Indwelling pleural catheterization maximizes functionality and quality of life in management of recurrent malignant pleural effusions

A clinical decision report using: Davies HE, Mishra EK, Kahan BC, et al. Effect of an indwelling pleural catheter vs chest tube and talc pleurodesis for relieving dyspnea in patients with malignant pleural effusion: The TIME2 randomized controlled trial. J Am Med Assoc. 2012;307(22):2383-2389. https://doi.org/10.1001/jama.2012.5535 for the management of recurrent malignant pleural effusions in a patient with metastatic renal cell carcinoma

Impact of COVID-19 on a Free Clinic Patient Population

The Robert R. Frank Student Run Free Clinic at WSUSOM, surveyed patients to determine the impact of the COVID-19 pandemic on its patient population. The study examined any challenges faced in food, financial status, transportation, and healthcare. A Qualtrics survey was administered with ethnicity, age, and gender as controls, while testing patient responses to social factors using the Likert scale. The survey was targeted to a portion of the clinic’s patient pool (n=33) over a span of three months and responses were analyzed using SPSS 26 regression analysis, ANOVA, and paired sample T-tests. Significant responses were across demographics, categories of impact, and pre/post COVID-19. Results show that access to fresh foods was severely impacted by COVID-19 (t = -3.19, p\u3c 0.05). Linear regression models show a correlation between difficulty accessing healthcare and medications, before and after COVID-19, indicating that the pandemic may have exacerbated pre-existing barriers to treatment (correlation = 0.810). Financial status has been the most affected with many patients indicating changes in employment or income status. 55% of the participants noted a greater use of savings or retirement money to make ends meet. A moderate correlation (0.471) was found between the use of public transportation prior to the pandemic and transportation barriers during the pandemic. We have decided to compile resources to address the needs based on the study results. Future research includes a longitudinal, follow-up survey to gauge any changes. Limitations include the study sample size and participation bias among the patient population

Histopathologic Analysis of Lung Cancer Incidence Associated with Radon Exposure among Ontario Uranium Miners

Although radon is a well-established contributor to lung cancer mortality among uranium miners, the effects of radon decay products on different histopathologies of lung carcinoma are not well established. Using a retrospective cohort design, this study aims to examine the risks of lung cancer by histological subtypes associated with exposure to radon decay products among the Ontario Uranium Miners cohort. Cases were stratified by histological groups, and associated risks were estimated for cumulative radon exposure after adjustment for attained age and calendar period. Between 1969 and 2005, 1274 incident cases of primary lung cancer were identified. Of these, 1256 diagnoses (99%) contained information on histology. Squamous cell carcinoma was most common (31%), followed by adenocarcinoma (20%), large cells (18%), small cell lung carcinoma (14%), and other or unspecified cell types (17%). Of the histological sub-groups, small cell lung carcinoma had the strongest association with cumulative radon exposure; compared to the reference group (<1 cumulative working level months (WLM)), the highest exposure category (>60 cumulative WLM) had a relative risk (RR) of 2.76 (95% CI: 1.67–4.57). Adenocarcinoma had the lowest risk and was not significantly associated with exposure to radon decay products (RR = 1.49, 95% CI: 0.96–2.31). An increasing, linear trend in relative risk was noted with increasing cumulative WLM across small cell, squamous cell, and large cell lung carcinomas (Ptrend < 0.05). Similarly, the excess relative risk (ERR) per WLM was highest for small cell lung carcinoma (ERR/WLM = 0.15, p < 0.01), followed by squamous cell carcinoma (ERR/WLM = 0.12, p < 0.01). Non-statistically significant excess risk was observed for adenocarcinoma (ERR/WLM = 0.004, p = 0.07). Our analysis of the Ontario Uranium Miners cohort data shows differences in the magnitude of the risks across four histological subtypes of lung carcinoma; the strongest association was noted for small cell lung carcinoma, followed by squamous cell, large cell, and lastly adenocarcinoma, which showed no significant associations with exposure to radon decay products

O6B.3 Risk of leukemia after chronic exposure to gamma radiation among ontario uranium miners?

Background and objectivesIncreases in leukemia risk after exposure to gamma radiation have been well-demonstrated among nuclear energy workers and atomic bomb survivors. Although uranium miners are also exposed to gamma radiation, its health effects are not well characterized, and assumed to be insignificant relative to the effects of radon decay products. The objective of this study is to quantify the effects of whole-body gamma radiation exposure on the incident risk of leukemia among Ontario Uranium Miners.MethodsBased on a retrospective cohort of 28 546 uranium miners, leukemia cases were identified through record linkages with the Canadian Cancer Registry and Canadian Mortality Database. Gamma doses were estimated through dose prediction models and badge dosimeter readings collated by the National Dose Registry, blinded from case status. Person-years at risk of leukemia were stratified by exposure category, calendar period of employment, and attained age at risk. Poisson regression was used to model the risk (RR) of incident leukemia at increasing levels of cumulative gamma radiation exposure, adjusting for calendar period and attained age.ResultsBetween 1969 and 2005, 116 incident cases of leukemia were identified. On average, these miners were employed for 4.4 years with a mean cumulative dose of 5.25 millisieverts (mSv). With exposure lagged by 2 years, preliminary analyses showed that when compared to the referent group (0 mSv), those with &gt;30 mSv of cumulative gamma dose had a non-statistically significant increase in the risk of leukemia diagnosis (RR=2.04, 95% CI: 0.93, 4.51) with increasing, linear trend (p=0.08).ConclusionsAlthough our results did not show a statistically significant relationship between gamma radiation and leukemia incidence, it is likely due to low statistically power. Future work may include pooling the Ontario Uranium Miners cohort with other similar cohorts to better quantify the potential associated risks.</jats:sec

Tumor Vasculature Changes Before or During Treatment to Predict Response to Systemic Therapy

A diagnosis of non-small cell lung cancer (NSCLC) carries a grim prognosis, with 5-year survival rates of 25%. 25-30% of NSCLC patients have brain metastases at initial presentation, which carries an even worse prognosis. New systemic therapies such as targeted-therapies and immuno-therapies have potential to provide better outcomes, but are not without challenges. First, efficacy is limited to a subset of patients. Second, the blood-brain barrier limits penetration, which varies among patients. Third, toxicities can be considerable. Current practice involves waiting 3-6 months to follow-up and assess tumor response; however, by then, it is later than ideal to try other therapies, and too late to limit toxicity. Establishing a non-invasive early predictor of response will accelerate the use of new promising agents and could improve tumor response and outcomes. Pre-clinical studies demonstrate changes in tumor vasculature hours after treatment are predictive of long-term treatment response. The aim of this study is to use dynamic-contrast enhanced magnetic resonance imaging (DCE-MRI) to evaluate both pre-treatment and post-treatment vascular measures (vascular volume, vascular permeability, interstitial tumor pressure) as predictors of long-term response. This exploratory clinical study will enroll 20 patients to complete 3 DCE-MRI studies. The response variables will be modeled against the vascular measures at three timepoints (pre-treatment, immediate post-treatment, and standard follow-up interval (6-8 weeks)) to assess the predictive ability of tumor vascular characteristics on survival, tumor progression, and imaging response. The data acquired in this study will be used in planning larger and more comprehensive trials in the future

O6B.2 Cancer risk by ore type in a mixed miners cohort

Background and objectivesMining may involve exposure to many carcinogens, including respirable crystalline silica (RSC), diesel engine exhaust (DEE), nickel (Ni), chromium (Cr), radon (Rn), and arsenic (As), which vary by ore being mined. The province of Ontario, Canada has a diverse mining sector with associated exposures including gold (RSC/DEE/As/Cr), uranium (RSC/DEE/Rn), and nickel-copper (DEE/Ni), and other ores (RSC/DEE). The study aim was to examine the risk of cancer by ore type in a mixed mining cohort.MethodsFrom 1928–1987 workers in the Ontario minerals industry were required to undergo an annual physical examination and chest x-ray, as well as record their mining work history in order to receive certification. Data from these exams was used to create the Mining Master File (MMF) cohort. Cancers were identified through linkage of the MMF with the Ontario Cancer Registry (1964–2017). Cancer risk among miners was compared to provincial rates using Standardized Incidence Ratios (SIR); internal analyses were conducted using Poisson regression.ResultsIndividuals who died or were lost before 1964, had missing or invalid data, or employment of less than two weeks were excluded. Too few women (n=161) were available for analysis. In total, 61 397 men were included in the analysis. Gold miners had excesses of lung (SIR=1.30, 95%CI=1.23–1.38) and nasopharyngeal cancer (SIR=2.34, 95%CI=1.39–3.70). Uranium miners had excesses of lung (SIR=1.57, 95%CI=1.45–1.70), bladder (SIR=1.20, 95%CI=1.02–1.40), and bone (SIR=2.45, 95%CI=1.30–4.19) cancers. Nickel-copper miners had excesses of lung (SIR=1.13, 95%CI=1.08–1.19), bone (SIR=2.02, 95%CI=1.32–2.96), and sinonasal cancer (SIR=1.73, 95%CI=1.12–2.56).ConclusionsIncreased risks for specific cancers were observed among people who mined many different ore types. Most of the associations were as expected, but several (e.g., bone cancers) will undergo further investigation. Future analyses will examine the impact of combined exposures among miners of multiple ore types.</jats:sec

Histopathologic Analysis of Lung Cancer Incidence Associated with Radon Exposure among Ontario Uranium Miners

Although radon is a well-established contributor to lung cancer mortality among uranium miners, the effects of radon decay products on different histopathologies of lung carcinoma are not well established. Using a retrospective cohort design, this study aims to examine the risks of lung cancer by histological subtypes associated with exposure to radon decay products among the Ontario Uranium Miners cohort. Cases were stratified by histological groups, and associated risks were estimated for cumulative radon exposure after adjustment for attained age and calendar period. Between 1969 and 2005, 1274 incident cases of primary lung cancer were identified. Of these, 1256 diagnoses (99%) contained information on histology. Squamous cell carcinoma was most common (31%), followed by adenocarcinoma (20%), large cells (18%), small cell lung carcinoma (14%), and other or unspecified cell types (17%). Of the histological sub-groups, small cell lung carcinoma had the strongest association with cumulative radon exposure; compared to the reference group (&lt;1 cumulative working level months (WLM)), the highest exposure category (&gt;60 cumulative WLM) had a relative risk (RR) of 2.76 (95% CI: 1.67&#8315;4.57). Adenocarcinoma had the lowest risk and was not significantly associated with exposure to radon decay products (RR = 1.49, 95% CI: 0.96&#8315;2.31). An increasing, linear trend in relative risk was noted with increasing cumulative WLM across small cell, squamous cell, and large cell lung carcinomas (Ptrend &lt; 0.05). Similarly, the excess relative risk (ERR) per WLM was highest for small cell lung carcinoma (ERR/WLM = 0.15, p &lt; 0.01), followed by squamous cell carcinoma (ERR/WLM = 0.12, p &lt; 0.01). Non-statistically significant excess risk was observed for adenocarcinoma (ERR/WLM = 0.004, p = 0.07). Our analysis of the Ontario Uranium Miners cohort data shows differences in the magnitude of the risks across four histological subtypes of lung carcinoma; the strongest association was noted for small cell lung carcinoma, followed by squamous cell, large cell, and lastly adenocarcinoma, which showed no significant associations with exposure to radon decay products

Management of heparin-induced thrombocytopenia with factor xa inhibitors: A systematic review

Heparin-induced thrombocytopenia (HIT) is a rare but severe prothrombotic disorder that develops in patients exposed to heparin products. Diagnosis is associated with significant morbidity and mortality. The mainstay of treatment for HIT involves discontinuing all heparin products and administering non-heparin anticoagulants. Since the publication of the American Society of Hematology (ASH) guidelines in 2018, factor Xa inhibitors have become an attractive alternative. We systematically reviewed the literature to determine the efficacy and safety of factor Xa inhibitors in managing HIT. We included any case series, retrospective, or prospective study that evaluated the efficacy of factor Xa inhibitors. We searched PubMed, Ovid, Embase, Cochrane Central Register of Controlled Trials, and Google Scholar from inception to September 2023. Three reviewers independently reviewed titles, abstracts, and full-text articles to determine eligibility using prespecified inclusion and exclusion criteria. Disagreements were resolved by discussion and consensus. Nine hundred sixty-four articles were screened against title and abstract, and 75 studies were selected for full-text review. Fifteen studies eventually met the inclusion criteria. Two hundred eighty-five patients across 15 studies were treated with factor Xa inhibitor. Across all study arms combined, HIT thrombosis-associated mortality was 0 % (n = 0), recurrent thrombosis was 4.56 % (n = 13), and major bleeding was 2.80 % (n = 8). Factor Xa inhibitors showed positive outcomes in HIT in terms of both safety and efficacy. Major limitation of this review is that the studies included are primarily retrospective and, thus, are subject to inherent limitations of observational study design. More randomized controlled trials (RCT) or prospective studies examining non-inferiority or superiority of transitioning to direct oral anticoagulant (DOAC) vs primary treatment with DOAC are needed