Equivalence in osteoporosis workup and management after femoral neck fracture fixation and vertebral compression fracture cement augmentation: A single-center retrospective study highlighting persistent Underdiagnosis and Undertreatment.

Background: The purpose of this study was to evaluate pre- and post-fracture medical management of osteoporosis among patients who underwent surgical fixation of femoral neck fractures (FNF) and vertebral compression fractures (VCF), and to investigate if there is a difference in treatment, management, and subsequent fractures between FNF and VCF patients. Methods: Patients who underwent surgical fixation of FNF or VCF were retrospectively reviewed at a minimum 1 year follow up. Patients were excluded if their fracture was caused by high energy trauma or malignancy, <50 years-old, deceased, or lost to follow up. Patient demographics such as age, sex, BMI, American Society of Anesthesiology Physical Status Classification System and Charleston Comorbidity index were recorded. Management of osteoporosis, including medication regimen and dual-energy X-ray absorptiometry (DEXA) scans were assessed preoperatively and at minimum one year follow up. Subsequent fractures were also recorded. Results: In the analysis of 370 patients (74.7% FNF, 25.2% VCF), demographics showed a predominantly female population (mean age 78.1). Preoperatively, 21.6% were diagnosed with osteoporosis, consistent between FNF and VCF. Postoperatively, there were no significant differences in new osteoporosis diagnoses, bisphosphonate use, or subsequent fractures. VCF patients, however, were more likely to receive denosumab and post-operative DEXA scans (p < 0.05). Within a year, 6.2% experienced subsequent fractures, with no significant FNF-VCF difference. Only 12.7% received appropriate post-operative osteoporosis treatment, 27.1% had DEXA scans, and 25% had a recorded osteoporosis diagnosis. Multivariable analysis highlighted pre-fracture osteoporosis diagnosis as the sole predictor for post-operative DEXA scans and anti-osteoporotic medication (p < 0.001). Conclusions: This study suggests that factors beyond the type of fragility fracture may influence subsequent fracture risk and anti-osteoporotic medication administration in elderly patients. These findings underscore the importance of a comprehensive approach to fracture risk assessment and treatment decisions in this population. Level of evidence: III.

Pediatric Patients with Osteomyelitis and/or Septic Joint Undergoing Surgical Debridement Have Equivalent Short-Term Outcomes with or without Preoperative MRI.

The purpose of this study was to determine if short-term outcomes differed for pediatric patients with suspected musculoskeletal infection with or without a preoperative MRI. This was a multicenter, retrospective review of patients aged 0-16 years who presented with atraumatic extremity pain, underwent irrigation and debridement (I&D), and received at least one preoperative or postoperative MRI over a 10-year period. Primary outcomes were time to OR, total I&Ds, readmission rate, time from OR to discharge, and total number of MRIs. Secondary outcomes entailed the rate at which concurrent osteomyelitis was identified in patients with septic arthritis and the extent of the resulting surgical debridement. Of the 104 patients, 72.1% had a preoperative MRI. Patients with a preoperative MRI were significantly less likely to have surgery on the day of admission. No difference was found between groups regarding total I&Ds, readmission rate, time from OR to discharge, and total number of MRIs. Of the 57 patients diagnosed with septic arthritis, those with a preoperative MRI were significantly more likely to have concurrent osteomyelitis identified and to undergo bony debridement in addition to arthrotomy of the joint. In conclusion, patient outcomes are not adversely affected by obtaining a preoperative MRI despite the delay in time to OR. Although preoperative MRI can be beneficial in ruling out other pathologies and identifying the extent of concurrent osteomyelitis, the decision to obtain a preoperative MRI and timing of surgery should be left to the discretion of the treating surgeon.

White Blood Cell and C-Reactive Protein Levels Are Similar in Obese Hispanic White Women Reporting Adherence to a Healthy Plant, Unhealthy Plant, or Animal-Based Diet, unlike in Obese Non-Hispanic White Women.

While modifying dietary patterns can reduce the effects of inflammation in obesity, less is known about the impact of dietary patterns on inflammation levels in women of different ethnicities. This study investigated the link between dietary patterns and mediators associated with inflammation, such as C-reactive protein (CRP) and white blood cells (WBCs), among obese Hispanic and Non-Hispanic White women. CRP and WBC counts were extracted from the National Health and Nutrition Examination Survey conducted between 2003 and 2010. Based on their recorded responses to two 24 h recall interviews, individuals were grouped into one of three dietary patterns: healthy plant-based, less healthy plant-based, or animal-based. Comparisons were run between obese Hispanic and Non-Hispanic women assigned to the same dietary pattern groups and between dietary pattern groups within ethnic groups. CRP and WBCs increased in obese Non-Hispanics as dietary patterns moved from healthy plant-based to animal-based (pCRP = 0.002 and pWBC = 0.017). Regardless of the dietary pattern, CRP and WBC expression were similar in Hispanic women. In addition, WBCs were higher in Hispanics compared to Non-Hispanics when both populations adhered to healthy plant and less healthy plant dietary patterns. The results indicate that dietary patterns may influence Hispanics' inflammation differently than Non-Hispanics.

Frailty Among Revision Total Knee Arthroplasty Recipients: Epidemiology and Propensity Score-weighted Analysis of Effect on In-hospital Postoperative Outcomes.

BACKGROUND: Frailty has been shown to correlate with worse outcomes after total knee arthroplasty (TKA), although less is known regarding its effect on revision TKA (rTKA). This study examines the epidemiologic characteristics and inpatient outcomes of patients with frailty undergoing rTKA. METHODS: Discharge data from National Inpatient Sample registry were used to identify all patients aged 50 years or older who underwent rTKA between 2006 and 2015. Patients were stratified into frail and nonfrail groupings, based on the presence of specific International Classification of Diseases-9 diagnostic coding. An analysis comparing the epidemiology, medical comorbidities, and propensity score-weighted postoperative clinical and economic outcomes of the two groups was done. RESULTS: From 2006 to the third quarter of 2015, a total of 576,920 patients (17,727 frail) who underwent rTKA were included. The average age in the study's population was 67.2 years, with a female distribution of 57.4%. Frail patients were more likely to exhibit markedly higher rates of almost all modified Elixhauser Comorbities than their nonfrail counterparts. Frail patients were also more likely to undergo different types of revisions, including an increased rate of removal of the prosthesis without replacement. In addition, frail patients displayed increased likelihood of experiencing any postoperative complication, deep vein thrombosis, postoperative anemia, respiratory complications, and wound dehiscence. Frail patients experienced lower rates of discharge home and increased length of stay than the nonfrail cohort. DISCUSSION: Patients with frailty undergoing rTKA are at markedly higher risk for inpatient postoperative complications and increased length of stay. Understanding the implications of frailty within rTKA is essential for risk assessment and preoperative optimization for this expanding population.

Mortality Outcomes in Patients With Cardiac Implantable Electronic Devices Before and After Transcatheter Aortic Valve Replacement.

Transcatheter aortic valve replacement (TAVR) carries a risk of high-grade AV block requiring cardiac implantable electronic device (CIED) implantation, which has been associated with a higher mortality rate. However, the outcomes of TAVR in patients with preexisting CIEDs are not well understood. We conducted a retrospective analysis of consecutive patients who underwent TAVR from December 2014 to December 2019 at our institution. Patients were categorized into 3 groups: preexisting CIED pre-TAVR (group 1), CIED implanted within 30 days after TAVR (group 2), and no CIED implanted (group 3). Cox proportional hazard was conducted to determine the primary end point of all-cause mortality. A total of 366 patients were included, of whom 93 (25.4%), 51 (13.9%), and 222 (60.7%) comprised group 1, 2, and 3, respectively. The median follow-up time was 2.3 years. The all-cause mortality rate was higher in group 1 than group 2 (hazard ratio [HR] 2.60, 95% confidence interval [CI] 1.09 to 6.18, p = 0.03) and group 3 (HR 1.96, 95% CI 1.24 to 3.08, p = 0.004). On the multivariate analysis, there was no statistically significant difference in mortality among the groups (group 1 vs group 2: HR 1.95, 95% CI 0.70 to 5.44, p = 0.20 and group 1 vs group 3: HR 1.27, 95% CI 0.66 to 2.43, p = 0.47). Preoperative hemoglobin ≤12 g/100 ml was an independent predictor of all-cause mortality (HR 1.75, 95% CI 1.10 to 2.80, p = 0.02). Group 1 had a higher 1 year congestive heart failure readmission rate (29%) than group 2 (17.6%) and group 3 (8.1%; p <0.0001). In conclusion, there was no difference in the adjusted long-term survival based on the CIED grouping. However, patients with preexisting CIEDs had higher all-cause mortality and 1-year congestive heart failure readmission rates owing to their higher co-morbidity burden, irrespective of their Society of Thoracic Surgeons score. This can be taken into account for preoperative risk stratification.

Frailty Among Total Hip and Knee Arthroplasty Recipients: Epidemiology and Propensity Score-weighted Analysis of Effect on In-hospital Postoperative Outcomes.

INTRODUCTION: Total joint arthroplasty (TJA) is one of the most successful and frequently performed procedures in the United States. The number of these procedures is projected to continue growing rapidly in the coming years, and with it comes the demand for more sophisticated perioperative risk and complication assessment. This study examines the effect of frailty on postoperative inpatient complications and hospital resource utilization after TJA. METHODS: Discharge data from the National Inpatient Sample were used to identify all patients aged 50 years or older who underwent TJA between 2006 and 2015. Nonelective admissions and hip fractures were excluded. Patients were stratified into two groups with and without concomitant ICD-9 diagnostic criteria that qualified them has having frailty. An analysis comparing the 2 groups' epidemiology, medical comorbidities, and propensity score-weighted postoperative clinical and economic outcomes was done. RESULTS: A total of 7,854,890 TJAs were included in this analysis, with 136,516 meeting the criteria for frailty and 7,718,374 being nonfrail. Among these patients, the average age was 67.3 years and the female distribution was 61.1%. Frail patients were found to have markedly higher rates of all but two individual comorbidities constituting the Modified Elixhauser Profile compared with nonfrail patients. Compared with the control group, frail patients were found to have increased risk of any postoperative complication, central nervous system complications, hematoma/seroma, wound dehiscence, infection, and postoperative anemia. Frail patients also had longer length of stay, higher discharge to rehabilitation facilities, and higher hospital charges. DISCUSSION: Patients with frailty undergoing TJA procedures are at a markedly higher risk for developing postoperative complications and worse hospital economic outcomes. As this patient population continues to increase, it is imperative for clinicians to use their risk factors in optimizing their perioperative care and support.

The evolution of leadership: analyzing the presidents of American Dermatology Societies overtime.

Within organized dermatology, it is imperative that leaders embody a diverse group of individuals, reflective of the dermatologists they represent and the greater U.S. population. Despite women constituting more than half of the dermatologic workforce, they represent a leadership minority in dermatology society higher level positions. This gap is evident by fewer women holding presidency positions within prominent dermatological societies; however, a comprehensive comparison across multiple societies has yet to be made. Our study analyzes and compares demographic as well as academic metrics of presidents from 16 prominent dermatology societies spanning 22 years, 2000-2021. Data were collected using organization websites, which demonstrated 247 unique presidents over 22 years. Of these presidents, 175 (70.9%) were male and 72 (29.1%) were female. Surgically focused societies had 63 (87.5%) male presidents and nine (12.5%) female presidents, while clinically focused societies had 112 (64.0%) male presidents and 63 (36.0%) female presidents (P < 0.0002). The publication h-index, academic rank, chairmanship, and number of advanced degrees, and total number of years in practice prior to election did not significantly differ between male and female leaders. There was no statistically significant difference in the proportion of female presidents across all societies between 2000 and 2021 by Cochran Armitage Trend Test. However, between 2016 and 2021, 35% of presidents were female and a general trend toward more gender balance may be noticed. This equality goal should continue to be emphasized in organized medicine.

Basal Cell Carcinoma With Perineural Invasion: A Systematic Review and Pooled Survival Analysis.

BACKGROUND: Perineural invasion (PNI) is considered a high-risk histopathologic feature in many skin cancers. Perineural invasion is a well-known poor prognostic factor of squamous cell carcinoma, but is poorly understood in the context of basal cell carcinoma (BCC). OBJECTIVE: To analyze available demographic, clinical, and treatment data for BCC with PNI and the effect of these variables on recurrence patterns, disease progression, and cancer-specific mortality (CSM). METHODS: A systematic review and pooled-survival analysis was performed using case reports and series of patients with perineural BCC. RESULTS: This review included 159 patients from 49 publications. Of these cases, 57 patients reported at least one recurrence. Where reported, median follow-up time was 31 months for patients without recurrence ( n = 79) and 21 months for patients with recurrence ( n = 32). The cumulative incidence of CSM at 5 years was 8.5% (95% confidence interval [CI] 0.028-0.186) and the overall five-year survival was 90.9% (95% CI 0.796-0.961). CONCLUSION: Male gender, multifocal nerve involvement, presence of clinical symptoms, and PNI detected on imaging are associated with poor prognosis of BCC with PNI. The high rate of disease recurrence and suboptimal cumulative incidence of CSM highlights the importance of early clinical detection, before the onset of symptomatic PNI and multifocal nerve involvement.

Optimizing anti-androgen treatment use among men with pathologic lymph-node positive prostate cancer treated with radical prostatectomy: the importance of postoperative PSA kinetics.

BACKGROUND: Optimal postsurgical management of prostate cancer (PCa) patients with nodal metastasis at the time of radical prostatectomy remains unclear. We sought to examine the role of postoperative PSA kinetics and pathologic tumor characteristics in guiding additional hormonal therapy use in pN1 men. METHODS: In total, 297 pN1 PCa patients treated with radical prostatectomy and ePLND between 2002 and 2018 were identified within our prospectively maintained institutional cancer data-registry. Following surgery, these patients were managed with either immediate androgen deprivation therapy (iADT) or observation with deferred ADT (dADT). The former was defined as ADT given within ≤6 months of surgery and the latter as >6 months. The primary outcome was metastasis. Regression-tree analysis was used to stratify patients into novel risk-groups based on post-prostatectomy tumor characteristics and PSA kinetics and the corresponding metastasis risk. Multivariable Cox regression analyses tested the impact of iADT versus observation ± dADT on metastasis, cancer-specific mortality, and overall mortality within each risk-group separately. RESULTS: The median follow-up was 6.1 years (IQR 3.2-9.0). Regression-tree analysis stratified patients into 3 novel risk-groups (Harrell's C-index 0.79) based on PSA-nadir and time to biochemical failure: group 1 (low-risk) included patients with time to biochemical recurrence >6 months (n = 115), while groups 2 and 3 included patients with biochemical failure within ≤6 months with a postoperative PSA-nadir <1.05 ng/mL (group 2 [intermediate-risk], n = 125) or ≥1.05 ng/mL (group 3 [high-risk], n = 57), respectively. No other patient or tumor characteristics were significant for risk stratification. Within each risk-group, the 10-year metastasis-free survival rates with iADT versus observation ± dADT use were: group 1, 100% versus 95.4% (Log-rank p = 0.738), group 2, 80.6% versus 53.5% (Log-rank p = 0.016), and group 3, 41.5% versus 0% (Log-rank p = 0.015), respectively. Adjusted Cox regression analyses confirmed the benefit of iADT utilization in reducing metastasis in group 2 (p = 0.029) and group 3 (p = 0.008) patients, with no benefit for group 1 patients (p = 0.918). Similar results were noted for cancer-specific and overall mortality. CONCLUSIONS: Following radical prostatectomy, early postoperative PSA kinetics may provide valuable information for guiding the timing of ADT initiation-this may reduce over- and undertreatment of pN1 PCa men.

Risk-Based Assessment Of the Impact Of Intravesical Therapy on Recurrence-Free Survival Rate Following Resection of Suspected Low-grade, Non-muscle-invasive Bladder Cancer (NMIBC): A Southwest Oncology Groups (SWOG) S0337 Posthoc Analysis.

BACKGROUND: Nonmuscle invasive bladder cancer (NMIBC) has an elevated risk of recurrence, and immediate postresection intravesical instillation of chemotherapy (IVC) significantly reduces the risk of recurrence. Questions remain about which subpopulation may maximally benefit from IVC. Our aim was to develop risk groups based on recurrence risk in NMIBC, and then evaluate the impact of a single, postoperative instillation of IVC on the subsequent risk of recurrence for each risk group. MATERIAL AND METHODS: Using the SWOG S0337 trial cohort, we performed a posthoc analysis of 345 patients who were diagnosed with suspected low-grade NMIBC, underwent transurethral resection of the bladder tumor (TURBT), and received post-operative IVC (gemcitabine vs. saline). Using regression tree analysis, the regression tree stratified patients based on their risk of recurrence into low-risk - single tumor and aged < 57 years, intermediate-risk - single tumor and aged ≥ 57 years, and high-risk - multiple tumors. We used Cox proportional hazard models to test the impact of recurrence-free rate, and after adjustment to available covariates. RESULTS: Median age of the cohort was 66.5 (IQR: 59.7-75.8 years) with 85% of patients being males. Median overall follow-up time was 3.07 years (IQR: 0.75-4.01 years). When testing the impact of treatment in each risk group separately, we found that patients in the intermediate-risk treated with gemcitabine had a 24-month recurrence free rate of 77% (95% CI: 68%-86%) vs. 59% (95% CI: 49%-70%) in the saline group. This survival difference was confirmed on multivariable analysis (hazard ratio: 0.39, 95% CI: 23%-66%, P < 0.001). This group represented 53% of our cohort. Conversely, we did not observe a significant difference in recurrence-free survival among patients in the low- (P = 0.7) and high-risk (P = 0.4) groups. CONCLUSION: Our findings indicate that older patients with a single tumor of suspected low-grade NMIBC at TURBT maximally benefit from immediate postresection IVC (gemcitabine).

Anti-Androgen Therapy Overcomes the Time Delay in Initiation of Salvage Radiation Therapy and Rescues the Oncological Outcomes in Men with Recurrent Prostate Cancer After Radical Prostatectomy: A Post Hoc Analysis of the RTOG-9601 Trial Data.

BACKGROUND: It is unknown whether the addition of anti-androgen therapy (AAT) to late salvage radiation therapy (sRT) can lead to oncological outcomes equivalent to that of early sRT in men with recurrent prostate cancer (CaP) after surgery. METHODS: Data on 670 men who participated in the Radiation Therapy Oncology Group (RTOG)-9601 trial and who experienced biochemical recurrence were extracted using the National Clinical Trials Network (NCTN) data archive platform. Patients were stratified into four treatment groups: early sRT (pre-sRT prostate-specific antigen [PSA] < 0.7 ng/mL) and late sRT (pre-sRT PSA ≥ 0.7 ng/mL) with/without concomitant AAT, based on cut-offs reported in the original trial. Time-varying Cox proportional hazards and Fine-Gray competing-risk regression analyses assessed the adjusted hazards of overall mortality, CaP-specific mortality, and metastasis among the four treatment groups. RESULTS: At 15-years (median follow-up of 14.7 years), for patients treated with early sRT, early sRT with AAT, late sRT, and late sRT with AAT, the overall mortality, CaP-specific mortality, and metastasis rates were 22.9, 22.8, 40.1, and 22.9% (log-rank p = 0.0039), 12.1, 3.9, 22.7, and 8.0% (Gray's p = 0.0004), and 18.8, 14.6, 35.9, and 19.5% (Gray's p = 0.0004), respectively. Time-varying multivariable adjusted analysis demonstrated increased hazards of overall mortality in patients receiving delayed sRT versus early sRT (hazards ratio [HR] 1.49, 95% confidence interval [CI] 1.02-2.17); however, no difference remained after the addition of concomitant AAT to late sRT (HR 0.85, 95% CI 0.55-1.32, referent early sRT). Likewise, the hazards of cancer-specific mortality and metastatic progression were worse for late sRT when compared with early sRT, but were no different after the addition of AAT to late sRT. CONCLUSIONS: Poorer outcomes associated with late sRT in men with recurrent CaP may be rescued by delivery of concomitant AAT.

High-intensity local treatment of clinical node-positive urothelial carcinoma of the bladder alongside systemic chemotherapy improves overall survival.

PURPOSE: Clinical node-positive urothelial carcinoma of the bladder (cN+UCaB) is a rapidly fatal disease with limited information on comparative-effectiveness of available treatment options. We sought to examine the impact of high-intensity vs. conservative local treatment (LT) regimens in management of these patients alongside systemic chemotherapy. MATERIALS AND METHODS: We identified 3,227 patients within the National Cancer Data Base who underwent multiagent systemic chemotherapy along with either high-intensity or conservative LT for primary cN+UCaB between 2004-2016. Patients who received no LT, TURBT alone, or <50 Gy radiation therapy to the bladder were included in the conservative group, while patients that received radical cystectomy with pelvic lymphadenectomy or ≥50 Gy radiation therapy with TURBT were included in the high-intensity group. Inverse probability of treatment weighting (IPTW) adjusted Kaplan-Meier and Cox regression analyses were used to assess overall survival (OS). Additionally, to assess whether the benefit of high-intensity LT differs by baseline mortality risk, we tested an interaction between 5-year predicted life-expectancy and the LT type. RESULTS: Overall, 784 (24.3%) and 2,443 (75.7%) cN+UCaB patients underwent high-intensity and conservative LT, respectively. IPTW-adjusted Kaplan-Meier analysis demonstrated OS to be significantly higher in the high-intensity group compared to the conservative group: 5-year OS 28.4% vs. 18.3%, respectively (Log-rank P<0.001). IPTW-adjusted multivariable Cox regression analysis confirmed the benefit of high-intensity LT in prolonging OS (HR 0.63, P<0.001). Interaction analysis showed that high-intensity LT approach was associated with longer OS in all patients regardless of their baseline 5-year life-expectancy (Pinteraction=0.79). CONCLUSION: Eligible patients with cN+UCaB should be considered for aggressive local treatment alongside multiagent systemic chemotherapy. Prospective trials are needed to validate these preliminary findings.

Subtotal surgical therapy for localized prostate cancer: a single-center precision prostatectomy experience in 25 patients, and SEER-registry data analysis.

BACKGROUND: We recently described a novel form of focal therapy for prostate cancer (CaP)-the precision prostatectomy. Here we report on the first 25 consecutive patients. Further, utilizing Surveillance Epidemiology and End Results (SEER)-registry data, we assess long-term oncological efficacies of various focal therapy techniques. METHODS: Men who met the criteria: (I) PSA ≤15 ng/mL, (II) stage ≤cT2, (III) dominant unilateral lesion with Gleason ≤4+3 with any number or percentage (%) of cores involved ipsilaterally on biopsy, (IV) no primary Gleason ≥4 contralaterally, and (V) preoperative erectile function score (IIEF-5/SHIM) of ≥17 with/without PDE-5i were included in this prospective, single-arm, IDEAL stage 2b study (December 2016 to July 2017). Safety of the technique, and intermediate-term urinary, sexual and oncological outcomes were studied. Descriptive statistics and Kaplan-Meier (KM) analysis were used to assess 12-month urinary continence (0-1 pad), 12-month sexual potency (SHIM ≥17), and 36-month freedom from clinically-significant CaP (grade group ≥2), radical treatment, metastatic disease and mortality. SEER-registry was queried to evaluate CaP-specific survival in patients undergoing hyperthermia, cryotherapy, or segmental prostatectomy. RESULTS: At study entry, the median (IQR) age, PSA and SHIM score were 56.5 (53.1-62.3) years, 4.2 (3.8-5.9) ng/mL and 23 [20-25], respectively. Only 1 patient met the Epstein criteria for active surveillance. All patients were followed for a minimum of 2 years. At 12 months, from a functional standpoint, all patients were continent. Twenty-three (92%) patients were potent at 12 months. From an oncological standpoint, at 36 months, the KM analysis (95% CI) demonstrated a 96.2% (92.9-98.7) rate of freedom from clinically-significant CaP and a 92.7% (88.9-97.2) rate of freedom from radical treatment. All patients were alive and free of metastatic disease at the latest follow-up. Analysis of the SEER-registry data demonstrated 10-year CaP-specific survival rates of 91.6% to 97.7% among the 3 studied modalities, P=0.298. CONCLUSIONS: Precision prostatectomy is feasible, technically safe, and offers excellent postoperative functional results. At 36 months of follow-up, the oncological outcomes and secondary procedure rates appear to be at-par with the ablative forms of focal therapy.

Renal Tumor Size and Presence of Synchronous Lung Metastasis at Time of Diagnosis: Implications for Chest Imaging.

OBJECTIVE: To quantify synchronous lung metastasis risk based on renal tumor size and determine a renal tumor size threshold to determine when chest imaging is warranted. METHODS: We assessed 253,838 patients diagnosed with a renal tumor who underwent staging chest imaging between 2010 and 2016 within the National Cancer Database. Patients were stratified by renal tumor size in 10 mm increments, and synchronous lung metastasis risk was calculated for each category. Logistic regression analyses were used to test the relationship between renal tumor size and presence of synchronous lung metastasis after adjusting to all available covariables. RESULTS: Overall, 14,524 out of 253,838 (5.7%) patients had evidence of synchronous lung metastasis. Median (IQR) tumor size for patients with vs without sLM was 90 mm (65-115) vs 40 mm (25-60), respectively. The incidence of synchronous lung metastasis was low for renal tumors <40 mm, without significant change, based on tumor size. Conversely, synchronous lung metastasis increased proportionally to renal tumor size for lesions ≥40 mm. In our cohort, 47% of patients (120,386/253,838) had a renal tumor <40 mm, and 0.9% (1,135/120,386) of these had patients had synchronous lung metastasis. Only 8% (1,135/14,524) of patients with synchronous lung metastasis had a renal tumor <40 mm. CONCLUSION: The risk of synchronous lung metastasis increased proportionally to renal tumor size; however, the risk was low for tumors <40 mm. These findings suggest that there may be minimal utility of performing screening chest imaging for patients with renal tumors <40 mm.

Impact of Lymphovascular Invasion on Overall Survival in Patients With Prostate Cancer Following Radical Prostatectomy: Stage-per-Stage Analysis.

BACKGROUND: The detrimental impact of lymphovascular invasion (LVI) in prostate cancer (PCa) on biochemical recurrence has been described; the impact of LVI on overall survival (OS) remains unclear. This investigation sought to evaluate the impact of LVI on OS in patients with PCa. METHODS: We examined men with nonmetastatic PCa treated with radical prostatectomy between 2010 and 2015. Only men with documented LVI status were included (n = 232,704). Patients were stratified according to final pathologic T stage (pT2, pT3a, and pT3b). RESULTS: Of the 232,704 patients who met inclusion criteria, 17,758 (8%) were found to have LVI on final pathology. Overall, 174,838 (75%), 40,281 (17%), and 17,585 (8%) patients had pT2, pT3a, and pT3b disease, respectively. Median follow-up was 42.7 months (27.1-58.7). At 5 years, the OS in LVI versus non-LVI patients was 94% versus 95% in pT2 (P = .0004), 92% versus 95% in pT3a (P < .0001), and 86% versus 92% in pT3b (P < .0001). On multivariable analysis, LVI status was not an independent predictor of OS in pT2 disease (hazard ratio, 1.12; 95% confidence interval [CI], 0.93-1.36; P = .2). In pT3a and pT3b disease, presence of LVI had 1.2-fold (95% CI, 1.03-1.44; P = .02) and 1.4-fold (95% CI, 1.20-1.59; P < .001) higher overall mortality than their counterparts without LVI. CONCLUSIONS: Our report demonstrates the detrimental impact of LVI on OS in locally advanced PCa (pT3a and higher). This information may prove valuable when risk stratifying based on final pathology.

Use of ultra-low dose computed tomography versus abdominal plain film for assessment of stone-free rates after shock-wave lithotripsy: implications on emergency room visits, surgical procedures, and cost-effectiveness.

The aims of this investigation were: (1) to compare residual stone-fragment (RSF) detection rates of ultra-low dose computed tomography (ULD-CT) and abdominal plain film (KUB) in urolithiasis patients undergoing shock-wave lithotripsy (SWL), and (2) to evaluate the downstream sequelae of utilizing these two disparate imaging pathways of differing diagnostic fidelity. A retrospective chart-review of patients undergoing SWL at two high-volume surgical centers was undertaken (2013-2016). RSF diagnostic rates of ULD-CT and KUB were assessed, and the impact of imaging modality used on subsequent emergency room (ER) visits, unplanned procedures, and cost-effectiveness was investigated. Adjusted analyses examined association between imaging modality used and outcomes, and Markov decision-tree analysis was performed to identify a cost advantageous scenario for ULD-CT over KUB. Of 417 patients studied, 57 (13.7%) underwent ULD-CT while the remaining 360 underwent KUB. The RSF rates were 36.8% and 22.8% in the ULD-CT and KUB groups, respectively (p = 0.019). A 5.6% and 18% of the patients deemed stone-free on ULD-CT and KUB, respectively, returned to the ER (p = 0.040). Similarly, 2.8% and 15.1% needed an unplanned surgery (p = 0.027). These findings were confirmed on multivariable analyses, Odds ratios CT-ULD versus KUB: 0.19 and 0.10, respectively, p < 0.05. With regards to cost-effectiveness, at low ULD-CT charges, the ULD-CT follow-up pathway was economically more favorable, but with increasing ULD-CT charges, the KUB follow-up pathway superseded. ULD-CT seems to provide a more 'true' estimate of stone-free status, and in consequence mitigates unwanted emergency and operating room visits by reducing untimely stent removals and false patient reassurances. Further, at low ULD-CT costs, it may also be economically more favorable.

Evaluation of lymphovascular invasion as a prognostic predictor of overall survival after radical prostatectomy.

OBJECTIVE: To assess the prognostic ability of lymphovascular invasion (LVI) as a predictor of overall survival (OS). MATERIALS AND METHODS: We included 126,682 prostate cancer (CaP) cM0 patients who underwent radical prostatectomy with lymph node dissection between 2010 and 2015, within the National Cancer Database. Patients who received androgen deprivation therapy were included. Patients were divided into four sub-cohorts based on LVI and lymph node invasion (LNI) status: pL0N0, pL1N0, pL0N1, and pL1N1. Kaplan-Meier curves estimated OS and Cox-regression analysis tested the relationship between LVI and OS. RESULTS: Median (IQR) age and PSA at diagnosis were 62 (57-66) years and 5.7 (4.5-8.9) ng/ml, respectively. Most patients had pT2 stage (68.5%), and pathological Gleason 3+4 (46.7%). 10.0% and 4.0% patients had LVI and LNI, respectively. Median follow-up was 42 months (27-58). At 5-years, OS was 96.5% in pL0N0 patients vs 93.1% pL1N0 patients vs 93.3% in pL0N1 patients vs 86.6% pL1N1 patients. LVI was an independent predictor of OS (hazard ratio [HR]:1.28). LVI showed interaction with LNI, as LVI was associated with a higher overall-mortality in patients with LNI (HR:1.66), than in patients without LNI (HR:1.22). (all P<0.0001) CONCLUSIONS: Our report highlights the detrimental impact of LVI on OS. Patients with LVI alone fared similarly to patients with LNI alone. Patients with both LVI and LNI had worse OS than those with only LVI or LNI, implying a synergetic detrimental interaction. Our findings demonstrate an important utility that LVI can provide in deciding patients' prognoses.

External validation of genomic classifier-based risk-stratification tool to identify candidates for adjuvant radiation therapy in patients with prostate cancer.

OBJECTIVE: To externally validate a Genomic Classifier (GC) based risk-stratification nomogram identifying candidates who would benefit from adjuvant radiation (aRT) therapy after radical prostatectomy (RP). METHODS: We identified 350 patients who underwent RP, between 2013 and 2018, and had adverse pathological features (positive margin, and/or pT3a or higher) on final pathology. Genomic profile was available for all these men. The clinical recurrence-free survival was estimated using the Kaplan-Meier method. The external validity of the nomogram was tested using the concordance index (c-index), calibration plot, and decision curve analysis. RESULTS: The median follow-up of the cohort was 26.5 months. Overall, 14% of the patients received aRT. During the follow-up period, 3.4% of the patients developed metastasis. Overall 3-year metastasis-free survival was 95% (95% CI 0.92-0.98). The c-index of the nomogram was 0.84. The calibration of the model was favorable. Decision-curve analysis showed a positive net benefit for probabilities ranging between 0.01 and 0.09, with the highest difference at threshold probability around 0.05. At that threshold, the net benefit is 0.06 for the model and 0 for treating all the patients. CONCLUSION: Our report is the first to confirm the validity of this genomic-based risk-stratification tool in identifying men who might benefit from aRT after RP. As such, it can be a useful instrument to be incorporated in shared decision making on whether administration of aRT will lead to a clinically meaningful benefit. Such a model can also be useful for patients' classification in future clinical trials.

Regression Discontinuity Analysis of Salvage Radiotherapy in Prostate Cancer.

There is a lack of randomized evidence comparing early (eSRT) to late (lSRT) salvage radiotherapy (SRT) after radical prostatectomy (RP) for prostate cancer (PCa). Moreover, the existing evidence is often affected by lead-time bias. We sought to address this gap in a cohort of 1458 PCa patients undergoing SRT for biochemical recurrence (BCR) after RP in two tertiary care centers between 1992 and 2013. Using a quasi-randomized study design known as regression discontinuity (RD) and adjusting for lead-time bias, we compared metastasis-free survival (MFS) at 5 and 10 years after surgery between eSRT (prostate-specific antigen [PSA] <0.5 ng/ml) and lSRT (PSA ≥ 0.5 ng/ml). Overall, 1049 patients (71.9%) underwent eSRT and 409 (28.1%) lSRT at a mean follow-up of 84 mo (interquartile range (IQR) 52-120.4). The MFS rate decreased nonsignificantly at the proposed cutoff by 0.04 (95% confidence interval [CI]: -0.06 to 0.19) at 5 years and by 0.07 (95% CI: - 0.12 to 0.32) at 10 years. Cox regression analysis revealed a hazard ratio for the cutoff examined of 1.3 (95% CI: 0.8-2.4; p = 0.2). In conclusion, in a quasirandomized study design accounting for lead-time bias, eSRT (PSA < 0.5 ng/ml) did not improve MFS. Our results underline the need for level-one evidence to compare eSRT and lSRT. PATIENT SUMMARY: We compared early versus late salvage radiotherapy (SRT) for biochemical recurrence after radical prostatectomy by simulating a randomized trial. We found that early SRT (initiated at prostate-specific antigen <0.5 ng/ml) compared to late SRT did not improve metastasis-free survival.

Robotic Kidney Transplantation with Regional Hypothermia versus Open Kidney Transplantation for Patients with End Stage Renal Disease: An Ideal Stage 2B Study.

PURPOSE: We report on comparative effectiveness of minimally invasive versus traditional open kidney transplantation. MATERIALS AND METHODS: We undertook a prospective cohort study of 654 patients who underwent open or robotic kidney transplantation at a single tertiary care hospital between January 2013 and December 2015. Primary outcome was delayed graft function, defined as the need for dialysis within 1 week of surgery. Secondary outcomes included postoperative complications, pain, graft rejection, and graft and patient survival. Nonparsimonious propensity score and Ding-VanderWeele analytical methods were used to account for confounding bias. RESULTS: Within the 1:3 matched cohort (robotic 126, open 378; well matched with standardized mean difference ∼10%), the robotic approach was associated with lower rates of wound infections (0% vs 4%, p=0.023) and symptomatic lymphoceles (0% vs 7% at 36 months, p=0.003), as well as reduced postoperative pain, requirement for narcotic analgesia and blood loss. There were no differences between the 2 groups, robotic versus open, with respect to graft function (delayed graft function 0% vs 2.4%, p=0.081), hospital stay (median 8 days for both, p=0.647), graft rejection (16.2% vs 18.6% at 36 months, p=0.643), and graft (95.2% vs 96.3% at 36 months, p=0.266) and overall survival (94.5% vs 98.1% at 36 months, p=0.307). Ding-VanderWeele analysis suggested minimal influence of unknown confounders on study findings. CONCLUSIONS: Robotic kidney transplantation with regional hypothermia was associated with a lower rate of postoperative complications and improved patient comfort in comparison to open kidney transplantation. Graft function, and graft and overall survival were comparable between the 2 techniques.