This study aims to determine the public's perception of telemedicine surgical consultations, during the COVID-19 pandemic and beyond. Summary Background Data: With rapid expansion and uptake of telemedicine during the pandemic, many have posited that virtual visits will endure even as in-person visits are reinstated. The public's perception of telemedicine for an initial surgical consultation has not been previously studied. Methods: A 43-question survey assessed respondents' attitudes toward telemedicine for initial consultations with surgeons, both in the context of COVID-19 and during ''normal circumstances.'' Participants were recruited through Amazon Mechanical Turk, an online crowd-sourcing marketplace. Results: Based on 1827 analyzable responses, we found that a majority (86%) of respondents reported being satisfied (either extremely or somewhat) with telemedicine encounters. Interestingly, preference for in-person versus virtual surgical consultation reflected access to care, with preference for telemedicine decreasing from 72% to 33% when COVID-related social distancing ends. Preferences for virtual visits decreased with increasing complexity of the surgical intervention, even during the pandemic. A majority felt that ''establishing trust and comfort'' was best accomplished in person, and the vast majority felt it was important to meet their surgeons before the day of surgery. Conclusions: The public views telemedicine as an acceptable substitute for in-person visits, especially during the pandemic. However, it seems that an inperson interaction is still preferred when possible for surgical consultations. If telemedicine services are to persist beyond social distancing, further exploration of its impact on the patient-surgeon relationship will be needed.
The incidence of secondary overtriage in our rural trauma center is 26%, with head and neck injuries being the most common reason for transfer. Costs for transportation and additional evaluation for such a significant percentage of patients has important resource utilization implications. Effective regionalization of rural trauma care should include methods to limit secondary overtriage.
Background— Increasing numbers of the very elderly are undergoing aortic valve procedures. We describe the short- and long-term survivorship for this cohort. Methods and Results— We conducted a cohort study of 7584 consecutive patients undergoing open aortic valve surgery without (51.1%; AVR) or with (48.9%; AVR + CABG) concomitant coronary artery bypass graft surgery between November 10, 1987 through June 30, 2006. Patient records were linked to the Social Security Administration’s Death Master File. Survivorship was stratified by age and concomitant CABG surgery. During 39 835 person-years of follow-up, there were 2877 deaths. Among AVR, there were 3304 patients <80 years of age, 419 patients 80 to 84 years, and 156 patients ≥85 years (24 patients >90 years). Among AVR+CABG patients, there were 2890 patients <80 years of age, 577 patients 80 to 84 years, and 238 patients ≥85 years (22 patients >90 years). Median survivorship for patients undergoing isolated AVR was 11.5 years (<80 years), 6.8 years (80 to 84 years), 6.2 years (≥85 years); for patients undergoing AVR+CABG, median survivorship was 9.4 years (<80 years), 6.8 years (80 to 84 years), and 7.1 years (≥85 years). Among both procedures, adjusted survivorship was significantly different across strata of age ( P <0.001). These findings are similar to life expectancy of the general population from actuarial tables: 80 to 84 years (7 years) and ≥85 years (5 years). Conclusions— Survivorship among octogenarians is favorable, with more than half the patients surviving more than 6 years after their surgery. Concomitant CABG surgery does not diminish median survivorship among patients >80 years of age.
Recently, antiretroviral agents directed at several steps involved in viral entry have been shown to reduce viral replication in vitro and in vivo. We have demonstrated a high level of in vitro synergistic antiretroviral activity for two entry inhibitors that are directed at sequential steps in the entry process.Combination chemotherapy has had a profound effect on human immunodeficiency virus type 1 (HIV-1)-associated morbidity and mortality (8). Although there are now more than 20 approved antiretroviral chemotherapeutic agents, there is significant overlap in resistance patterns among these agents, effectively limiting the number of sequential antiretroviral regimens available to a given patient. Recent clinical trials have demonstrated that agents that either block the binding of HIV-1 to its chemokine coreceptors or prevent reconfiguration of the gp41 molecule significantly reduce the replication of HIV-1 in vivo (5,6,13,14). These in vivo observations have been complemented by a series of in vitro observations that demonstrate that antiviral agents acting at several steps of the entry cascade exhibit substantial antiviral synergism (15, 16). TNX-355 (formerly hu5A8) is a humanized monoclonal antibody that binds to a unique epitope in domain 2 of the CD4 molecule that is involved in the conformational change required for entry into target cells following binding of the virus to the CD4 molecule (2, 7). We report here in vitro studies that demonstrate the synergistic activity of TNX-355 and enfuvirtide against HIV-1.Peripheral blood mononuclear cells were isolated from HIV-1-uninfected donors by Ficoll-Hypaque density gradient centrifugation and grown in RPMI 1640 medium supplemented with 20% fetal calf serum, 5% interleukin-2, and 5 g/ml phytohemagglutinin (R-3 medium). Three-day phytohemagglutinin blasts (2 ϫ 10 6 ) were incubated with HIV-1 (100 50% tissue culture infective doses) and TNX-355, enfuvirtide, or both agents in 2.0 ml of medium overnight in 24-well tissue culture plates at 37°C in a humidified 5% CO 2 atmosphere. Peripheral blood mononuclear cells were washed three times in phosphate-buffered saline and resuspended in 2 ml of R-3 medium with replacement of the antiviral compound(s) being tested. HIV-1 p24 antigen production was assessed on days 4 and 7 of culture in cell-free supernatant fluid from each well by enzymelinked immunosorbent assay (Beckman Coulter, Miami, FL). Fresh R-3 medium with appropriate antiviral compound concentrations replaced the 0.5 ml of supernatant removed for p24 assay on day 4. Primary HIV-1 isolates (302076, 302077, 302143, 302054, and 301714) were provided by the National Institutes of Health AIDS Reference Reagent Repository. Human T-cell lymphotropic virus strain IIIB (HTLV-IIIB) was provided by Robert Gallo (Institute of Human Virology, Baltimore, MD). TNX-355 (Tanox, Inc., Houston, TX) was used at concentrations of 2.0, 0.4, 0.08, 0.016, 0.0032, and 0.00064 g/ml. Enfuvirtide (T-20; Trimeris, Inc., Durham, NC) was used at concentrations of 1.0, 0.2, 0.04, 0...
6513 Background: Treatment options for aggressive TC are limited. Pre-clinical data suggests efficacy of CTLA-4 plus PD-1 blockade in aggressive RAIR TC. Methods: This investigator initiated phase II study tested N (3mg/kg every 2 weeks) plus I (1mg/kg every 6 weeks) until disease progression or completion of 24 mo of treatment in RAIR differentiated TC including poorly differentiated TC (PDTC) with exploratory cohorts in anaplastic (ATC) and medullary TC (MTC). Radiographic response rate by RECIST v1.1 (CR+PR) was primary endpoint. At least 6 pts with disease response among n=32 DTC provided 84% power to distinguish between a 10% and a 25% RR (one-sided 9% binomial test). Results: Accrual is complete with n=32 patients with DTC, 10 with ATC and 7 with MTC enrolled between October 2017 and May 2019. Thirty-two DTC included: n=17 papillary, n=7 Hurthle, n=4 follicular TC, n=4 PDTC. Among n=49, median (range) age was 65 (30-88), 51% (25/49) were female. To date, in DTC, 3/32 achieved a PR (n=2 Hurthle and n=1 PDTC), 9.4% RR (.95CI:2%-25%). One near complete response has been observed. Among pts w ATC, 3/ 10 profound PR by RECIST occurred (30% RR, .95CI: 7%-65%). Among them, two remain without clear evidence of disease at 26 and 13 mo after treatment start. No PR's were observed in MTC. Most frequent grade 3-4 TRAEs were as expected and included increased lipase (n=8), increased serum amylase (n=4). There was an unexpected number of treatment related adrenal insufficiency (AI) (n=4) which was associated with long PFS (range 10.1—16.4+mo). Conclusions: N+I appears to have considerable activity in ATC. In unselected RAIR DTC, activity was low but responses were seen in PDTC and Hurthle cell TC. Exceptional responses with prolonged remissions were observed. Clinical trial information: NCT03246958 .
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