Sequoia Hospital

Introducción: La neuralgia del trigémino corresponde a la neuralgia craneofacial más frecuente, cursa con dolor intenso, debilitante, en hemicara y que afecta la calidad de vida de los pacientes, teniendo como causa principal un conflicto neurovascular. Sin embargo, en casos refractarios, se indican distintos tratamientos quirúrgicos, siendo la cirugía de descompresión neurovascular la más efectiva, el presente trabajo, presenta una serie clínica personal de cirugía de descompresión neurovascular. Materiales y Métodos: Estudio retrospectivo, 20 casos operados por el autor principal del trabajo, entre 2018 y 2022. Resultados: El alivio del dolor inmediato, se obtuvo en el 100% de los casos y a los 18 meses de seguimiento, en 90% de los pacientes. Con respecto al estudio preoperatorio, en la resonancia magnética, en 3 casos no se informó conflicto neurovascular. Sin embargo, en dos de estos pacientes, si se encontró conflicto neurovascular en el intraoperatorio. En cuanto a las complicaciones, dos pacientes presentaron fistula de líquido cefalorraquídeo y un caso paresia facial que revirtió a los 6 meses de seguimiento. Discusión y Conclusión: Varias series destacan una especificidad relativamente baja de la resonancia para demostrar conflicto neurovascular, por lo tanto, si la imagen no demuestra conflicto neurovascular, esto no debería descarta la indicación de cirugía y en caso de no hallar compresión vascular, la neurolisis directa también ha mostrado una efectividad alta en la resolución del dolor. La descompresiva neurovascular en neuralgia del trigémino es segura y efectiva.

Functional precision medicine offers a promising complement to genomics-based cancer therapy guidance by testing drug efficacy directly on a patient’s tumor cells. Here, we describe a workflow that utilizes single-cell mass measurements with inline brightfield imaging and machine-learning based image classification to broaden the clinical utility of such functional testing for cancer. Using these image-curated mass measurements, we characterize mass response signals for 60 different drugs with various mechanisms of action across twelve different cell types, demonstrating an improved ability to detect response for several slow acting drugs as compared with standard cell viability assays. Furthermore, we use this workflow to assess drug responses for various primary tumor specimen formats including blood, bone marrow, fine needle aspirates (FNA), and malignant fluids, all with reports generated within two days and with results consistent with patient clinical responses. The combination of high-resolution measurement, broad drug and malignancy applicability, and rapid return of results offered by this workflow suggests that it is well-suited to performing clinically relevant functional assessment of cancer drug response.

PurposeThe optimal radiofrequency (RF) power and lesion duration using contact force (CF) sensing catheters for atrial fibrillation (AF) ablation are unknown. We evaluate 50 W RF power for very short durations using CF sensing catheters during AF ablation.MethodsWe evaluated 51 patients with paroxysmal (n = 20) or persistent (n = 31) AF undergoing initial RF ablation.ResultsA total of 3961 50 W RF lesions were given (average 77.6 ± 19.1/patient) for an average duration of only 11.2 ± 3.7 s. As CF increased from < 10 to > 40 g, the RF application duration decreased from 13.7 ± 4.4 to 8.6 ± 2.5 s (p < 0.0005). Impedance drops occurred in all ablations, and for patients in sinus rhythm, there was loss of pacing capture during RF delivery suggesting lesion creation. Only 3% of the ablation lesions were at < 5 g and 1% at > 40 g of force. As CF increased, the force time integral (FTI) increased from 47 ± 24 to 376 ± 102 gs (p < 0.0005) and the lesion index (LSI) increased from 4.10 ± 0.51 to 7.63 ± 0.50 (p < 0.0005). Both procedure time (101 ± 19.7 min) and total RF energy time (895 ± 258 s) were very short. For paroxysmal AF, the single procedure freedom from AF was 86% at 1 and 2 years. For persistent AF, it was 83% at 1 year and 72% at 2 years. There were no complications.ConclusionsShort duration 50 W ablations using CF sensing catheters are safe and result in excellent long-term freedom from AF for both paroxysmal and persistent AF with short procedure times and small amounts of total RF energy delivery.

BackgroundChronic kidney disease (CKD) is a major public health concern in the United States with high prevalence, growing incidence, and serious adverse outcomes.ObjectiveWe aimed to develop and validate a model to identify patients at risk of receiving a new diagnosis of CKD (incident CKD) during the next 1 year in a general population.MethodsThe study population consisted of patients who had visited any care facility in the Maine Health Information Exchange network any time between January 1, 2013, and December 31, 2015, and had no history of CKD diagnosis. Two retrospective cohorts of electronic medical records (EMRs) were constructed for model derivation (N=1,310,363) and validation (N=1,430,772). The model was derived using a gradient tree-based boost algorithm to assign a score to each individual that measured the probability of receiving a new diagnosis of CKD from January 1, 2014, to December 31, 2014, based on the preceding 1-year clinical profile. A feature selection process was conducted to reduce the dimension of the data from 14,680 EMR features to 146 as predictors in the final model. Relative risk was calculated by the model to gauge the risk ratio of the individual to population mean of receiving a CKD diagnosis in next 1 year. The model was tested on the validation cohort to predict risk of CKD diagnosis in the period from January 1, 2015, to December 31, 2015, using the preceding 1-year clinical profile.ResultsThe final model had a c-statistic of 0.871 in the validation cohort. It stratified patients into low-risk (score 0-0.005), intermediate-risk (score 0.005-0.05), and high-risk (score ≥ 0.05) levels. The incidence of CKD in the high-risk patient group was 7.94%, 13.7 times higher than the incidence in the overall cohort (0.58%). Survival analysis showed that patients in the 3 risk categories had significantly different CKD outcomes as a function of time (P<.001), indicating an effective classification of patients by the model.ConclusionsWe developed and validated a model that is able to identify patients at high risk of having CKD in the next 1 year by statistically learning from the EMR-based clinical history in the preceding 1 year. Identification of these patients indicates care opportunities such as monitoring and adopting intervention plans that may benefit the quality of care and outcomes in the long term.

Abstract PURPOSE: Use “off the shelf” reagents to eradicate an established tumor and induce a tumor specific T cell response that destroys distant tumor. PROCEDURES: We have identified a cooperative interaction between local tumor RT, intratumoral (IT) injection of IC hu14.18-IL2 (anti-GD2 hu14.18 mAb linked to IL2), and checkpoint blockade with anti-CTLA4 mAb. C57Bl/6 mice were implanted with 2×106 B78 (GD2+) melanoma in one flank (1-tumor model). In the 2-tumor model, mice received 2×106 B78 3 weeks (w) later in the opposite flank. After 5w the primary (1st) tumor was ∼200mm3, and ∼500mm3 after 7w. The 2nd tumor was ∼ 50mm3 at 5w. At 5w or 7w, mice received single fraction RT (12Gy) to the 1st tumor and 6 days later received 5-daily 50μg injections of IC (IT-IC). When used, anti-CTLA4 was given i.p. on days 3, 6 and 9 after RT. NEW UNPUBLISHED DATA: For mice bearing a single 200mm3 tumor, RT+ IT-IC results in complete response (CR) in 71% of mice and a tumor-specific memory T cell response. Mice with a single 500mm3 tumor showed slowing of tumor growth, but only 27% CR after radiation + IT-IC. Adding anti-CTLA-4 to RT + IT-IC improved tumor response (73% CR) and survival compared to doublet combinations of these 3 modalities. In contrast, in the 2-tumor model, providing RT + IT-IC to the 1st ∼200mm3 tumor, but not to the distant ∼50mm3 tumor, did not enhance 1st tumor shrinkage compared to RT alone and had no effect on the 2nd 50mm3 tumor. The presence of the 2nd B78 tumor resulted in systemic immune suppression that prevented the local RT and IT-IC from eliminating the 1st tumor. This was tumor specific, as local RT + IT-IC to the 1st ∼200mm3 B78 tumor was still effective in treating the 1st tumor if the 2nd (∼50 mm3 tumor) was the syngeneic but unrelated Panc02 tumor. Delivering RT to both the 1st + 2nd B78 tumors eliminated the inhibitory effect of the 2nd tumor, enabling IT-IC to the 200mm3 tumor to cause eradication of that tumor in 64% of mice. Preliminary PCR analyses of FoxP3 in the 1st tumor showed Tregs are depleted by 1st tumor RT only in mice with 1 tumor and not in mice with 2 tumors. In this 2 tumor model we combined RT + IT-IC of the 1st tumor with anti-CTLA-4. The IgG2b anti-CTLA-4 (which doesn't substantially deplete Tregs) had minimal effect on 1st tumor response to RT + IT-IC. In contrast the IgG2a anti-CTLA-4 (that depletes Tregs) rendered 60% of mice disease-free (durable CR of both the treated 200mm3 and the untreated 50mm3 tumors). Preliminary data, using DEREG mice that enable diphtheria toxin to deplete Tregs, show Treg depletion in the 2 tumor model also enables eradication of both 1st and 2nd tumors in 60% of mice after RT + IT-IC to only the 1st tumor. CONCLUSIONS: Local RT+ IT-IC can result in long-term tumor eradication of macroscopic tumors via adaptive immunity to the “in situ vaccine”, provided that Treg-associated immune suppression from distant tumor is eliminated by RT or Treg-depletion. Citation Format: Zachary S. Morris, Emily Guy, David Francis, Monica M. Gressett, Eric A. Armstrong, Shyhmin Huang, Lauryn R. Werner, Stephen D. Gillies, Alan Korman, Jacquelyn A. Hank, Alexander L. Rakhmilevich, Paul M. Harari, Paul M. Sondel. Effective in situ immunization via local radiation therapy (RT) and tumor-specific immunocytokine (IC): Suppression from distant tumor is blocked by RT or Treg-depleting CTLA-4 antibody. [abstract]. In: Proceedings of the 107th Annual Meeting of the American Association for Cancer Research; 2016 Apr 16-20; New Orleans, LA. Philadelphia (PA): AACR; Cancer Res 2016;76(14 Suppl):Abstract nr 4011.