This review explores the intricacies of evaluating cirrhotic patients for liver resection while exploring how to extend surgical intervention to those typically excluded by the Barcelona Clinic Liver ...Cancer (BCLC) criteria guidelines by focusing on the need for robust preoperative assessment and innovative surgical strategies. Cirrhosis presents unique challenges and complicates liver resection due to the altered physiology of the liver, portal hypertension, and liver decompensation. The primary objective of this review is to discuss the current approaches in assessing the suitability of cirrhotic patients for liver resection and aims to identify which patients outside of the BCLC criteria can safely undergo liver resection by highlighting emerging strategies that can improve surgical safety and outcomes.
(1) Background: Despite advances in surgical technique and systemic chemotherapy, some patients with multifocal, bilobar colorectal liver metastases (CRLM) remain unresectable. These patients may ...benefit from surgical debulking of liver tumors in combination with chemotherapy compared to chemotherapy alone. (2) Methods: A retrospective study including patients evaluated for curative intent resection of CRLM was performed. Patients were divided into three groups: those who underwent liver resection with recurrence within 6 months (subtotal debulked, SD), those who had the first stage only of a two-stage hepatectomy (partially debulked, PD), and those never debulked (ND). Kaplan-Meier survival curves and log-rank test were performed to assess the median survival of each group. (3) Results: 174 patients underwent liver resection, and 34 patients recurred within 6 months. Of the patients planned for two-stage hepatectomy, 35 underwent the first stage only. Thirty-two patients were never resected. Median survival of the SD, PD, and ND groups was 31 months, 31 months, and 19.5 months, respectively (
= 0.012); (4) Conclusions: Patients who underwent a debulking of CRLM demonstrated a survival benefit compared to patients who did not undergo any surgical resection. This study provides support for the evaluation of intentional debulking versus palliative chemotherapy alone in a randomized trial.
Background
Parenchymal-sparing hepatectomies (PSH) are liver resections with preservation of as much liver parenchyma as possible. PSH can be performed laparoscopically (LPSH), but access to the ...posterosuperior segments is difficult and they are challenging when there are multiple bilobar lesions; the procedure may require repositioning and may be long and cumbersome. The objective of this systematic review is to analyze the feasibility and limitations of laparoscopic PSH in the literature.
Methods
A systematic review of the literature was performed by searching Medline/PubMed, Scopus, and Cochrane databases. Resections were categorized by segment(s), and data regarding operative time, blood loss, length of hospital stay, complications, and R0 resection were analyzed.
Results
Of 351 studies screened for relevance, 48 studies were reviewed. Ten publications fulfilled inclusion criteria, reporting data from 579 patients undergoing LPSH. The most common indication was CRLM (58%) followed by hepatocellular carcinoma (16%). Only 92 patients were reported to have resections of more than one tumor; the maximum number of lesions resected was seven. Of resected lesions, 21.5% were located in the cranial segments. Mean operating time was 335.2 min, estimated blood loss was 462 cc, and hospital stay was 7.6 days. Conversion rate was 9.7%, and complications occurred in 19.4% of cases. No perioperative mortality was reported. R0 resections were achieved in 87.7% of cases.
Conclusion
Laparoscopic PSH is performed and reported, but the data quality is low so far. The main limitation of LPSH is the low number of lesions resected, especially for bilobar, metastatic disease. Prospective reports with tumor-specific oncological data are desirable.
The purpose of this study was to compare 3-year overall survival after simultaneous portal (PVE) and hepatic vein (HVE) embolization versus PVE alone in patients undergoing liver resection for ...primary and secondary cancers of the liver.
In this multicentre retrospective study, all DRAGON 0 centres provided 3-year follow-up data for all patients who had PVE/HVE or PVE, and were included in DRAGON 0 between 2016 and 2019. Kaplan-Meier analysis was undertaken to assess 3-year overall and recurrence/progression-free survival. Factors affecting survival were evaluated using univariable and multivariable Cox regression analyses.
In total, 199 patients were included from 7 centres, of whom 39 underwent PVE/HVE and 160 PVE alone. Groups differed in median age (P = 0.008). As reported previously, PVE/HVE resulted in a significantly higher resection rate than PVE alone (92 versus 68%; P = 0.007). Three-year overall survival was significantly higher in the PVE/HVE group (median survival not reached after 36 months versus 20 months after PVE; P = 0.004). Univariable and multivariable analyses identified PVE/HVE as an independent predictor of survival (univariable HR 0.46, 95% c.i. 0.27 to 0.76; P = 0.003).
Overall survival after PVE/HVE is substantially longer than that after PVE alone in patients with primary and secondary liver tumours.
Since the 1940s, researchers have purposefully infected healthy adult humans with pathogenic organisms to study how these pathogens cause disease and can be treated and prevented. 'Challenge studies' ...can be safe, ethical, extremely informative and an efficient use of resources during the clinical development of vaccines, but knowledge of this form of clinical research trial is not widespread. A review of the human challenge literature was performed to determine whether common elements of challenge studies can be identified in the articles published to date. The review demonstrated incomplete reporting of study characteristics deemed necessary for the correct interpretation and application of human challenge study results and for the accurate replication of study methodology. An unofficial extension of the Consolidated Standards of Reporting Trials (CONSORT) statement is proposed.
How Resilient are General Surgery Residents? Kalil, Jennifer A.; Johnson, Melissa K.; Poirier, Jennifer ...
Journal of the American College of Surgeons,
October 2018, 2018-10-00, Volume:
227, Issue:
4
Journal Article
Abstract
Background
Clinical trials initiated during emerging infectious disease outbreaks must quickly enroll participants to identify treatments to reduce morbidity and mortality. This may be at ...odds with enrolling a representative study population, especially when the population affected is undefined.
Methods
We evaluated the utility of the Centers for Disease Control and Prevention’s COVID-19–Associated Hospitalization Surveillance Network (COVID-NET), the COVID-19 Case Surveillance System (CCSS), and 2020 United States (US) Census data to determine demographic representation in the 4 stages of the Adaptive COVID-19 Treatment Trial (ACTT). We compared the cumulative proportion of participants by sex, race, ethnicity, and age enrolled at US ACTT sites, with respective 95% confidence intervals, to the reference data in forest plots.
Results
US ACTT sites enrolled 3509 adults hospitalized with COVID-19. When compared with COVID-NET, ACTT enrolled a similar or higher proportion of Hispanic/Latino and White participants depending on the stage, and a similar proportion of African American participants in all stages. In contrast, ACTT enrolled a higher proportion of these groups when compared with US Census and CCSS. The proportion of participants aged ≥65 years was either similar or lower than COVID-NET and higher than CCSS and the US Census. The proportion of females enrolled in ACTT was lower than the proportion of females in the reference datasets.
Conclusions
Although surveillance data of hospitalized cases may not be available early in an outbreak, they are a better comparator than US Census data and surveillance of all cases, which may not reflect the population affected and at higher risk of severe disease.
The ability to evaluate representation depends on timely and accurate demographic data within and outside the trial. Surveillance data of hospitalized cases are the best reference comparator during an outbreak as they reflect the population affected and at higher risk of severe disease.
We investigated the impact of a health sciences centre-wide, high-fidelity, simulation-based interprofessional team training program on participants’ knowledge, skills and attitudes towards teams and ...teamwork. Senior medical, nurse anaesthesia and allied health profession students participated in dual-scenario, simulation-based, interprofessional team training sessions with immediate debriefings about team-based competencies (2015–2017). Pre- and post-intervention, students completed the Interprofessional Teamwork (IPT) questionnaire and the Readiness for Interprofessional Learning Scale (RIPLS). Observers and students rated team performance using the Teamwork Assessment Scales (TAS). Descriptive statistics were determined for IPT and RIPLS items and TAS subscales; student Students from five health professions participated ( A health sciences centre-wide high-fidelity, simulation-based, interprofessional team training program improves students’ team-based behaviours, teamwork attitudes and interprofessional learning attitudes. Widespread adoption of such large-scale team training programs has the potential to improve teamwork among healthcare providers over time.
Abstract Introduction Effective teamwork remains a crucial component in providing high-quality care to patients in today’s complex healthcare environment. A prevalent ‘us’ versus ‘them’ mentality ...among professions, however, impedes reliable team function in the clinical setting. More importantly, its corrosive influence extends to health professional students who model the ineffective behaviour as they learn from practicing clinicians. Simulation-based training (SBT) of health professional students in team-based competencies recognized to improve performance could potentially mitigate such negative influences. This quasi-experimental prospective study will evaluate the effectiveness and impact of incorporating a multi-year, health science centre-wide SBT curriculum for interprofessional student teams. It targets health professional students from the Schools of Medicine, Nursing and Allied Health at Louisiana State University (LSU) Health New Orleans. Methods and analysis The intervention will teach interprofessional student teams key team-based competencies for highly reliable team behaviour using SBT. The study will use the Kirkpatrick framework to evaluate training effectiveness. Primary outcomes will focus on the impact of the training on immediate improvements in team-based skills and attitudes (Level 2). Secondary outcomes include students’ perception of the SBT (Level 1), its immediate impact on attitudes towards interprofessional education (Level 2) and its impact on team-based attitudes over time (Level 3). Ethics and dissemination The Institutional Review Board at LSU Health New Orleans approved this research as part of an exempt protocol with a waiver of documentation of informed consent due to its educational nature. The research description for participants provides information on the nature of the project, privacy, dissemination of results and opting out of the research.
Effective teamwork remains a crucial component in providing high-quality care to patients in today’s complex healthcare environment. A prevalent ‘us’ versus ‘them’ mentality among professions, ...however, impedes reliable team function in the clinical setting. More importantly, its corrosive influence extends to health professional students who model the ineffective behaviour as they learn from practicing clinicians. Simulation-based training (SBT) of health professional students in team-based competencies recognized to improve performance could potentially mitigate such negative influences. This quasi-experimental prospective study will evaluate the effectiveness and impact of incorporating a multi-year, health science centre-wide SBT curriculum for interprofessional student teams. It targets health professional students from the Schools of Medicine, Nursing and Allied Health at Louisiana State University (LSU) Health New Orleans. The intervention will teach interprofessional student teams key team-based competencies for highly reliable team behaviour using SBT. The study will use the Kirkpatrick framework to evaluate training effectiveness. Primary outcomes will focus on the impact of the training on immediate improvements in team-based skills and attitudes (Level 2). Secondary outcomes include students’ perception of the SBT (Level 1), its immediate impact on attitudes towards interprofessional education (Level 2) and its impact on team-based attitudes over time (Level 3). The Institutional Review Board at LSU Health New Orleans approved this research as part of an exempt protocol with a waiver of documentation of informed consent due to its educational nature. The research description for participants provides information on the nature of the project, privacy, dissemination of results and opting out of the research.
