher median income (OR, 1.08 per 1-quartile increase 95% CI, 1.04-1.12) and care in a cardiovascular medicine clinic (OR, 1.17 95% CI, 1.05-1.30) were associated with greater odds of device use.
Among patients in primary and cardiovascular medicine clinics, consumer wearable device use is common, and most users perceive value in wearable health data.
Physical activity is regarded as favorable to health but effects across the spectrum of human disease are poorly quantified. In contrast to self-reported measures, wearable accelerometers can provide ...more precise and reproducible activity quantification. Using wrist-worn accelerometry data from the UK Biobank prospective cohort study, we test associations between moderate-to-vigorous physical activity (MVPA) - both total MVPA minutes and whether MVPA is above a guideline-based threshold of ≥150 min/week-and incidence of 697 diseases using Cox proportional hazards models adjusted for age, sex, body mass index, smoking, Townsend Deprivation Index, educational attainment, diet quality, alcohol use, blood pressure, anti-hypertensive use. We correct for multiplicity at a false discovery rate of 1%. We perform analogous testing using self-reported MVPA. Among 96,244 adults wearing accelerometers for one week (age 62 ± 8 years), MVPA is associated with 373 (54%) tested diseases over a median 6.3 years of follow-up. Greater MVPA is overwhelmingly associated with lower disease risk (98% of associations) with hazard ratios (HRs) ranging 0.70-0.98 per 150 min increase in weekly MVPA, and associations spanning all 16 disease categories tested. Overall, associations with lower disease risk are enriched for cardiac (16%), digestive (14%), endocrine/metabolic (10%), and respiratory conditions (8%) (chi-square p < 0.01). Similar patterns are observed using the guideline-based threshold of ≥150 MVPA min/week. Some of the strongest associations with guideline-adherent activity include lower risks of incident heart failure (HR 0.65, 95% CI 0.55-0.77), type 2 diabetes (HR 0.64, 95% CI 0.58-0.71), cholelithiasis (HR 0.61, 95% CI 0.54-0.70), and chronic bronchitis (HR 0.42, 95% CI 0.33-0.54). When assessed within 456,374 individuals providing self-reported MVPA, effect sizes for guideline-adherent activity are substantially smaller (e.g., heart failure HR 0.84, 95% CI 0.80-0.88). Greater wearable device-based physical activity is robustly associated with lower disease incidence. Future studies are warranted to identify potential mechanisms linking physical activity and disease, and assess whether optimization of measured activity can reduce disease risk.
Abstract
BACKGROUND:
Survival duration and prognostic factors in adult high-grade glioma have been comprehensively analyzed, but less is known about factors contributing to overall survival (OS) and ...progression-free survival (PFS) in pediatric patients.
OBJECTIVE:
To identify these factors in the pediatric population.
METHODS:
We retrospectively reviewed institutional databases evaluating all patients ⩽21 years with high-grade glioma treated between 1988 and 2010. Kaplan-Meier curves and log-rank statistics were used to compare groups univariately. Multivariate analyses were completed using Cox proportional hazards regression models.
RESULTS:
Ninety-seven patients were identified with a median age of 11 years. Median OS was 1.7 years, and median PFS was 272 days. Location was significant for OS (P > .001). Patients with gross total resection (GTR) had a median OS of 3.4 years vs 1.6 years for subtotal resection and 1.3 years for biopsy patients (P > .001). Female patients had improved OS (P = .01). Female patients with GTR had a mean OS of 8.1 years vs 2.4 years for male patients with GTR and 1.4 years for all other female patients and male patients (P = .001). PFS favored patients ⩽3 and ≥13 years and females (P = .003 and .001).
CONCLUSION:
OS was significantly correlated with the location of the tumor and the extent of resection. GTR significantly improved overall survival for both glioblastoma multiforme and anaplastic astrocytoma patients, and female patients showed a much larger survival benefit from GTR than male patients.
As medical students' interest in surgical fields wanes, we investigated the impact of a preclinical surgical exposure program on students’ attitudes toward pursuing surgical careers.
This is a ...prospective longitudinal study of PreOp, a preclinical rotation-based surgical exposure program for first-year medical students, from 2013 to 2017. Surveys assessed PreOp rotation quality, students’ surgical interest, and students’ self-reported preparedness for the surgical clerkship. Surgery clerkship grades were obtained as a measure of surgical competency and compared to class-wide peers. Match data was collected and compared to class-wide peers as well as historical norms.
NewYork-Presbyterian Hospital/Weill Cornell Medicine, New York, NY; tertiary care center.
Fifty-four PreOp students from 2013 to 2017.
Fifty-four PreOp participants were recruited. After completing the PreOp program, 66.7% of PreOp students reported being very likely to apply into a surgical field compared to 29.4% when they started medical school. Ultimately, 71.4% of PreOp students versus 21.7% of non-PreOp class-wide peers matched into surgical fields (p < 0.001). From the preceding 5 match years before PreOp implementation, 21.4% of all students matched into surgical fields compared to 25.6% of all students after PreOp was started (p = 0.26). In terms of preparedness, 75% of PreOp students reported feeling more prepared for the third-year surgery clerkship than their non-PreOp peers after the second year of medical school. PreOp students were significantly more likely than non-PreOp class-wide peers to receive honors in the surgery clerkship when controlling for cumulative clerkship GPA (p = 0.012, adjusted odds ratio = 5.5 95% confidence interval 1.5-22.1).
Hands-on preclinical surgical exposure was associated with student-reported increased surgical interest that was maintained longitudinally and reflected in significantly increased surgical matches relative to non-PreOp class-wide peers. This study uniquely demonstrates that participation in PreOp was also associated with increased self-reported surgical preparedness and significantly higher surgery clerkship grades relative to overall academic performance.
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