Clinical Simulation Augments Traditional Interviewing of Advanced Practice Provider Candidates

An essential role of critical care advanced practice providers—advanced practice registered nurses and physician assistants—is to have knowledge and competency to make accurate and efficient decisions. The ability to manage clinical scenarios involving medically deteriorating patients requires higher-order cognitive thinking and leadership skills that are challenging to extrapolate in traditional interviews. In critical care, advanced practice providers must make rapid clinical assessments and implement appropriate medical interventions to deter progression of life-threatening illnesses. Adding clinical simulation to the traditional interview allows interviewers to evaluate applicants’ crisis resource management skills, leadership, and clinical competency.     

Surgical resection after neoadjuvant durvalumab and radiation is feasible and safe in non–small cell lung cancer: Results from a randomized trial

ObjectiveSeveral trials have recently reported the safety of pulmonary resection after neoadjuvant immunotherapy with encouraging major pathological response rates. We report the detailed adverse events profile from a recently conducted randomized phase II trial in patients with resectable non–small cell lung cancer treated with neoadjuvant durvalumab alone or with sub-ablative radiation.MethodsWe conducted a randomized phase II trial in patients with non–small cell lung cancer clinical stages I to IIIA who were randomly assigned to receive neoadjuvant durvalumab alone or with sub-ablative radiation (8Gyx3). Secondary end points included the safety of 2 cycles of preoperative durvalumab with and without radiation followed by pulmonary resection. Postoperative adverse events within 30 days were recorded according to the National Cancer Institute Common Terminology Criteria for Adverse Events (version 4.0).ResultsSixty patients were enrolled and randomly assigned, with planned resection performed in 26 patients in each arm. Baseline demographics and clinical variables were balanced between groups. The median operative time was similar between arms: 128 minutes (97-201) versus 146 minutes (109-214) (P = .314). There was no 30- or 90-day mortality. Grade 3/4 adverse events occurred in 10 of 26 patients (38%) after monotherapy and in 10 of 26 patients (38%) after dual therapy. Anemia requiring transfusion and hypotension were the 2 most common adverse events. The median length of stay was similar between arms (5 days vs 4 days, P = .172).ConclusionsIn this randomized trial, the addition of sub-ablative focal radiation to durvalumab in the neoadjuvant setting was not associated with increased mortality or morbidity compared with neoadjuvant durvalumab alone.     

An Interdisciplinary Collaboration for Environmental Education

Climate change education in advanced practice registered nursing curricula prepares nurse practitioners to respond to the health effects of climate change. Knowledge of the relationship between human and environmental health is essential for nurse practitioners to identify, teach, and respond to the health effects of climate change in clinical and community settings. This article describes a webinar hosted by the Sarah P. Duke Gardens in partnership with the Duke University School of Nursing. Our webinar provided an opportunity for attendees to understand how gardening can mitigate climate change, the important relationship between human and environmental health, and nurses’ role in climate crisis.     

Survival effects of time to surgery for Stage I lung cancer: A population-based study

ObjectivesTo examine the impact of time to surgery (TTS) on survival among patients with stage I non-small cell lung cancer (NSCLC).MethodsAll patients in the Canadian province of Ontario with stage I NSCLC from 2007 to 2017 were included. A logistic regression identified the predictors of TTS and a flexible parametric model estimated survival rates based on TTS.ResultsOver the study period, 6428 patients with stage I NSCLC undergoing surgical resection were identified, of which 62.5% had TTS >28 days. Less than half these patients (40.8%) underwent open resection, with 19.3% undergoing open sublobar and 21.5% undergoing open lobectomy. Adenocarcinoma and squamous cell carcinoma tumors accounted for 33.3% and 22.0% of cases, respectively. The majority (85.6%) of patients lived in urban areas within 50 km of a regional cancer center (76.9%). Variables that predicted TTS >28 days include age and extent of resection. After adjustment for VATS vs. open resection, age, sex, frailty, year of diagnosis, histology of tumor, and extent of resection, the hazard ratio for TTS >28 days was 1.26 (95%CI:1.13–1.40), indicating a 26% increased risk of all-cause mortality (p < 0.0001). The highest 5-year survival was observed for patients with stage I disease undergoing resection within 28 days.ConclusionsThe present study found age and extent of resection to be associated with increased TTS. Importantly, patients with TTS >28 days had reduced long-term survival.     

Tumor-associated high endothelial venules mediate lymphocyte entry into tumors and predict response to PD-1 plus CTLA-4 combination immunotherapy

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Tumor-induced erythroid precursor-differentiated myeloid cells mediate immunosuppression and curtail anti-PD-1/PD-L1 treatment efficacy

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First-line nivolumab plus chemotherapy vs chemotherapy in patients with advanced gastric,gastroesophageal junction and esophageal adenocarcinoma: CheckMate 649 Chinese subgroup analysis

First-line chemotherapy for advanced/metastatic human epidermal growth factor receptor 2 (HER2)-negative gastric/gastroesophageal junction cancer (GC/GEJC) has poor median overall survival (OS; <1 year). We report efficacy and safety results from Chinese patients in the phase III global CheckMate 649 study of nivolumab plus chemotherapy vs chemotherapy for the first-line treatment of GC/GEJC/esophageal adenocarcinoma (EAC). Chinese patients with previously untreated advanced or metastatic GC/GEJC/EAC were randomized to receive nivolumab (360 mg Q3W or 240 mg Q2W) plus chemotherapy (XELOX [capecitabine and oxaliplatin] Q3W or FOLFOX [oxaliplatin, leucovorin and 5-fluorouracil] Q2W), nivolumab plus ipilimumab (not reported) or chemotherapy alone. OS, blinded independent central review-assessed progression-free survival (PFS), objective response rate (ORR), duration of response (DOR) and safety are reported. Of 1581 patients enrolled and randomized, 208 were Chinese. In these patients, nivolumab plus chemotherapy resulted in clinically meaningful improvement in median OS (14.3 vs 10.2 months; HR 0.61 [95% CI: 0.44-0.85]), median PFS (8.3 vs 5.6 months; HR 0.57 [95% CI: 0.40-0.80]), ORR (66% vs 45%) and median DOR (12.2 vs 5.6 months) vs chemotherapy, respectively. The safety profile was acceptable, with no new safety signals observed. Consistent with results from the global primary analysis of CheckMate 649, nivolumab plus chemotherapy demonstrated a clinically meaningful improvement in OS and PFS and higher response rate vs chemotherapy and an acceptable safety profile in Chinese patients. Nivolumab plus chemotherapy represents a new standard first-line treatment for Chinese patients with non-HER2-positive advanced GC/GEJC/EAC.     

Different pulmonary adenocarcinoma growth patterns significantly affect survival

ObjectiveAdenocarcinoma (AC) is the number one pathological entity of lung cancer with approximately 30–40% of cases. It is known to be heterogeneous and has 5 histopathological growth patterns. We evaluated the long-term survival rates of patients with predominant subtypes.Methods290 patients with AC underwent pulmonary resection between 2012 and 2017 at our institution. We excluded all patients with lymph node involvement and distant metastases. Hence, 163 patients were included for further analysis. Predominant growth pattern was defined if more than 10% of cells showed a growth pattern. 1, 3, and 5-year survival rates were evaluated. Survival was assessed by Kaplan-Meier curves and the Cox proportional hazards model was used to identify prognostic factors for overall survival.ResultsPredominant growth patterns >10% were compared to <10% growth patterns of the same subtype. 1-year, 3-year, and 5-year overall survival rates of patients with predominant solid tumor growth >10% differed significantly from patients with <10% (88.4% vs. 97.6%, p = 0.04; 65.8% vs. 87.4% p = 0.001, 36.4% vs. 65.9% p = 0.01). Survival rates did not differ between >10% papillary and acinar growth compared to <10%. Kaplan-Meier curves showed reduced overall survival for patients with solid tumor growth >10% (log-rank 0.002). Solid tumor growth >10% was an independent prognostic factor for worse long-term survival (Hazard ratio: 3.05, p = 0.01).ConclusionOur study demonstrates that the presence of a predominant solid pattern in pulmonary adenocarcinoma is a factor for an unfavorable prognosis. This should be kept in mind in daily clinical practice.