Multidisciplinary care and immortal time bias

Adults with congenital heart disease (CHD) have become a rapidly expanding group of complex patients requiring multidisciplinary care in specialty centers by those trained in CHD. They represent one of the most challenging subgroups of patients with pulmonary arterial hypertension (PAH) due to the presence of structural heart disease with or without coexisting cyanosis and its complications. The primary focus of attention for these patients is the lungs, whose vascular system is affected by shunt flow, or is also congenitally malformed, or has been altered by surgical procedures. When PAH develops, it affects physical exercise tolerance, travel to high altitudes, pregnancy, operability, and anesthesia (myocardial failure due to pulmonary hypertensive crisis), and thus general morbidity and mortality in this special patient group.

Download Full-text

Outcomes of Multidisciplinary Care for Pediatric Post-Concussive Symptoms

Neurology ◽

10.1212/01.wnl.0000581004.98313.0c ◽

2019 ◽

Vol 93 (14 Supplement 1) ◽

pp. S18.1-S18

Author(s):

Jillian O’Neil ◽

Sean Rose ◽

Ashley Davidson ◽

Kathleen Shiplett ◽

Anthony Castillo ◽

...

Keyword(s):

Aerobic Exercise ◽

Psychological Intervention ◽

Multidisciplinary Treatment ◽

Symptom Burden ◽

Multidisciplinary Care ◽

Exercise Session ◽

Symptom Improvement ◽

Final Visit ◽

Post Injury ◽

History Of

ObjectiveTo evaluate the effectiveness of a multidisciplinary treatment approach for adolescents experiencing prolonged recovery from concussion.BackgroundAlthough most youth recover from a concussion within 2–4 weeks, an estimated 14% of those injured remain symptomatic at 3 months post-injury. For those experiencing protracted recovery, the 2017 Berlin Concussion in Sport Group Consensus Statement recommends multidisciplinary collaborative care. While recent research utilizing progressive aerobic exercise among adolescents with concussion has shown promise for reduction in symptom burden, limited evidence exists for multidisciplinary care.Design/MethodsParticipants included 39 adolescents (77% female, 87% Caucasian) referred to the Nationwide Children’s Hospital Complex Concussion Clinic. All patients included had persistent (≥30 days post-injury) post-concussion symptoms (SCAT-5 symptom score ≥10). The sample ranged in age from 11-20 years (mean = 15.0, SD = 2.0) and median days since injury was 60 (range = 30–161). 31% of participants had a history of one or more previous concussions, 54% had a history of anxiety or depression, and 26% had a history of ADHD or a learning disorder. The multidisciplinary treatment included sessions with Neurology (mean number of sessions = 2.5), Neuropsychology (mean = 2.1), Physical Therapy (mean = 3.6), and Athletic Training sessions involving graded physical exercise (mean = 4.0), with an average treatment duration of 57.4 days. SCAT-5 symptom rating scales were completed at each visit.ResultsSymptom burden among participants significantly decreased between their initial visit (mean = 49.6, SD = 19.2) and final exercise session (mean = 12.8, SD = 14.1); p < 0.001. Gender did not predict symptom ratings at treatment onset, though males (mean = 5.6) had significantly lower symptom scores than females (mean = 15.0) at their final visit (p < 0.05). Demographic factors and premorbid psychological history did not predict rate of symptom improvement.ConclusionsHigh rates of premorbid psychological problems are evident in children referred for treatment of PCS. Multidisciplinary care involving graded aerobic exercise and psychological intervention shows promise, though specific factors associated with treatment response remain to be elucidated.

Download Full-text

Management of recurrent or progressive spinal metastases: reirradiation techniques and surgical principles

Neuro-Oncology Practice ◽

10.1093/nop/npaa045 ◽

2020 ◽

Vol 7 (Supplement_1) ◽

pp. i45-i53

Author(s):

Rupesh Kotecha ◽

Nicolas Dea ◽

Jay S Detsky ◽

Arjun Sahgal

Keyword(s):

Progressive Disease ◽

Organs At Risk ◽

Methodological Approach ◽

Spinal Metastases ◽

Multidisciplinary Care ◽

Rehabilitation Medicine ◽

Surgical Approaches ◽

Mechanical Instability ◽

Conventional Radiotherapy ◽

Treated Site

Abstract With the growing incidence of new cases and the increasing prevalence of patients living longer with spine metastasis, a methodological approach to the management of patients with recurrent or progressive disease is increasing in relevance and importance in clinical practice. As a result, disease management has evolved in these patients using advanced surgical and radiotherapy technologies. Five key goals in the management of patients with spine metastases include providing pain relief, controlling metastatic disease at the treated site, improving neurologic deficits, maintaining or improving functional status, and minimizing further mechanical instability. The focus of this review is on advanced reirradiation techniques, given that the majority of patients will be treated with upfront conventional radiotherapy and further treatment on progression is often limited by the cumulative tolerance of nearby organs at risk. This review will also discuss novel surgical approaches such as separation surgery, minimally invasive percutaneous instrumentation, and laser interstitial thermal therapy, which is increasingly being coupled with spine reirradiation to maximize outcomes in this patient population. Lastly, given the complexities of managing recurrent spinal disease, this review emphasizes the importance of multidisciplinary care from neurosurgery, radiation oncology, medical oncology, neuro-oncology, rehabilitation medicine, and palliative care.

Download Full-text

IMMU-04. IMMUNE-RELATED ADVERSE EVENTS STRONGLY PREDICT SUPERIOR OUTCOMES IN BRAIN METASTASES PATIENTS RECEIVING LOCAL TREATMENT AND IMMUNE CHECKPOINT INHIBITORS

Neuro-Oncology ◽

10.1093/neuonc/noaa215.435 ◽

2020 ◽

Vol 22 (Supplement_2) ◽

pp. ii105-ii105

Author(s):

Alexander Hulsbergen ◽

Asad Lak ◽

Yu Tung Lo ◽

Nayan Lamba ◽

Steven Nagtegaal ◽

...

Keyword(s):

Sensitivity Analysis ◽

Adverse Events ◽

Brain Metastases ◽

Immune Checkpoint ◽

Immune Checkpoint Inhibitors ◽

Checkpoint Inhibitors ◽

Local Treatment ◽

Sensitivity Analyses ◽

Immortal Time Bias ◽

The Brain

Abstract INTRODUCTION In several cancers treated with immune checkpoint inhibitors (ICIs), a remarkable association between the occurrence of immune-related adverse events (irAEs) and superior oncological outcomes has been reported. This effect has hitherto not been reported in the brain. This study aimed to investigate the relation between irAEs and outcomes in brain metastases (BM) patients treated with both local treatment to the brain (LT; i.e. surgery and/or radiation) and ICIs. METHODS This study is a retrospective cohort analysis of patients treated for non-small cell lung cancer (NSCLC) BMs in a tertiary institution in Boston, MA. Outcomes of interest were overall survival (OS) and intracranial progression-free survival (IC-PFS), measured from the time of LT. Sensitivity analyses were performed to account for immortal time bias (i.e., patients who live longer receive more cycles of ICIs and thus have more opportunity to develop an irAE). RESULTS A total of 184 patients were included; 62 (33.7%) were treated with neurosurgical resection and 122 (66.3%) with upfront brain radiation. irAEs occurred in 62 patients (33.7%). After adjusting for lung-Graded Prognostic Assessment, type of LT, type of ICI, newly diagnosed vs. recurrent BM, BM size and number, targetable mutations, and smoking status, irAEs were strongly associated with better OS (HR 0.33, 95% CI 0.19 – 0.58, p < 0.0001) and IC-PFS (HR 0.41; 95% CI 0.26 – 0.65; p = 0.0001). Landmark analysis including only patients who received more than 3 cycles of ICI (n = 133) demonstrated similar results for OS and IC-PFS, as did sensitivity analysis adjusting for the number of cycles administered (HR range 0.36 – 0.51, all p-values < 0.02). CONCLUSIONS After adjusting for known prognostic factors, irAEs strongly predict superior outcomes after LT in NSCLC BM patients. Sensitivity analysis suggests that this is unlikely due to immortal time bias.

Download Full-text