Outcomes of patients with non-small cell lung cancer and poor performance status treated with immune checkpoint inhibitors in the real-world setting

International Journal of Clinical Oncology - Immune-checkpoint inhibitors (ICIs) are standard treatments for metastatic non-small cell lung cancer (NSCLC). Patients with poor performance status...     

Interactive design of patient-oriented video-games for rehabilitation: concept and application

Purpose: Serious video-games are innovative tools used to train the motor skills of subjects affected by neurological disorders. They are often developed to train a specific type of patients and the rules of the game are standardly defined. A system that allows the therapist to design highly patient-oriented video-games, without specific informatics skills, is proposed.

Method: The system consists of one personal computer, two screens, a Kinect? sensor and a specific software developed here for the design of the video-games. It was tested with the collaboration of three therapists and six patients, and two questionnaires were filled in by each patient to evaluate the appreciation of the rehabilitative sessions.

Results: The therapists learned easily how to use the system, and no serious difficulties were encountered by the patients. The questionnaires showed an overall good satisfaction by the patients and highlighted the key-role of the therapist in involving the patients during the rehabilitative session.

Conclusions: It was found that the proposed system is effective for developing patient-oriented video-games for rehabilitation. The two main advantages are that the therapist is allowed to (i) develop personalized video-games without informatics skills and (ii) adapt the game settings to patients affected by different pathologies.

• Implications for rehabilitation

• Virtual reality and serious video games offer the opportunity to transform the traditional therapy into a more pleasant experience, allowing patients to train their motor and cognitive skills.

• Both the therapists and the patients should be involved in the development of rehabilitative solutions to be highly patient-oriented.

• A system for the design of rehabilitative games by the therapist is described and the feedback of three therapists and six patients is reported.

     

Impact of alternate definitions of fever resolution on the composite endpoint in clinical trials of empirical antifungal therapy for neutropenic patients with persistent fever: analysis of results from the Caspofungin Empirical Therapy Study

BACKGROUND: Sensitivity analyses were incorporated in a Phase III study of caspofungin vs. liposomal amphotericin B as empirical antifungal therapy for febrile neutropenic patients to determine the impact of varying definitions of fever resolution on response rates. METHODS: The primary analysis used a 5-part composite endpoint: resolution of any baseline invasive fungal infection, no breakthrough invasive fungal infection, survival, no premature discontinuation of study drug, and fever resolution for 48 h during the period of neutropenia. Pre-specified analyses used 3 other definitions for fever resolution: afebrile for 24 h during the period of neutropenia, afebrile at 7 days post therapy, and eliminating fever resolution altogether from the composite endpoint. Patients were stratified on entry by use of antifungal prophylaxis and risk of infection. Allogeneic hematopoietic stem cell transplants or relapsed acute leukemia defined high-risk patients. RESULTS: In the primary analysis, 41% of patients in each treatment group met the fever-resolution criteria. Low-risk patients had shorter durations of neutropenia but failed fever-resolution criteria more often than high-risk patients. In each exploratory analysis, response rates increased in both treatment groups compared to the primary analysis, particularly in low-risk patients. CONCLUSIONS: Response rates for the primary composite endpoint for both treatment groups in this study were driven by low rates of fever resolution. Requiring fever resolution during neutropenia in a composite endpoint can mask more clinically relevant outcomes.     

How to Avoid Nontherapeutic Laparotomy in Patients With Multiple Organ Failure of Unknown Origin. The Role of CT Scan Revisited

Diagnosis of intra-abdominal diseases in critically ill patients remains a clinical challenge. Physical examination is unreliable whereas exploratory laparotomy may aggravate patient''s condition and delay further evaluation. Only a few studies have investigated the place of computed tomography (CT) on this hazardous situation. We aimed to evaluate the ability of CT to prevent unnecessary laparotomy during the management of critically ill patients. Charts of all consecutive patients who had undergone an emergency nontherapeutic laparotomy from 1996 to 2013 were retrospectively studied and patient''s demographic, clinical characteristics, and surgical findings were collected. During this period 59 patients had an unnecessary laparotomy. Fifty-one patients had at least one preoperative imaging and 36 had a CT scan. CT scans were interpreted to be normal (n = 12), with minor anomalies (n = 10), or major anomalies (pneumoperitoneum, portal venous gas/pneumatosis intestinalis, thickened gallbladder wall, and small bowel obstruction signs). Surgical exploration was performed through laparotomy (n = 55) or laparoscopy. Overall mortality was 37% with a median survival after surgery of 7 days. In univariate analysis, hospitalization in ICU before surgical exploration was the only factor related to death. In our series CT scans, objectively interpreted, helped avoid unnecessary surgical exploration in 61% of our patients.Key words: Laparotomy, Critical care, Abnormalities, Digestive system, CT scansEarly diagnosis of acute nontraumatic life-threatening intra-abdominal diseases remains a clinical challenge. In critically ill patients, pathologies such as mesenteric ischemia, intestinal perforation, pancreatitis and biliary diseases carry a high mortality rate ranging from 50% to 100%.^1,2 For these patients, physical examination can be unreliable due to deep sedation and absence of acute abdomen symptoms, and use of imaging studies may therefore be necessary to identify intra-abdominal pathologies and prevent delay in diagnosis. Also, imaging studies may help avoiding unnecessary laparotomy which can be associated with a morbidity rate up to 22%.³ Ultrasonography (US) can be performed at the bedside and is a good alternative for the diagnosis of biliary tract disease; however, it is highly operator dependent, made difficult by abdominal distension,⁴ and not effective for bowel perforation or ischemia.⁵ Computed tomography (CT) scans are increasingly used for emergency patients with acute nontraumatic abdominal pain and tenderness, however, misinterpretation or overinterpretation of CT findings are not rare.^6,7 Despite the large use of imaging procedures in the evaluation of intra-abdominal pathologies, few studies have attempted to assess their impact on the management of critically ill patients.^8,9 The aim of this observational work was to evaluate the results of preoperative imaging procedures, especially CT, in a consecutive series of nontraumatic critically ill patients who underwent nontherapeutic surgical abdominal exploration in a French university tertiary care hospital.     

Hepatocellular adenoma: an excellent indication for laparoscopic liver resection

Objectives

Laparoscopic resection for benign liver disease has gained wide acceptance in recent years and hepatocellular adenoma (HA) seems to be an appropriate indication. This study aimed to discuss diagnosis and treatment strategies, and to assess the feasibility, safety and outcomes of pure laparoscopic liver resection (LLR) in a large series of patients with HA.

Methods

Of 88 patients who underwent pure LLR, 31 were identified as having HA. Diagnosis was based on radiological evaluation and resections were performed for lesions measuring >5.0 cm.

Results

The sample included 29 female and two male patients. Their mean age was 33.2 years. A total of 27 patients had a single lesion, one patient had two and one had four lesions. The two remaining patients had liver adenomatosis. Mean tumour size was 7.5 cm. Three right hepatectomies, 17 left lateral sectionectomies and 11 wedge resections or segmentectomies were performed. There was no need for blood transfusion or conversion to open surgery. Postoperative complications occurred in two patients. Mean hospital stay was 3.8 days.

Conclusions

Hepatocellular adenoma should be regarded as an excellent indication for pure LLR. Pure LLR is safe and feasible and should be considered the standard of care for the treatment of HA when performed by surgeons with experience in liver and laparoscopic surgery.     

Laparoscopic Hepatic Posterior Sectionectomy: A Hand-assisted Approach

Background

Hepatic resection remains a challenging procedure in laparoscopy, requiring trained surgical teams and specialized centers.1 ^– 3 Operating on the posterior segments of the liver brings additional concerns, such as vascular control, right liver mobilization from the retroperitoneum and diaphragm, and a large transection area.1 ^, 3 ^– 6 Here we present a case of a hepatitis B-positive 42-year-old woman with a neoplastic nodule on the right posterior section of the noncirrhotic liver.

Methods

Pneumoperitoneum was made through a hand port, and three additional trocars were placed. Intrahepatic glissonian pedicle control was achieved after liver mobilization. Parenchymal transection was performed through the demarcation line between the anterior well vascularized and the posterior ischemic right segments of the liver. All surgical steps were performed with hand assistance.

Results

Operative time was 210 min, and estimated blood loss was 300 ml. Postoperative was uneventful. The patient was discharged on the fourth postoperative day. Histological evaluation confirmed the diagnosis of a well-differentiated hepatocellular carcinoma. The patient was free of disease after 18 months of follow-up.

Discussion

Our video shows a standardized operative strategy in which the hand assistance plays important role. Posterosuperior segments of the liver are still less often approached by laparoscopic surgery as a result of its limitations on visualization, mobilization, pedicle control, and parenchymal transection.1 ^, 3 ^, 6 Hand assistance helps solve these issues, making assisted resection easier than a purely laparoscopic approach and more advantageous over the open technique, providing the benefits of laparoscopy without compromising oncological safety.7