Purpose To compare clinical outcomes of MR-based versus CT-based high-dose-rate (HDR) interstitial brachytherapy (ISBT) for vaginal recurrence of endometrioid endometrial cancer (EC). Methods We reviewed 66 patients with vaginal recurrent EC; 18 had MR-based ISBT on a prospective clinical trial and 48 had CT-based treatment. Kaplan-Meier (K-M) survival modeling was used to generate estimates for local control (LC), disease-free interval (DFI), and overall survival (OS) and multivariate Cox modeling was used to assess prognostic factors. Toxicities were evaluated and compared. Results Median follow up was 33 months (CT 30 months, MR 35 months). Median cumulative EQD2 was 75.5 Gy for MR-ISBT and 73.8 Gy for CT-ISBT (p=0.58). MR patients were older (p=0.03) and had larger tumor size (>4cm vs ≤4cm) compared to CT patients (p=0.04). For MR- vs. CT-based ISBT, 3-year KM rate for LC was 100% vs. 78% (p = 0.04), DFI was 69% vs. 55% (p= 0.1), and OS was 63% vs. 75% (p= 0.81), respectively. On multivariate analysis, tumor grade 3 was associated with worse OS (HR 3.57, 95%CI 1.25,11.36) in a model with MR-ISBT (HR=0.56, 95%CI 0.16,1.89). Toxicities were not significantly different between the two modalities. Conclusion Despite worse patient prognostic features, MR-ISBT was associated with a significantly better (100%) 3-year local control, comparable survival, and improved DFI rates compared to CT. Toxicities did not differ compared to CT-ISBT patients. Tumor grade contributed as the most significant predictor for survival. Larger prospective studies are needed to assess the impact of MR-ISBT on survival outcomes.

PURPOSE To compare clinical outcomes of image-based versus non-image-based interstitial brachytherapy (IBBT) for vaginal cancer METHODS AND MATERIALS Of 72 patients with vaginal cancer treated with brachytherapy (BT), 47 had image guidance (CT=31, MRI=16) and 25 did not. Kaplan-Meier (KM) estimates were generated for any recurrence, local control (LC), disease-free interval (DFI), and overall survival (OS) and Cox models were used to assess prognostic factors. RESULTS Median age was 66 and median follow-up time was 24 months. Median cumulative EQD2 dose was 80.8 Gy in the non-IBBT group and 77 Gy in the IBBT group. For non-IBBT versus IBBT, the 2-year KM LC was 71% vs. 93% (p=0.03); DFI was 54% vs. 86% (p=0.04); and OS 52% vs. 82% (p=0.35). On multivariate analysis, IBBT was associated with better DFI (HR 0.24, 95% CI 0.07–0.73). Having any 2 or more of chemotherapy, high-dose-rate (HDR) BT or IBBT (temporally correlated variables) significantly reduced risk of relapse (HR=0.33, 95% CI= 0.13–0.83), compared to having none of these factors. CONCLUSION Over time, the use of chemotherapy, HDR and IBBT has increased in vaginal cancer. The combination of these factors resulted in the highest rates of disease control. Image-guided brachytherapy for vaginal cancer patients maximizes disease control.

Objective The purpose was to compare local control (LC), overall survival (OS) and dose to the organs at risk (OAR) in women with locally advanced cervical cancer treated with MR-guided versus CT-guided interstitial brachytherapy (BT). Methods 56 patients (29 MR, 27 CT) were treated with high-dose-rate (HDR) interstitial BT between 2005–2015. The MR patients had been prospectively enrolled on a Phase II clinical trial. Data were analyzed using Kaplan-Meier (K-M) and Cox proportional hazards statistical modeling in JMP® & R®. Results Median follow-up time was 19.7 months (MR group) and 18.4 months (CT group). There were no statistically significant differences in patient age at diagnosis, histology, percent with tumor size >4 cm, grade, FIGO stage or lymph node involvement between the groups. Patients in the MR group had more lymphovascular involvement compared to patients in the CT group (p<0.01). When evaluating plans generated, there were no statistically significant differences in median cumulative dose to the high-risk clinical target volume or the OAR. 2-year K-M LC rates for MR-based and CT-based treatments were 96% and 87%, respectively (log-rank p=0.65). At 2 years, OS was significantly better in the MR-guided cohort (84% vs. 56%, p=0.036). On multivariate analysis, squamous histology was associated with longer OS (HR 0.23, 95% CI 0.07–0.72) in a model with MR BT (HR 0.35, 95% CI 0.08–1.18). Conclusion In this population of locally advanced cervical-cancer patients, MR-guided HDR BT resulted in estimated 96% 2-year local control and excellent early survival rates. Squamous cell histology was the most significant predictor for survival.

Objectives Focused research on pediatric agitation is lacking despite being a common mental and behavioral health (MBH) emergency. Prevalence of pediatric agitation remains unknown, and prior reports may have underestimated the rate of restraint use for pediatric agitation. This is the largest study to provide a focused evaluation of the prevalence and predictors of pediatric agitation and restraint use as well as the emergency department (ED) length of stay (LOS) and admission rates for agitated patients. Methods We reviewed records of patients aged ≤18 years with MBH needs who visited the pediatric ED of a tertiary care hospital during a 3‐year‐period. We identified and ascertained agitated/aggressive patients using documented signs/symptoms, International Classification of Diseases, Tenth Revision codes, and Behavioral Activity Rating Scale scores. We performed descriptive and multivariable analyses using SAS 9.4 (SAS Institute). Results Of 10,172 patients with MBH needs, 1408 (13.8%) were agitated/aggressive. Of these (n = 1408), 63.7% were boys, and the mean age was 11.9 years. Among agitated patients, the prevalence of restraint use was 28.7%, with a predominance of pharmacologic restraint with atypical antipsychotics. Non‐Hispanic Blacks were more likely to be agitated (adjusted odd ratio [aOR], 1.8; 95% CI, 1.2–2.7), but not restrained (aOR, 0.8; 95% CI, 0.3–1.8). Predictors of restraint use include history of attention deficit hyperactivity disorder (aOR, 2.2; 95% CI, 1.5–3.3), autism (aOR, 2.9; 95% CI, 1.9–4.5), conduct disorder (aOR, 1.7; 95% CI, 1.2–2.5), psychosis (aOR, 14.3; 95% CI, 2.5–271.8), and substance use/overdose states (aOR, 1.9; CI, 1.2–3.2). Restrained agitated patients had longer ED LOS (8.4 vs 5.0 hours; P < 0.0001) and higher admission rates (aOR, 2.6; 95% CI, 2.0–3.5). Depression (aOR, 0.4; 95% CI, 0.3–0.5) and suicidality (aOR, 0.2; 95% CI, 0.1–0.3) were protective against agitation and restraint use. Conclusion Prevalence of acute agitation and restraint use in pediatric EDs may be much higher than previously reported. Predictors of acute agitation and restraint use among MBH patients were consistent with prior reports. Restrained agitated patients had longer ED LOS and higher admission rates.

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BackgroundThe shortage of mental health services across the United States has turned pediatric emergency departments (PEDs) into safety‐nets for the increasing population of children with mental and behavioral health (MBH) needs. This study provides a descriptive characterization of MBH‐related PED visits, the trends in visit, ED length of stay (EDLOS), and admission rate.MethodsWe reviewed electronic health records of children ≤18 years with MBH needs, who visited the PED of a large tertiary hospital from January 2017 to December 2019. We performed descriptive statistics, chi‐square (χ2), and logistic regression analyses to evaluate trend in visit, EDLOS, admission rate, and predictors of prolonged EDLOS and inpatient admission.ResultsOf 10,167 patients, 58.4% were females, median age was 13.8 years, and 86.1% were adolescents. On average, visits increased by 19.7% annually, with a 43.3% increase over 3 years. Common ED diagnoses include, suicidality (56.2%), depression (33.5%), overdose/poisoning, and substance use (18.8%), and agitation/aggression (10.7%). Median EDLOS was 5.3 hr, average admission rate was 26.3%, with 20.7% boarding in the ED for >10 hr. Independent predictors of admission include depression (pOR: 1.5, CI: 1.3–1.7), bipolar disorder (pOR: 3.5, CI: 2.4–5.1), overdose/substance use disorder (pOR: 4.7, CI: 4.0–5.6), psychosis (pOR: 3.3, CI: 1.5–7.3), agitation/aggression (pOR: 1.8, CI: 1.5–2.1), and ADHD (pOR: 2.5, CI: 2.0–3.0). Principal independent driver of prolonged EDLOS was patient admission/transfer status (pOR: 5.3, CI: 4.6–6.1).ConclusionsGiven the study results, MBH‐related PED visits, ED length‐of‐stay, and admission rates continue to rise even in recent years. PEDs lack the resources and capability to provide high‐quality care for the increasing population of children with MBH needs. Novel collaborative approaches and strategies are urgently needed to find lasting solutions.

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