This study establishes performance metrics for angiography and neuroendovascular surgery procedures based on longitudinal improvement in individual trainees with differing levels of training and experience.Over the course of 30 days, five trainees performed 10 diagnostic angiograms, coiled 10 carotid terminus aneurysms in the setting of subarachnoid hemorrhage, and performed 10 left middle cerebral artery embolectomies on a Simbionix Angio Mentor™ simulator. All procedures were nonconsecutive. Total procedure time, fluoroscopy time, contrast dose, heart rate, blood pressures, medications administered, packing densities, the number of coils used, and the number of stent-retriever passes were recorded. Image quality was rated, and the absolute value of technically unsafe events was recorded. The trainees’ device selection, macrovascular access, microvascular access, clinical management, and the overall performance of the trainee was rated during each procedure based on a traditional Likert scale score of 1=fail, 2=poor, 3=satisfactory, 4=good, and 5=excellent. These ordinal values correspond with published assessment scales on surgical technique.After performing five diagnostic angiograms and five embolectomies, all participants demonstrated marked decreases in procedure time, fluoroscopy doses, contrast doses, and adverse technical events; marked improvements in image quality, device selection, access scores, and overall technical performance were additionally observed (p < 0.05). Similarly, trainees demonstrated marked improvement in technical performance and clinical management after five coiling procedures (p < 0.05). However, trainees with less prior experience deploying coils continued to experience intra-procedural ruptures up to the eighth embolization procedure; this observation likely corresponded with less tactile procedural experience to an exertion of greater force than appropriate for coil placement.Trainees across all levels of training and prior experience demonstrated a significant performance improvement after completion of our simulator curriculum consisting of five diagnostic angiograms, five embolectomy cases, and 10 aneurysm coil embolizations.
While various tools such as the International Prognostic Index (IPI) and its derivatives exist for risk-stratification of diffuse large B-cell lymphoma (DLBCL) at diagnosis, patient and disease characteristics capable of predicting outcome after high-dose chemotherapy followed by autologous stem cell transplantation (HDC/ASCT) are not clearly defined. We retrospectively analyzed medical records of 111 DLBCL patients (78 relapsed and 33 refractory) who underwent HDC/ASCT at our institution from 2010-2015. After a median follow-up time of 4.6 years (interquartile range [IQR] 2.2-8.1), the likelihood of 5-year progression-free survival (PFS) was 62.2% (95% CI, 53.4%-72.4%) and the likelihood of 5-year overall survival (OS) was 68.9% (95% CI, 60.7%-78.2%). More than three chemotherapy regimens prior to ASCT was the only variable associated with lower likelihood of PFS (P = .004) and OS (P = 0.026). Male gender and high IPI score at time of ASCT were also associated with lower likelihood of PFS (P = .043; P = .013). NCCN IPI and age-adjusted IPI at time of ASCT were not predictive of outcome following ASCT. Patients with refractory and relapsed disease had similar outcomes post-ASCT (P = .207 for PFS, P = .073 for OS). K E Y W O R D S diffuse large B-cell lymphoma, autologous stem cell transplant, progression-free survival, overall survival, international prognostic index
Although patients with multiple myeloma (MM) have improved survival with current therapies, there remains a long-term risk of treatment-associated second primary malignancies. We present a case of a patient with IgG kappa MM undergoing treatment for relapsed disease who was noted to have progressive pancytopenia. For his MM, he had previously undergone autologous stem cell transplant with high-dose melphalan and had received immunomodulatory (IMiD) agents in induction, maintenance and relapse regimens. A peripheral blood smear showed abnormal lymphoid cells, and a bone marrow biopsy revealed B-cell acute lymphoblastic leukaemia (B-ALL). He underwent intensive induction chemotherapy with plans for possible allogeneic stem cell transplant. Secondary B-ALL is a rare occurrence in patients with MM, with exposure to alkylating and IMiD agents being potential risk factors.
e19030 Background: High-dose chemotherapy followed by autologous stem cell transplantation (HDC/ASCT) is standard of care for patients with diffuse large B-cell lymphoma (DLBCL) whose diseases relapse after, or are refractory to, first-line therapy. However, there are still high rates of relapse following ASCT, and non-relapse mortality also affects survival rates. Prognostic indicators are therefore needed to identify the best candidates for HDC/ASCT. Methods: We retrospectively analyzed medical records of 111 DLBCL patients (78 relapsed, 33 refractory) who underwent HDC/ASCT at the University of California Los Angeles from 2010-2015. Results: The median age at the time of ASCT was 61 years (IQR 51.5-68.0). 80 patients (72%) had DLBCL in a complete response at the time of ASCT, and the majority (98 patients, 88%) had ECOG performance status of 0-1. After a median follow-up of 4.6 years (IQR 2.2-8.1), the 1-year progression-free survival (PFS) rate was 77.3% (95% CI 69.7%-85.7%) and the 1-year overall survival (OS) rate was 84.7% (95% CI 78.2%-91.7%). 41 patients (37%) relapsed after ASCT with a median PFS of 11 months (IQR 5.0-20.0). 37 patients (33%) died, 23 (21%) from relapse mortality, 11 (10%) from non-relapse mortality, and 3 (3%) from unknown cause of death. In univariate analysis, 2 variables were significantly associated with curtailed PFS and OS: higher number (≥ 3 vs < 3) of chemotherapy regimens prior to ASCT (HR 2.20, 95% CI 1.19-4.06, p = 0.013 for PFS; HR 2.01, 95% CI 1.06-3.84, p = 0.036 for OS) and higher International Prognostic Index (IPI) score at time of ASCT (trend HR 1.61, 95% CI 1.10-2.35, p = 0.018 for PFS; trend HR 2.02, 95% CI 1.37-2.98, p = 0.001 for OS). Higher National Comprehensive Cancer Network (NCCN) IPI score at time of ASCT (trend HR 2.29, 95% CI 1.34-3.90, p = 0.002) and refractory versus relapsed disease (HR 1.99, 95% CI 1.04-3.82, p = 0.038) were also significantly associated with curtailed OS. Conclusions: Our study suggests that IPI, while a validated prognostic tool at diagnosis, is also a prognostic indicator at time of ASCT for PFS and OS. NCCN IPI at time of ASCT was also found to be predictive of OS. Age-adjusted IPI was not associated with outcome following ASCT.
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