Faculty Bibliography

BACKGROUND AND AIMS/OBJECTIVE:Portal vein thrombosis (PVT) is associated with increased mortality post-transplant, but treatment of the clot is not definitively associated with improvement in mortality. We aimed to assess the effect of anticoagulation (AC), transjugular intrahepatic portosystemic shunt (TIPS), or best supportive care only (SCO) as treatment options in patients with PVT and cirrhosis. METHODS:This was a retrospective controlled cohort study from a large urban health system. Patients with cirrhosis and PVT were identified and analyzed based on treatment provided (1) AC, (2) TIPS, and (3) SCO. Outcomes included patent portal vein at the end of follow-up and overall mortality. RESULTS:150 patients on AC, 93 who underwent TIPS, and 172 who received SCO were analyzed. Final portal vein (PV) patency was not significantly different by treatment group in those with partial obstruction at presentation (p = 0.64), while any treatment improved final patency over SCO in those presenting with complete obstruction (p = 0.01). Rate of survival, transplant-free survival, and successful liver transplantation were not different between treatment groups. CONCLUSION/CONCLUSIONS:In our cohorts, treatment of PVT versus SCO showed no impact on survival in those presenting with partial obstruction of the PV. In those with complete obstruction, any treatment was more effective than SCO in achieving patency of the PV, but overall survival was no different. PVT may not be a pathologic mechanism that causes worsening of liver disease but may be an event in the progression that in itself is not directly responsible for worsening liver function.

Digital therapeutics have evolved rapidly with technological advances in healthcare. Despite their increasing use, gaps remain in understanding their regulatory frameworks, integration, and efficacy for conditions like substance use disorder, insomnia, attention deficit hyperactivity disorder, and post-traumatic stress disorder. This study evaluates FDA-approved digital therapeutics and explores their potential to revolutionize psychiatric treatments amid ongoing technological and regulatory changes. We conducted a comprehensive review of major databases, focusing on articles published up to January 2024 on FDA-approved digital therapeutics. We excluded non-English articles and those lacking empirical data or focusing on non-FDA-approved therapeutics. Our analysis covered regulatory compliance, clinical outcomes, and integration with traditional treatments. The review of nine FDA-cleared digital therapeutics revealed benefits like improved treatment accessibility and potential reductions in healthcare costs. For example, Somryst, a cognitive-behavioral therapy-based treatment for insomnia, showed that over 40 percent of users overcame chronic insomnia, and 60 percent experienced improvements without adverse effects. However, challenges remain, including low provider adoption, inadequate insurance coverage, and high user dropout rates. While digital therapeutics enhance accessibility, they face regulatory challenges, reimbursement issues, and the need for robust clinical evidence. Success depends on collaboration among stakeholders to demonstrate value, ensure safety, and integrate them into existing healthcare systems.

OBJECTIVE:In the ENGOT-EN6-NSGO/GOG3031/RUBY trial, dostarlimab+carboplatin-paclitaxel demonstrated significant improvement in progression free survival and a positive trend in overall survival compared with placebo+carboplatin-paclitaxel, with manageable toxicity, in patients with primary advanced or recurrent endometrial cancer. Here we report on patient-reported outcomes in the mismatch repair-deficient/microsatellite instability-high population, a secondary endpoint in the trial. METHODS:Patients were randomized 1:1 to dostarlimab+carboplatin-paclitaxel or placebo+carboplatin-paclitaxel every 3 weeks for 6 cycles followed by dostarlimab or placebo monotherapy every 6 weeks for ≤3 years or until disease progression. Patient-reported outcomes, assessed with the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 and Endometrial Cancer Module, were prespecified secondary endpoints. A mixed model for repeated measures analysis, a prespecified exploratory analysis, was conducted to generate least-squares means to compare between-treatment differences while adjusting for correlations across multiple time points within a patient and controlling for the baseline value. Results are provided with 2-sided, nominal p values. RESULTS:Of 494 patients enrolled, 118 were mismatch repair-deficient/microsatellite instability-high. In this population, mean change from baseline to end of treatment showed visual improvements in global quality of life (QoL), emotional and social function, pain, and back/pelvis pain for dostarlimab+carboplatin-paclitaxel. Meaningful differences (least-squares mean [standard error]) favoring the dostarlimab arm were reported for change from baseline to end of treatment for QoL (14.7 [5.45]; p=0.01), role function (12.7 [5.92]); p=0.03), emotional function (14.3 [4.92]; p<0.01), social function (13.5 [5.43]; p=0.01), and fatigue (-13.3 [5.84]; p=0.03). CONCLUSIONS:Patients with mismatch repair-deficient/microsatellite instability-high primary advanced or recurrent endometrial cancer receiving dostarlimab+carboplatin-paclitaxel demonstrated improvements in several QoL domains over patients receiving placebo+carboplatin-paclitaxel. The observed improvements in progression free survival and overall survival while improving or maintaining QoL further supports dostarlimab+carboplatin-paclitaxel as a standard of care in this setting. TRIAL REGISTRATION/BACKGROUND:ClinicalTrials.gov NCT03981796.

OBJECTIVE:Distinguishing post-COVID-19 residual abnormalities from interstitial lung abnormalities (ILA) on CT can be challenging if clinical information is limited. This study aimed to evaluate the diagnostic performance of radiologists in distinguishing post-COVID-19 residual abnormalities from ILA. METHODS:This multi-reader, multi-case study included 60 age- and sex-matched subjects with chest CT scans. There were 40 cases of ILA (20 fibrotic and 20 non-fibrotic) and 20 cases of post-COVID-19 residual abnormalities. Fifteen radiologists from multiple nations with varying levels of experience independently rated suspicion scores on a 5-point scale to distinguish post-COVID-19 residual abnormalities from fibrotic ILA or non-fibrotic ILA. Interobserver agreement was assessed using the weighted κ value, and the scores of individual readers were compared with the consensus of all readers. Receiver operating characteristic curve analysis was conducted to evaluate the diagnostic performance of suspicion scores for distinguishing post-COVID-19 residual abnormalities from ILA and for differentiating post-COVID-19 residual abnormalities from both fibrotic and non-fibrotic ILA. RESULTS:Radiologists' diagnostic performance for distinguishing post-COVID-19 residual abnormalities from ILA was good (area under the receiver operating characteristic curve (AUC) range, 0.67-0.92; median AUC, 0.85) with moderate agreement (κ = 0.56). The diagnostic performance for distinguishing post-COVID-19 residual abnormalities from non-fibrotic ILA was lower than that from fibrotic ILA (median AUC = 0.89 vs. AUC = 0.80, p = 0.003). CONCLUSION/CONCLUSIONS:Radiologists demonstrated good diagnostic performance and moderate agreement in distinguishing post-COVID-19 residual abnormalities from ILA, but careful attention is needed to avoid misdiagnosing them as non-fibrotic ILA. KEY POINTS/CONCLUSIONS:Question How good are radiologists at differentiating interstitial lung abnormalities (ILA) from changes related to COVID-19 infection? Findings Radiologists had a median AUC of 0.85 in distinguishing post-COVID-19 abnormalities from ILA with moderate agreement (κ = 0.56). Clinical relevance Radiologists showed good diagnostic performance and moderate agreement in distinguishing post-COVID-19 residual abnormalities from ILA; nonetheless, caution is needed in distinguishing residual abnormalities from non-fibrotic ILA.

BACKGROUND AND OBJECTIVES/OBJECTIVE:Iatrogenic cerebrovascular injury can cause intracranial hemorrhage and pseudoaneurysm formation, putting patients at high risk for postoperative bleeding. No consensus for management exists. This study describes endovascular treatment of these acute injuries with flow diverter stents. METHODS:Electronic medical records were retrospectively reviewed for injury type and etiology, timing of diagnosis, and endovascular management, including antiplatelet regimens, embolization results, and clinical outcome. RESULTS:Six patients were included. Three suffered an injury to the internal carotid artery, 1 suffered an injury to the left anterior cerebral artery, 1 suffered an injury to the right posterior cerebral artery, and 1 suffered an injury to the basilar artery. Four of the 6 injuries occurred during attempted tumor resection, 1 occurred during cerebrospinal fluid leak repair, and 1 occurred during an ophthalmic artery aneurysm clipping. All injuries resulted in pseudoaneurysm formation. Four were immediately detected on angiography; 2 were initially negative on imaging. Five were treated with a pipeline embolization device, and 1 was treated with a Silk Vista Baby. Two were treated with 2 pipeline embolization devices telescopically overlapped across the pseudoaneurysm. All devices deployed successfully. No pseudoaneurysm recurrence or rebleeding occurred. No parent artery occlusion or stenosis was observed, and complete pseudoaneurysm occlusion was observed in 4 patients (in 2 patients, follow-up imaging could not be obtained). CONCLUSION/CONCLUSIONS:With proper antiplatelet regimens, flow diverter stents can be used safely to successfully treat complex acute iatrogenic injuries. Early repeat angiogram is needed when immediate postinjury imaging does not discover the point of vessel injury.

OBJECTIVE:Gastric antral vascular ectasia (GAVE) is characterized by vascular ectasias accounting for 4% of nonvariceal upper gastrointestinal bleeds, which can range from occult bleeds to severe acute upper gastrointestinal bleeding. In turn, GAVE can lead to severe morbidity and recurrent hospitalization. Current endoscopic treatments for GAVE include argon plasma coagulation (APC), endoscopic band ligation (EBL), and radiofrequency ablation. With this significant burden in mind, a systematic review and network meta-analysis were conducted to compare the efficacy and safety of various modalities in the treatment of GAVE. METHODS:All studies that involved adults and children with endoscopic characteristics of GAVE undergoing treatment with APC, EBL, radiofrequency ablation, or a combination of 2 treatment modalities were included. RESULTS:There was no statistical difference in the rate of adverse events and the number of red blood cell transfusions across all 3 groups (APC, EBL, and APC + EBL). However, statistical differences were noted for outcomes of bleeding recurrence, length of hospitalization, and change in hemoglobin status. EBL exhibited a significant decrease in bleeding recurrence when compared with APC. Moreover, shorter hospitalization stays were seen in APC + EBL and EBL groups compared with APC, and a beneficial change in hemoglobin status was also more often seen in APC + EBL and EBL groups compared with APC. CONCLUSIONS:Based on this study, EBL was found to have superior efficacy when compared with APC for the treatment of GAVE; however, there was no significant difference in rates of adverse events between APC, EBL, and combination therapy.

INTRODUCTION/BACKGROUND:Peripheral arterial disease (PAD) is a progressive, systemic atherosclerotic disease that is associated with an increased risk of coronary artery disease (CAD), cerebrovascular disease (CVD), and critical limb ischemia (CLI). CLI represents the most severe stage of PAD, characterized by progressive endothelial dysfunction and arterial narrowing. We hypothesized that the incidence of CLI and PAD would increase over the study period and that the rates of in-hospital mortality and major amputations among patients admitted with CLI would rise correspondingly. METHODS:We utilized the National Inpatient Sample (NIS) database from year 2016 to 2021 using the ICD-10-CM codes. Patients with a primary or secondary diagnoses of PAD were initially selected and subsequently hospitalization with CLI were appropriately identified. Cochran Armitage test was used to describe the trend of outcomes across the years. All statistical analyses were conducted using the software Stata version 17.0. RESULTS:From 2016-2021, there were 2,930,639 admissions for critical limb ischemia. 65% of these patients were over the age of 60 and 35.8% of these patients were women. Most of these individuals were white (64.7%), followed by African Americans (15.8%) and Hispanics (12.6%). In-hospital mortality rates varied by revascularization method, with hybrid revascularization showing the highest rate at 2.6%, followed by endovascular revascularization at 1.8%, and surgical revascularization at 1.6%. Additionally, hospitalization costs were highest for patients undergoing hybrid revascularization ($46,257 ± $36,417), compared to endovascular ($36,924 ± $27,945) and surgical revascularization ($35,672 ± $27,127). Endovascular revascularization rates seemed to increase while surgical revascularization rates decreased during this time period. CONCLUSION/CONCLUSIONS:PAD is a progressive, systemic atherosclerotic disease that is associated with an increased risk of CAD, CVD, and CLI. Our data showed that the rates of PAD and CLI hospitalizations has remained relatively stable from 2016-2021, but there seems to be a trend towards doing more revascularization via an endovascular approach as compared to a surgical approach.

Leptomeningeal disease (LMD), spread of cancer to the lining of the brain and its protective coverings, is a feared complication of many different types of cancer. LMD negatively affects prognosis across tumor types. Palliative care (PC) clinicians caring for patients with advanced cancer may be faced with discussing limited prognosis, assisting with symptom management, and helping with medical decision making for patients with LMD. An understanding of pathophysiology, symptomatology, prognosis, and treatment options is essential in providing optimal care. This article, written by clinicians who work across the cancer spectrum, uses an accessible "ten tips" format to help increase PC providers' confidence and competence around caring for people with LMD.