BackgroundGiven improvements in multimodality therapy, survival among children with Wilms tumor (WT) exceeds 90%. However, 15% of children with favorable histology and 50% of children with anaplastic WT experience recurrence or progression. Of patients with advanced disease, only 50% survive to adulthood. In adult malignancies (including renal tumors), patient survival has improved with the advent of immunotherapy. However, little is known about the immune microenvironment of WT, making the potential role of immunotherapy unclear.Drs. Holl and Routh contributed equally to this manuscript.
Introduction: Tables predicting the probability of a positive bone scan in men with non-metastatic, castrate-resistant prostate cancer have recently been reported. We performed an external validation study of these bone scan positivity tables. Materials and Methods: We performed a retrospective cohort study of patients seen at a tertiary care medical center (1996-2012) to select patients with non-metastatic, castrate-resistant prostate cancer. Abstracted data included demographic, anthropometric, and disease-specifi c data such as patient race, BMI, PSA kinetics, and primary treatment. Primary outcome was metastasis on bone scan. Multivariable logistic regression was performed using generalized estimating equations to adjust for repeated measures. Risk table performance was assessed using ROC curves. Results: We identifi ed 6.509 patients with prostate cancer who had received hormonal therapy with a post-hormonal therapy PSA ≥2ng/mL, 363 of whom had non-metastatic, castrate-resistant prostate cancer. Of these, 187 patients (356 bone scans) had calculable PSA kinetics and ≥1 bone scan. Median follow-up after castrate-resistant prostate cancer diagnosis was 32 months (IQR: 19-48). There were 227 (64%) negative and 129 (36%) positive bone scans. On multivariable analysis, higher PSA at castrate-resistant prostate cancer (4.67 vs. 4.4ng/mL, OR=0.57, P=0.02), shorter time from castrate-resistant prostate cancer to scan (7.9 vs. 14.6 months, OR=0.97, P=0.006) and higher PSA at scan (OR=2.91, P <0.0001) were signifi cantly predictive of bone scan positivity. The AUC of the previously published risk tables for predicting scan positivity was 0.72. Conclusion: Previously published risk tables predicted bone scan positivity in men with non-metastatic, castrate-resistant prostate cancer with reasonable accuracy.
Our weekly huddle serves to surface logistic, safety or equipment concerns, generate and mark progress on improvement ideas amongst stakeholders. On operating room (OR) days, we conduct a 5 minute huddle prior to case start to review cases, anesthetic approach, positioning and equipment needs. RESULTS: Over a 2 year period 34 projects were developed by the resident team to improve work flow and patient experience. Projects most often impacted the outpatient setting (65%), followed by inpatient (21%) and the overall service (14%). Most projects related to the quality (n[13), workforce development (n[7), care experience (n[5), equity (n[5), safety (n[2), and financial stewardship (n[2). UroLean was used to improve next available outpatient clinic appointment wait from 168 to 21 days. BCG treatment times reduced from 180 to 105 minutes by identifying clinic flow changes such as ordering BCG the evening before, sending reminders to patients and prompt insertion of catheter. The urology on-time OR average start-time was better than the overall OR mean (71% v 61%, respectively) (Fig 1). Common barriers to on-time start identified via this process included: patient related factors (25.93%), anesthesia (17.59%), housekeeping (17.54%) and surgeons (12.9%). CONCLUSIONS: Residents were successful in applying LEAN in a safety-net hospital. Our department improved communication within our team and across service lines. Lean provides structure and can be an effective tool to improve resident engagement in quality and safety endeavors.
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