OBJECTIVE:We sought to describe contemporary presentation, treatment, and outcomes of patients presenting with acute (A), perforated (P), and gangrenous (G) appendicitis in the United States.
SUMMARY ...BACKGROUND DATA:Recent European trials have reported that medical (antibiotics only) treatment of acute appendicitis is an acceptable alternative to surgical appendectomy. However, the type of operation (open appendectomy) and average duration of stay are not consistent with current American practice and therefore their conclusions do not apply to modern American surgeons.
METHODS:This multicenter prospective observational study enrolled adults with appendicitis from January 2017 to June 2018. Descriptive statistics were performed. P and G were combined into a “complicated” outcome variable and risk factors were assessed using multivariable logistic regression.
RESULTS:A total 3597 subjects were enrolled across 28 sitesmedian age was 37 (27–52) years, 1918 (53%) were male, 90% underwent computed tomography (CT) imaging, 91% were initially treated by appendectomy (98% laparoscopic), and median hospital stay was 1 (1–2) day. The 30-day rates of Emergency Department (ED) visit and readmission were 10% and 6%. Of 219 initially treated with antibiotics, 35 (16%) required appendectomy during index hospitalization and 12 (5%) underwent appendectomy within 30 days, for a cumulative failure rate of 21%. Overall, 2403 (77%) patients had A, whereas 487 (16%) and 218 (7%) patients had P and G, respectively. On regression analysis, age, symptoms >48 hours, temperature, WBC, Alvarado score, and appendicolith were predictive of “complicated” appendicitis, whereas co-morbidities, smoking, and ED triage to appendectomy >6 hours or >12 hours were not.
CONCLUSION:In the United States, the majority of patients presenting with appendicitis receive CT imaging, undergo laparoscopic appendectomy, and stay in the hospital for 1 day. One in five patients selected for initial non-operative management required appendectomy within 30 days. In-hospital delay to appendectomy is not a risk factor for “complicated” appendicitis.
Oncotype Dx (ODX) is a genetic assay that analyzes tumor recurrence risk and provides chemotherapy recommendations for T1-T2 stage, hormone receptor-positive, human epidermal growth factor ...receptor-negative, and nodal-negative breast cancer patients. Despite its established validity, the utilization of this assay is suboptimal. The study aims to evaluate factors that are associated with adherence rate with the testing guidelines and examine changes in utilization trends.
This is a retrospective study, utilizing data from the National Cancer Database from 2010 to 2017. Patients who met the ODX testing guidelines were first evaluated for testing adherence. Secondly, all patients who underwent ODX testing were assessed to evaluate the trend in ODX utilization.
A total of 429,648 patients met the criteria for ODX, and 43.4% of this population underwent testing. Advanced age, racial minorities, low-income status, well-differentiated tumor grade, uninsured status, and treatment at community cancer centers were associated with a decreased likelihood of receiving ODX in eligible patients. Additionally, a notable amount of testing was performed on patients who did not meet the ODX testing criteria. Among the 295,326 patients that underwent ODX testing, 16.6% of patients were node-positive and 1.8% had T3 or T4 stage tumors.
A considerable number of patients who were eligible for ODX did not receive it, indicating potential barriers to care and disparities in breast cancer treatment. ODX usage has been expanded to broader patient populations, indicating more research is needed to validate the effectiveness of the assay in these patient groups.
Esophageal cancer therapy is commonly multimodal. The CROSS trial demonstrated a survival benefit of neoadjuvant chemoradiation versus surgery alone in T1N1 or T2-3N0-1 patients. Theoretically, ...chemoradiation should be most beneficial to patients with advanced disease. Treating the intermediary stage, T2N0M0, is challenging as national guidelines offer multiple options. This study aims to compare survival outcomes and associated factors in clinical T2N0M0 esophageal cancer via treatment modality and compare clinical to pathological stage. The authors conclude that neoadjuvant therapy use has increased; however, there is no associated survival benefit, which may be due to over- or under-staging.
A retrospective study was performed using the National Cancer Database (2006-2016). Patients who underwent neoadjuvant chemoradiation followed by surgery (NCRT + ESOPH) were compared to patients who underwent esophagectomy first (ESOPH). Multivariable logistic regression was used to determine factors associated with treatment pathway. Overall survival was compared using Kaplan–Meier estimates and log-rank tests at 1-, 3-, and 5-y post-treatment. Additionally, a multiple logistic regression analysis was conducted to identify factors associated with adjuvant therapy in ESOPH patients.
There were 1662 patients (NCRT + ESOPH: 904 54.4%, ESOPH: 758 45.6%). There was no difference in 5-y survival between NCRT + ESOPH and ESOPH patients. Despite this, NCRT + ESOPH treatment rates rose from 33% to 74% between 2006 and 2016. Patients who received NCRT + ESOPH were younger and more commonly had no Charlson-Deyo comorbidities. Notably, 41% of patients were over-staged (T1 or lower), and 32.8% were under-staged (N ≥ 1).
T2N0M0 remains difficult to characterize, and pathological staging corresponds poorly to clinical staging. Neoadjuvant therapy use has increased; however, the lack of a significant survival benefit to correlate with such may be secondary to over- or under-staging.
ABSTRACT
Purpose
Survival nomograms offer individualized predictions using a more diverse set of factors than traditional staging measures, including the American Joint Committee on Cancer Tumor Node ...Metastasis (AJCC TNM) Staging System. A nomogram predicting overall survival (OS) for resected, non-metastatic non-small cell lung cancer (NSCLC) has been previously derived from Asian patients. The present study aims to determine the nomogram’s predictive capability in the US using the National Cancer Database (NCDB).
Methods
This was a retrospective review of adults with resected, non-metastatic NSCLC entered into the NCDB between 2004 and 2012. Concordance indices and calibration plots analyzed discrimination and calibration, respectively. Multivariate analysis was also used.
Results
A total of 57,313 patients were included in this study. The predominant histologies were adenocarcinoma (48.2%) and squamous cell carcinoma (31.3%), and patients were diagnosed with stage I-A (38.3%), stage I-B (22.7%), stage II-A (14.2%), stage II-B (11.5%), and stage III-A (13.3%). Median OS was 74 months. 1-, 3- and 5-year OS rates were 89.8% 95% confidence interval (CI) 89.5–90.0%, 71.1% (95% CI 70.7–71.6%), and 55.7% (95% CI 54.7–56.6%), respectively. The nomogram’s concordance index (C-index) was 0.804 (95% CI 0.792–0.817). AJCC TNM staging demonstrated higher discrimination (C-index 0.833, 95% CI 0.821–0.840).
Conclusions
The nomogram’s individualized estimates accurately predicted survival in this patient collective, demonstrating higher discrimination in this population than in the developer’s cohorts. However, the generalized survival estimates provided by traditional staging demonstrated superior predictive capability; therefore, AJCC TNM staging should remain the gold standard for the prognostication of resected NSCLC in the US.
To learn about the perceptions of healthcare personnel (HCP) on the barriers they encounter when performing infection prevention and control (IPC) practices in labor and delivery to help inform ...future IPC resources tailored to this setting.
Qualitative focus groups.
Labor and delivery units in acute-care settings.
A convenience sample of labor and delivery HCP attending the Infectious Diseases Society for Obstetrics and Gynecology 2022 Annual Meeting.
Two focus groups, each lasting 45 minutes, were conducted by a team from the Centers for Disease Control and Prevention. A standardized script facilitated discussion around performing IPC practices during labor and delivery. Coding was performed by 3 reviewers using an immersion-crystallization technique.
In total, 18 conference attendees participated in the focus groups: 67% obstetrician-gynecologists, 17% infectious disease physicians, 11% medical students, and 6% an obstetric anesthesiologist. Participants described the difficulty of consistently performing IPC practices in this setting because they often respond to emergencies, are an entry point to the hospital, and frequently encounter bodily fluids. They also described that IPC training and education is not specific to labor and delivery, and personal protective equipment is difficult to locate when needed. Participants observed a lack of standardization of IPC protocols in their setting and felt that healthcare for women and pregnant people is not prioritized on a larger scale and within their hospitals.
This study identified barriers to consistently implementing IPC practices in the labor and delivery setting. These barriers should be addressed through targeted interventions and the development of obstetric-specific IPC resources.
This study characterized the failure rate of non-operative management (NOM) for complicated appendicitis (CA; perforation, abscess, phlegmon), and compared outcomes among patients undergoing acute ...appendectomy (AA), elective interval appendectomy (EIA), and unplanned appendectomy after failing to improve with NOM.
Adults treated at one facility between 2007 and 2014 were retrospectively studied.
Ninety-five patients presented with CA. Sixty individuals underwent AA. The remaining 35 patients initially underwent NOM: 14 underwent EIA, nine (25.7%) failed NOM, 12 never underwent surgery.
All patients failing NOM had an open operation with most (55.6%) requiring bowel resection. AA and EIA were comparable in surgical approach, bowel resection and post-operative readmission. However, AA demonstrated a lower incidence of bowel resection (3.3% vs 17.1%, P = 0.048) when compared to all patients initially undergoing NOM.
Due to the high incidence of failed NOM and the morbidity associated with failure, AA may be appropriate for CA.
•Non-operative management failed in 25.7% of patients with complicated appendicitis.•Most patients who failed non-operative management required major bowel resection.•The incidence and morbidity of failed non-operative management favors acute surgery.
This article describes a survey-based study of graduate medical residents and fellows in an integrated health system. The study explores pain curricula, learner perspectives about pain education, and ...learner knowledge, attitudes, and confidence. Results indicate that pain education in the graduate medical setting is inadequate to meet learner needs.
Resident autonomy is essential to the development of a surgical resident. This study aims to analyze gender differences in meaningful autonomy (MA) given to general surgery trainees intraoperatively.
...This is a retrospective study of general surgery residents at an academic-affiliated tertiary care facility. Attending surgeons completed post-operative evaluations based on the Zwisch model (4-point scale, ≥3 indicating MA).
Attending faculty members (37 males, 15 females) completed evaluations of 35 residents (18 males, 17 females). A total of 3574 evaluations were analyzed (1380 female, 2194 male residents) over 28 months. Multivariate analysis revealed case complexity, post graduate year level and rater gender were significantly associated with MA. Resident gender and faculty experience did not impact MA.
In contrast to published literature, resident gender did not influence MA. This may be encouraging to surgical programs seeking strategies to address gender bias.
•Evaluation for gender bias in surgical training is vital to resident autonomy.•Increasing case complexity is associated with less meaningful autonomy.•Likelihood of meaningful autonomy increased with increasing post-graduate year.•Resident gender did not impact autonomy in a general surgery residency.
NIPBL::NACC1 Fusion Hepatic Carcinoma Hissong, Erika; Al Assaad, Majd; Bal, Munita ...
The American journal of surgical pathology,
2024-Feb-01, 2024-02-00, 20240201, Letnik:
48, Številka:
2
Journal Article
Recenzirano
Several reports describing a rare primary liver tumor with histologic features reminiscent of follicular thyroid neoplasms have been published under a variety of descriptive terms including ...thyroid-like, solid tubulocystic, and cholangioblastic cholangiocarcinoma. Although these tumors are considered to represent histologic variants, they lack classic features of cholangiocarcinoma and have unique characteristics, namely immunoreactivity for inhibin and NIPBL::NACC1 fusions. The purpose of this study is to present clinicopathologic and molecular data for a large series of these tumors to better understand their pathogenesis. We identified 11 hepatic tumors with these features. Immunohistochemical and NACC1 and NIPBL fluorescence in situ hybridization assays were performed on all cases. Four cases had available material for whole-genome sequencing (WGS) analysis. Most patients were adult women (mean age: 42 y) who presented with abdominal pain and large hepatic masses (mean size: 14 cm). Ten patients had no known liver disease. Of the patients with follow-up information, 3/9 (33%) pursued aggressive behavior. All tumors were composed of bland cuboidal cells with follicular and solid/trabecular growth patterns in various combinations, were immunoreactive for inhibin, showed albumin mRNA by in situ hybridization, and harbored the NIPBL::NACC1 fusion by fluorescence in situ hybridization. WGS corroborated the presence of the fusion in all 4 tested cases, high tumor mutational burden in 2 cases, and over 30 structural variants per case in 3 sequenced tumors. The cases lacked mutations typical of conventional intrahepatic cholangiocarcinoma. In this report, we describe the largest series of primary inhibin-positive hepatic neoplasms harboring a NIPBL::NACC1 fusion and the first WGS analysis of these tumors. We propose to name this neoplasm NIPBL:NACC1 fusion hepatic carcinoma.
Abstract Smoke from the 2018 Camp Fire in Northern California blanketed a large part of the region for 2 weeks, creating poor air quality in the “unhealthy” range for millions of people. The NOAA ...Global System Laboratory’s HRRR-Smoke model was operating experimentally in real time during the Camp Fire. Here, output from the HRRR-Smoke model is compared to surface observations of PM 2.5 from AQS and PurpleAir sensors as well as satellite observation data. The HRRR-Smoke model at 3-km resolution successfully simulated the evolution of the plume during the initial phase of the fire (8–10 November 2018). Stereoscopic satellite plume height retrievals were used to compare with model output (for the first time, to the authors’ knowledge), showing that HRRR-Smoke is able to represent the complex 3D distribution of the smoke plume over complex terrain. On 15–16 November, HRRR-Smoke was able to capture the intensification of PM 2.5 pollution due to a high pressure system and subsidence that trapped smoke close to the surface; however, HRRR-Smoke later underpredicted PM 2.5 levels due to likely underestimates of the fire radiative power (FRP) derived from satellite observations. The intensity of the Camp Fire smoke event and the resulting pollution during the stagnation episodes make it an excellent test case for HRRR-Smoke in predicting PM 2.5 levels, which were so high from this single fire event that the usual anthropogenic pollution sources became insignificant. The HRRR-Smoke model was implemented operationally at NOAA/NCEP in December 2020, now providing essential support for smoke forecasting as the impact of U.S. wildfires continues to increase in scope and magnitude.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
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