Aim The purpose of this systematic review was to use the Appraisal of Guidelines for Research and Evaluation tool to assess the methodological quality of clinical practice guidelines (CPGs) for the workup and management of paediatric neck masses. Methods MEDLINE, Embase, Cochrane and grey literature were searched to identify CPG incorporating paediatric neck masses. Four authors with previous training of the Appraisal of Guidelines for Research and Evaluation tool evaluated the included studies. Results Nine studies met inclusion criteria. The highest scoring domains were ‘Scope and Purpose’ (74.0 ± 4.5) and ‘Clarity of Presentation’ (72.9 ± 6.3). The lowest scoring domains were ‘Rigour and Development’ (18.8 ± 7.5) and ‘Applicability’ (23.7 ± 6.1). One study was ‘High’ quality, three received scores of ‘Average’ and five were found to be ‘Low’ quality. Conclusion The majority of paediatric neck mass CPGs were low to average quality. The domains in need of greatest improvement were ‘Rigour and Development’ and ‘Applicability’, suggesting significant concerns in current CPGs focused on paediatric neck masses.
To develop and validate on a simulator a learnable technique to decrease deviation of biopsied cores from the template schema during freehand, side-fire systematic prostate biopsy (sPBx) with the goal of reducing prostate biopsy (PBx) falsenegatives, thereby facilitating earlier sampling, diagnosis and treatment of clinically significant prostate cancer. Participants and MethodsUsing a PBx simulator with real-time three-dimensional visualization, we devised a freehand, pitch-neutral (0°, horizontal plane), side-fire, transrectal ultrasonography (TRUS)-guided sPBx technique in the left lateral decubitus position. Thirtyfour trainees on four Canadian and US urology programmes learned the technique on the same simulator, which recorded deviation from the intended template location in a double-sextant template as well as the TRUS probe pitch at the time of sampling. We defined deviation as the shortest distance in millimeters between a core centre and its intended template location, template deviation as the mean of all deviations in a template, and mastery as achieving a template deviation ≤5.0 mm. ResultsAll results are reported as mean AE SD. The mean absolute pitch and template deviation before learning the technique (baseline) were 8.2 AE 4.1°and 8.0 AE 2.7 mm, respectively, and after mastering the technique decreased to 4.5 AE 2.7°(P = 0.001) and 4.5 AE 0.6 mm (P < 0.001). Template deviation was related to mean absolute pitch (P < 0.001) and increased by 0.5 mm on average with each 1°increase in mean absolute pitch. Participants achieved mastery after practising 3.9 AE 2.9 double-sextant sets. There was no difference in time to perform a double-sextant set at baseline (277 AE 102 s) and mastery (283 AE 101 s; P = 0.39). ConclusionA pitch-neutral side-fire technique reduced template deviation during simulated freehand TRUS-guided sPBx, suggesting it may also reduce PBx false-negatives in patients in a future clinical trial. This pitch-neutral technique can be taught and learned; the University of Florida has been teaching it to all Urology residents for the last 2 years.
nmCRPC, demonstrated that APA added to androgen deprivation therapy (ADT) prolonged metastasis-free survival (MFS) by > 2 yrs (median 40.5 vs 16.2 mo; HR, 0.28; p < 0.0001) and provided a 55% reduction in the risk of symptomatic progression (HR, 0.45; 95% CI, 0.32-0.63; p < 0.0001) (Smith et al. N Engl J Med 2018). We examined whether treatment with APA, a next-generation androgen receptor inhibitor, provided the same benefit and safety profile in pts with or without prior RP and/or XRT (RP/XRT).METHODS: Pts with nmCRPC and a high risk of developing metastasis (prostate-specific antigen doubling time [PSADT] 10 mo) were randomized 2:1 to APA (240 mg QD) þ ADT or PBO þ ADT. Pt outcomes were evaluated based on any RP/XRT prior to the study. Cox proportional hazard analysis was used to estimate the HR and 95% CI for MFS.RESULTS: 41% of pts in each arm (334/806 APA; 166/401 PBO) had prior RP/XRT. Pts with prior RP/XRT were younger with longer time since diagnosis, had lower PSA values, lower ECOG and Gleason scores, and were less likely to have renal impairment. Despite these baseline advantages in the PBO group, pts with prior RP/XRT had poorer outcomes. MFS was significantly shorter for PBO pts with vs without prior local therapy (HR, 1.73; p [ 0.0002). This negative prognosis for pts with prior RP/XRT was overcome with APA (HR, 0.80; p [ 0.13), which delayed development of metastases by 68%-84% vs PBO (Table ). The relative magnitude of improvement with APA vs PBO was highest in pts with prior local therapy. No impact of prior local therapy was observed on incidence of grade 3/4 treatment-emergent adverse events with APA and PBO. Incidence of falls, fractures, hypothyroidism, seizures, and skin rash was similar in pts with or without prior RP/XRT. CONCLUSIONS: Regardless of prior local therapy, pts received highly significant MFS benefit from treatment with APA. Prior therapy did not have an impact on tolerability of APA.
IntroductionPatients with advanced cancers often face significant symptoms from their cancer and adverse effects from cancer-associated therapy. Patient-generated health data (PGHD) are routinely collected information about symptoms and activity levels that patients either directly report or passively record using devices such as wearable accelerometers. The objective of this study was to test the impact of an intervention integrating remote collection of PGHD with clinician and patient nudges to inform communication between patients with advanced cancer and their oncology team regarding symptom burden and functional status.Methods and analysisThis single-centre prospective randomised controlled trial randomises patients with metastatic gastrointestinal or lung cancers into one of three arms: (A) usual care, (B) an intervention that integrates PGHD (including weekly text-based symptom surveys and passively recorded step counts) into a dashboard delivered to oncology clinicians at each visit and (C) the same intervention as arm B but with an additional text-based active choice intervention to patients to encourage discussing their symptoms with their oncology team. The study will enrol approximately 125 participants. The coprimary outcomes are patient perceptions of their oncology team’s understanding of their symptoms and their functional status. Secondary outcomes are intervention utility and adherence.Ethics and disseminationThis study has been approved by the institutional review board at the University of Pennsylvania. Study results will be disseminated using methods that describe the results in ways that key stakeholders can best understand and implement.Trial registration numbersNCT04616768 and 843 616.
1506 Background: Oncologists suboptimally assess patient symptoms and functional status, possibly leading to poor symptom management or over-treatment. Remote patient-reported symptoms and passive activity monitoring may provide objective measures of symptoms and functional status to improve patient-clinician communication and symptom understanding. We assessed the impact of a clinician-centered dashboard of longitudinal patient-reported symptoms and step counts on patient-clinician communication regarding symptoms and functional status. Methods: This randomized trial enrolled 108 patients with incurable GI or lung cancers treated with chemotherapy at a large academic health center. Patients were randomized to either of Arms A) control, B) weekly patient-reported symptoms via text message + step tracking from a wearable activity monitor, with summary dashboards given to clinicians at each visit, or C) arm B plus text message-based prompts to patients encouraging discussion of symptoms and functional status prior to each visit. We used Kruskal Wallis tests to compare co-primary outcomes (patient-reported perceptions of clinician symptom and functional status understanding at 6 months after enrollment) between control (A) and intervention (B+C) arms on a 5-point scale (1 = Not at all; 2 = Slightly; 3 = Moderately; 4 = Considerably; 5 = Completely). Results: 33, 37, and 38 patients were enrolled in arms A, B, and C, respectively. Patients were 54.6% male, mean age was 58.9 years, 77% had GI cancer, and 23% had lung cancer. At six months, there was no difference between control and intervention arms in patient perception of clinician understanding of symptoms (Arm A: 4.5, Arm B/C: 4.5, p = 0.85) or functional status (Arm A: 4.5, Arm B/C: 4.3, p = 0.59). Patients reported that their oncology team seldom discussed PROstep data during appointments (mean 2.3 on 5-point scale where 2 = seldom). Hospitalization rates were 42% and 45% for Arms A and B/C (p = 0.8), respectively, and new palliative care referrals were 9% and 10% (p = 0.8), respectively. Mean adherence to weekly patient reports and Fitbit data (at least 4 of 7 days in a week) was 64% and 53%, respectively. Net promoter score was 8.3 on a 10-point scale. Conclusions: Clinician and patient-directed dashboards based on patient-generated health data did not lead to higher patient-perceived clinician understanding of symptoms and functional status, although this was limited by moderate adherence to remote symptom and step count collection and low frequency of clinician discussion of PROStep data with patients, highlighting challenges to clinical application of these data sources. Further efforts are needed to improve patient-clinician communication about symptoms and functional status. Clinical trial information: NCT04616768.
Comparing pre-and post-webinar responses, applicants had a significantly improved conception of what they must do both prior to and during the application process (P < 0.01). Furthermore, applicants reported a significantly greater degree of confidence in the NRMP (P < 0.01). Conclusions: In this study, it was found that the virtual webinar did have a significant positive impact on applicants' assurance in and understanding of the NRMP. Furthermore, fears concerning new limitations imposed upon applicantssuch as not being able to pursue away rotationswere also alleviated. Interventional radiology is one of the most competitive specialties, with the highest applicant to available position ratio of 4.53 and the 7 th highest average USMLE Step 1 score. Thus, the dissemination of appropriate information to applicants is integral to their success. Overall, this analysis suggests that virtual webinars and program director communication are a powerful tool that can promote applicants' confidence in and knowledge of the NRMP in the face of the COVID-19 Pandemic and its concomitant challenges.
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