Evaluation of Novel Targets, Including CC-Chemokine Receptor 4, in Adult T-Cell Acute Lymphoblastic Leukemia/Lymphoma: A Mayo Clinic Clinical and Pathologic Study.

CONTEXT.­: Unlike B-cell acute lymphoblastic leukemia/lymphoma (ALL/LBL), there have been few therapeutic advances in T-cell ALL (T-ALL)/LBL, an aggressive ALL/LBL subtype. OBJECTIVE.­: To perform a focused tissue array study to elucidate tumor markers of therapeutic potential in T-ALL/LBL. DESIGN.­: Using immunohistochemistry, we evaluated expression of leukemic antigens of interest, specifically CC-chemokine receptor 4 (CCR4), among others, on available remnant diagnostic material, including tumor tissue slides obtained from formalin-fixed, paraffin-embedded preserved tissues. RESULTS.­: Our analysis identified, for the first time, expression of CCR4 in T-ALL/LBL in 11 of 27 cases (40.7%) and confirmed common expression of BCL2, CD38, and CD47, as reported previously. We also identified the expression of CD123 in 4 of 26 cases (15.4%), whereas BCL6 and PDL1 were expressed in a small number of T-ALL/LBL cases. The potential novel target CCR4 was significantly more common in the Pre/Pro-T immunophenotypic subtype, 6 of 9 (66.7%, P = .01). No additional differences in clinical and epidemiologic variables were noted among positive or negative CCR4 cases. CONCLUSIONS.­: These findings support preclinical and clinical testing of therapies targeting CCR4, CD47, BCL2, CD38, and CD123 in T-ALL/LBL, and may help guide the development of targeted clinical trials in T-ALL/LBL, a rare disease in urgent need of novel therapies.

Trends in Cardiovascular Implantable Electronic Device Insertion Between 1988 and 2018 in Olmsted County.

OBJECTIVES: This study sought to describe trends in cardiovascular implantable electronic device (CIED) insertion over the past 3 decades in Olmsted County. BACKGROUND: Trends in CIED insertion in the United States have not been extensively studied. METHODS: The Rochester Epidemiology Project is a medical records linkage system comprising the records of all residents of Olmsted County from 1966 to the present. CIED insertion between 1988 and 2018 was determined using International Classification of Diseases-Ninth Revision, International Classification of Diseases-10th Revision, and Current Procedural Terminology codes. Age- and sex-adjusted incidence rates, adjusted to the 2010 US White population, were calculated. Trends in incidence over time, across age groups, and between sex are estimated using Poisson regression models. RESULTS: The age- and sex-adjusted incidence of device implants for the study period were as follows: overall CIED: 82.4 (95% CI: 79.2-85.6); permanent pacemaker (PPM): 62.9 (95% CI: 60.0-65.7); implantable cardioverter-defibrillator (ICD): 14.0 (95% CI: 12.6-15.3); and cardiac resynchronization therapy (CRT): 5.6 (95% CI: 4.7-6.4) per 100,000 per year. The overall incidence of CIED insertion increased between 1988 to 1993 and 2000 to 2005 and then decreased between 2000 to 2005 and 2012 to 218 (P < 0.0001). PPM and ICD insertion incidence followed these trends, whereas the incidence of CRT insertion increased between 2000 to 2005 and 2012 to 2018. CIED insertion incidence increased with age (P < 0.0001). CIED insertion incidence was greater in men (116.3 vs 57.3 per 100,000 per year in men vs women; P < 0.0001). The overall survival of CRT recipients improved (P = 0.0044). CONCLUSIONS: The incidence values for PPM and ICD implants are decreasing, while the incidence of CRT implants is increasing. CIEDs are increasingly inserted in the elderly, men, and patients with higher comorbidities.

Effect of health care disparities on procedure selection of autologous breast reconstruction in Florida.

INTRODUCTION: Disparities in access to reconstructive surgery after breast cancer have been reported. We aim to evaluate demographic and socioeconomic factors influencing type of autologous breast reconstruction in Florida. METHODS: We queried the Florida Inpatient Discharge Dataset to evaluate disparities in type of autologous breast reconstructive surgery between January 1, 2013, and September 30, 2017. Patients 18 years of age or older were included. Women younger than 65 years old on Medicare were excluded. Patients were categorized into three groups according to type of autologous reconstruction: latissimus dorsi pedicled flap (pedicled flap), free flap, or pedicled flap with implant (combined flap). Demographic and socioeconomic variables were evaluated. 𝜒2 and Mann-Whitney tests were used to estimate statistical significance. A multivariate logistic regression was performed to find independent associations. RESULTS: Our results showed higher odds of reconstruction with free flap in Hispanic patients (odds ratio (OR), 1.66; 95% CI, 1.32-2.09; P < 0.0001) and patients with comorbidities (OR, 1.45; 95% CI, 1.23-1.71; P < 0.0001). However, patients treated in Central and South Florida were less likely to undergo free flap than combined and pedicled flap reconstructions compared with those treated in North Florida (P < 0.05). Patients insured by Medicaid and Medicare were less likely to undergo free flap than combined or pedicled flap reconstruction compared to patients with private insurance (P < 0.05). CONCLUSIONS: Our study identified that race, region, insurance, and comorbidity are factors associated with type of autologous breast reconstruction in Florida.

Survival of Black and White Patients With Stage IV Small Cell Lung Cancer.

BACKGROUND: Small cell lung cancer (SCLC) is associated with aggressive biology and limited treatment options, making this disease a historical challenge. The influence of race and socioeconomic status on the survival of stage IV SCLC remains mostly unknown. Our study is designed to investigate the clinical survival outcomes in Black and White patients with stage IV SCLC and study the demographic, socioeconomic, clinical features, and treatment patterns of the disease and their impact on survival in Blacks and Whites. METHODS AND RESULTS: Stage IV SCLC cases from the National Cancer Database (NCDB) diagnosed between 2004 and 2014 were obtained. The follow-up endpoint is defined as death or the date of the last contact. Patients were divided into two groups by white and black. Features including demographic, socioeconomic, clinical, treatments and survival outcomes in Blacks and Whites were collected. Mortality hazard ratios of Blacks and Whites stage IV SCLC patients were analyzed. Survival of stage IV SCLC Black and White patients was also analyzed. Adjusted hazard ratios were analyzed by Cox proportional hazards regression models. Patients' median follow-up time was 8.18 (2.37-15.84) months. Overall survival at 6, 12, 18 and 24 months were 52.4%, 25.7%, 13.2% and 7.9% in Blacks in compared to 51.0%, 23.6%, 11.5% and 6.9% in Whites. White patients had significantly higher socioeconomic status than Black patients. By contrast, Blacks were found associated with younger age at diagnosis, a significantly higher chance of receiving radiation therapy and treatments at an academic/research program. Compared to Whites, Blacks had a 9% decreased risk of death. CONCLUSION: Our study demonstrated that Blacks have significant socioeconomic disadvantages compared to Whites. However, despite these unfavorable factors, survival for Blacks was significantly improved compared to Whites after covariable adjustment. This may be due to Blacks with Stage IV SCLC having a higher chance of receiving radiation therapy and treatments at an academic/research program. Identifying and removing the barriers to obtaining treatments at academic/research programs or improving the management in non-academic centers could improve the overall survival of stage IV SCLC.

Impact of supine versus prone position on endoscopic retrograde cholangiopancreatography performance: a retrospective study.

BACKGROUND: Endoscopic retrograde cholangiopancreatography (ERCP) is frequently performed in the prone or supine position. We compared the technical success and other outcomes between these positions. METHODS: This was a retrospective cohort study using the Clinical Outcomes Research Initiative database. Demographics, procedure and fluoroscopy time, visualization of main structures, and technical success rates were compared between the supine and prone positions. Univariate and multivariate regressions were performed to adjust for age, sex, ethnicity and clinical setting. RESULTS: A total of 21,090 patients who underwent ERCP were included, of whom 1769 (8.4%) were supine and 19,321 (91.6%) were prone. The common bile duct (CBD) was visualized and cannulated in 89.1% of supine vs. 91.4% of prone positions (P=0.017), while the ampulla was visualized in 97.1% of supine vs. 97.7% of prone (P=0.414). The ERCP was incomplete in 10% of supine vs. 5% of prone cases (P<0.001). On multivariate analysis, supine position required shorter procedure times than prone (adjusted odds ratio [aOR] 0.98, 95% confidence interval [CI] 0.98-0.98; P<0.001). The supine position also yielded lower odds of CBD visualization and cannulation (aOR 0.63, 95%CI 0.44-0.91; P=0.011) and higher odds of an incomplete examination (aOR 1.84, 95%CI 1.46-2.30; P<0.001) vs. prone. CONCLUSIONS: The supine position leads to shorter procedures but is more likely to result in poorer visualization and cannulation of the CBD and an incomplete examination. This may reflect the technical difficulty of performing ERCP in the supine position for the endoscopist. Our study supports recommendations for an individualized ERCP approach.

Invasive Nocardiosis in Transplant and Nontransplant Patients: 20-Year Experience in a Tertiary Care Center.

OBJECTIVE: To present the clinical characteristics and outcome of transplant and nontransplant patients with invasive nocardiosis. PATIENTS AND METHODS: We conducted a retrospective chart review of 110 patients 18 years and older diagnosed with culture-proven invasive nocardiosis (defined as the presence of clinical signs and/or radiographic abnormalities) between August 1, 1998, and November 30, 2018. Information on demographic, clinical, radiographic, and microbiological characteristics as well as mortality was collected. RESULTS: One hundred ten individuals with invasive nocardiosis were identified, of whom 54 (49%) were transplant and 56 nontransplant (51%) patients. Most transplant patients were kidney and lung recipients. The overall mean age was 64.9 years, and transplant patients had a higher prevalence of diabetes and chronic kidney disease. A substantial proportion of nontransplant patients were receiving corticosteroids (39%), immunosuppressive medications (16%), and chemotherapy (9%) and had chronic obstructive pulmonary disease (20%), rheumatologic conditions (18%), and malignant neoplasia (18%). A higher proportion of transplant patients (28%) than nontransplant patients (4%) received trimethoprim-sulfamethoxazole prophylaxis. In both groups, the lung was the most common site of infection. Seventy percent of all Nocardia species isolated were present in almost equal proportion: N brasiliensis (16%), N farcinica (16%), N nova (15%), N cyriacigeorgia (13%), and N asteroides (11%). More than 90% of isolates were susceptible to trimethoprim-sulfamethoxazole, linezolid, and amikacin. There was no significant difference in mortality between the 2 groups at 1, 6, and 12 months after the initial diagnosis. CONCLUSION: The frequency of invasive Nocardia infection was similar in transplant and nontransplant patients and mortality at 1, 6, and 12 months was similar in both groups. Trimethoprim-sulfamethoxazole prophylaxis failed to prevent Nocardia infection.

Impact on urinary oxalate levels with use of ezetimibe.

Background: Calcium oxalate stones are the most common cause of nephrolithiasis in the United States. Smaller studies of <15 patients investigating ezetimibe, a selective cholesterol absorption inhibitor, have suggested increased urine oxalate levels with use of the drug. We attempt to better define this relationship of ezetimibe on urinary oxalate using a larger patient sample analysing multiple urine collections on and off treatment. Materials and Methods: We retrospectively reviewed all consecutive patients from 01/2018 through 04/2019 evaluated for nephrolithiasis with use of ezetimibe documented in their medical record at Mayo Clinic Florida. Primary outcomes included increase in urinary oxalate with use of ezetimibe and reduction in urinary oxalate with discontinuation of medication. Results: Of 57 reviewed patients, 30 (53%) met inclusion criteria yielding 117 24-h urine measurements either on ezetimibe (72 measurements) or off ezetimibe (41 measurements). The mean urinary oxalate level off ezetimibe was 39.86 mg versus 40.45 mg with ezetimibe. After adjusting for age and sex, the estimated difference was 1.239 mg (95% CI, -4.856 to 7.335 mg; p = 0.93). A subset of six patients with urinary oxalate values both on and off ezetimibe showed a difference in 24-h urinary oxalate levels ranged from -16.40 to 14.95 mg (mean difference = 0.93 mg; median difference = 3.84 mg). Conclusion: Use of ezetimibe does not provide clear evidence of a difference in urinary oxalate levels.

Initial treatment of patients with thyroid cancer: Outcomes and factors associated with care at academic versus nonacademic cancer centers.

BACKGROUND: Factors associated with receiving initial care for thyroid cancer (TC) at academic centers (ACs) versus nonacademic centers (NACs) and their impact on patient outcomes have not been reported. METHODS: The National Cancer Database with TC cases from 2004 to 2013 was evaluated for association of type of center for initial care with socioeconomic factors and disease and treatment characteristics, as well as overall survival (OS; all-cause mortality). RESULTS: The patients with TC (n = 200,824) included were predominantly women (74%), non-Hispanic Whites (85%), and from metro areas (84%). Sixty percent received initial care at a NAC. There were no significant differences between treatment groups by age or gender. Among those treated at an AC, a higher proportion belonged to racial/ethnic minorities (16.5%) versus at a NAC (11.6%). Hormone therapy was used more in an AC versus a NAC (60% vs 47%). Patients with all TC pathologies combined had a lower likelihood of death when they received initial care at an AC (hazard ratio [HR], 0.948; P = .0006). Among individual pathologic subtypes, a lower likelihood of death was noted when initial care was received at an AC for follicular (HR, 0.828, P = .0010) and Hurthle cell cancers (HR, 792; P = .0008), as well as stage II papillary thyroid cancer (HR, 0.828; P = .0026), but not for other histopathologic subtypes. CONCLUSIONS: Initial care at an AC was associated with lower likelihood of death for patients with TC, especially for those with follicular or Hurthle cell subtypes. Optimal resource use with consideration of patients' socioeconomic and demographic factors is imperative to ensure the most appropriate management of patients with TC in various treatment settings.

Association of Race, Socioeconomic Factors, and Treatment Characteristics With Overall Survival in Patients With Limited-Stage Small Cell Lung Cancer.

Importance: It has been established that disparities in race and socioeconomic status are associated with outcomes of non-small cell lung cancer. However, it remains unknown whether this extends to stage I, II, or III small cell lung cancer (SCLC), or limited-stage SCLC (L-SCLC). Objective: To investigate the associations of race, socioeconomic factors, and treatment characteristics with survival among patients with L-SCLC. Design, Setting, and Participants: Demographic information for patients with L-SCLC diagnosed between 2004 and 2014 was obtained from the National Cancer Database. The follow-up end point is death or last follow-up (date of last contact). Patients were divided into 5 mutually exclusive cohorts by race. Data analysis was performed in October 2019. Main Outcomes and Measures: Cox proportional hazards models were used to calculate univariable and multivariable models. Multivariable analyses were conducted to assess the associations of race and socioeconomic factors with risk-adjusted outcomes. Overall survival between groups was depicted by Kaplan-Meier curves. Results: Of 72 409 patients analyzed (median [range] age, 67.0 [23.0-90.0] years), 40 289 (55.6%) were women. The distribution of disease stage was 10 619 patients (14.7%) with stage I disease, 7689 patients (10.6%) with stage II disease, and 54 101 patients (74.7%) with stage III disease. The median (range) duration of follow-up was 8.2 (2.4-15.8) months. Compared with White patients, the hazard of death decreased to 0.92 (95% CI, 0.89-0.95; P < .001) for African American patients and 0.83 (95% CI, 0.77-0.91; P < .001) for Asian patients. The difference in median survival among different racial groups was significant only among those with stage III SCLC. Other factors associated with better survival were female sex, high income, high education, private insurance, diagnostic confirmation by positive cytological analysis, increase in number of sampled regional lymph nodes, and earlier stage at diagnosis. Conclusions and Relevance: This analysis highlights disparities in race and socioeconomic factors associated with outcomes of L-SCLC. Racial minorities, including African American and Asian patients, have better survival than White patients for L-SCLC after adjustment for sociodemographic factors.

Hospital robotic use for colorectal cancer care.

The use of robotic surgery for colorectal cancer continues to increase. However, not all organizations offer patients the option of robotic intervention. This study seeks to understand organizational characteristics associated with the utilization of robotic surgery for colorectal cancer. We conducted a retrospective study of hospitals identified in the United States, State of Florida Inpatient Discharge Dataset, and linked data for those hospitals with the American Hospital Association Survey, Area Health Resource File and the Health Community Health Assessment Resource Tool Set. The study population included all robotic surgeries for colorectal cancer patients in 159 hospitals from 2013 to 2015. Logistic regressions identifying organizational, community, and combined community and organizational variables were utilized to determine associations. Results indicate that neither hospital competition nor disease burden in the community was associated with increased odds of robotic surgery use. However, per capita income (OR 1.07 95% CI 1.02, 1.12), average total margin (OR 1.01, 95% CI 1.001, 1.02) and large-sized hospitals compared to small hospitals (OR: 5.26, 95% CI 1.13, 24.44) were associated with increased odds of robotic use. This study found that market conditions within the U.S. State of Florida are not primary drivers of hospital use of robotic surgery. The ability for the population to pay for such services, and the hospital resources available to absorb the expense of purchasing the required equipment, appear to be more influential.

Influence of surgeon specialty and volume on the utilization of minimally invasive surgery and outcomes for colorectal cancer: a retrospective review.

BACKGROUND: Utilization of minimally invasive surgery (MIS) has multiple determinants, one being the specialization of the surgeon. The purpose of this study was to assess the differences in the utilization of MIS, associated length of stay (LOS), and complications for colorectal cancer between colorectal (CRS) and general surgeons (GS). Previous studies have documented the influence of surgical volume and surgeon specialty on clinical outcomes and patient survival following colorectal cancer surgery. It is unclear whether there are differences in the utilization of MIS for colorectal cancer based on surgeon's specialization and how this influences clinical outcomes. METHODS: Using the 2013-2015 Florida Inpatient Discharge Dataset and the National Plan & Provider Enumeration System, colorectal cancer patients experiencing a colorectal surgery were identified as well as the operating physician's specialty. Mixed-effects regression models were used to identify associations between the use of MIS, complications during the hospital stay, and patient LOS with patient, physician, and hospital characteristics. RESULTS: There is no difference in the use of MIS, complication, nor LOS between GS and CRS for colorectal cancer surgery. However, physician volume was associated with increased use of MIS (OR 1.26, 95% CI 1.09, 1.46) and MIS was associated with decreases in certain complications as well as reductions in LOS overall (ß = - 0.16, p < 0.001) and for each specialty (GS: ß = - 0.18, p < 0.001; CRS ß = - 0.12, p < 0.001) CONCLUSIONS: Despite the higher amount of proctectomies performed by CRS, no difference in MIS utilization, complication rate, or LOS was found for colorectal cancer patients based on surgeon specialty. While there are some differences in clinical outcomes attributable to specialized training, results from this study indicate that differences in surgical approach (MIS vs. Open), as well as the patient populations encountered by these two specialties, are key factors in the outcomes observed.

Impact of travel distance on quality outcomes in colorectal cancer.

OBJECTIVES: This study sought to examine the impact of distance traveled from place of residence to surgical facility for elective colorectal surgery on surgical outcomes, length of stay, and complication rate. STUDY DESIGN: Retrospective study. METHODS: Patients with colorectal cancer were identified from the Florida Inpatient Discharge Database. Distance traveled from primary residence to surgical facility was estimated using zip code. After adjusting for patient and hospital characteristics, multivariate regression models compared bypassed hospitals, the length of stay, and complication rates for patients traveling different distances to receive care. RESULTS: Patients residing in rural areas and in South (odds ratio [OR], 2.37; 95% CI, 1.55-3.63) and Central Florida (OR, 5.86; 95% CI, 3.86-8.89) were more likely to travel more than 50 miles for treatment. Teaching status of the hospital (OR, 9.99; 95% CI, 6.98-14.31), a hospital's availability of a colorectal surgeon (OR, 1.83; 95% CI, 1.45-2.31), and metastasized cancer (OR, 1.43; 95% CI, 1.17-1.82) influenced the patient's decision to travel farther for treatment. Length of stay was significantly higher for patients traveling farther (P < .0343). However, there was no significant difference in the rate of complications among the groups (those traveling 25-50 miles vs < 25 miles [P = .5766] and those traveling > 50 miles vs < 25 miles [P = .4516]). CONCLUSIONS: A greater number of patients travel more than 50 miles to the surgical facility at a later stage of disease. These patients do not significantly differ from those traveling less than 50 miles in their rates of complications; however, they stay longer at the surgical facility.

Disparities in Access to Autologous Breast Reconstruction.

Background and objectives: This study aimed to determine if age, race, region, insurance, and comorbidities affect the type of breast reconstruction that patients receive. Materials and methods: This analysis used the Florida Inpatient Discharge Dataset from 1 January 2013 to 30 September 2017, which contains deidentified patient-level administrative data from all acute care hospitals in the state of Florida. We included female patients, diagnosed with breast cancer, who underwent mastectomy and a subsequent breast reconstruction. We performed an χ2 test and logistic regression in this analysis. Results: On the multivariable analysis, we found that age, race, patient region, insurance payer, and Elixhauser score were all variables that significantly affected the type of reconstruction that patients received. Our results show that African American (odds ratio (OR): 0.68, 95%CI: 0.58-0.78, p < 0.001) and Hispanic or Latino (OR: 0.82, 95%CI: 0.72-0.93, p = 0.003) patients have significantly lower odds of receiving implant reconstruction when compared to white patients. Patients with Medicare (OR: 1.57, 95%CI: 1.33-1.86, p < 0.001) had significantly higher odds and patients with Medicaid (OR: 0.61, 95%CI: 0.51-0.74, p < 0.001) had significantly lower odds of getting autologous reconstruction when compared to patients with commercial insurance. Conclusions: Our study demonstrated that, in the state of Florida over the past years, variables, such as race, region, insurance, and comorbidities, play an important role in choosing the reconstruction modality. More efforts are needed to eradicate disparities and give all patients, despite their race, insurance payer, or region, equal access to health care.

Use of a simulation-based advanced resuscitation training curriculum: Impact on cardiopulmonary resuscitation quality and patient outcomes.

BACKGROUND: Despite a continued focus on improved cardiopulmonary resuscitation quality, survival remains low from in-hospital cardiac arrest. Advanced Resuscitation Training has been shown to improve survival to hospital discharge and survival with good neurological outcome following in-hospital cardiac arrest at its home institution. We sought to determine if Advanced Resuscitation Training implementation would improve patient outcomes and cardiopulmonary resuscitation quality at our institution. METHODS: This was a prospective, before-after study of adult in-hospital cardiac arrest victims who had cardiopulmonary resuscitation performed. During phase 1, standard institution cardiopulmonary resuscitation training was provided. During phase 2, providers received the same quantity of training, but with emphasis on Advanced Resuscitation Training principles. Primary outcomes were return of spontaneous circulation, survival to hospital discharge, and neurologically favorable survival. Secondary outcomes were cardiopulmonary resuscitation quality parameters. RESULTS: A total of 156 adult in-hospital cardiac arrests occurred during the study period. Rates of return of spontaneous circulation improved from 58.1 to 86.3% with an adjusted odds ratios of 5.31 (95% CI: 2.23-14.35, P < 0.001). Survival to discharge increased from 26.7 to 41.2%, adjusted odds ratios 2.17 (95% CI: 1.02-4.67, P < 0.05). Survival with a good neurological outcome increased from 24.8 to 35.3%, but was not statistically significant. Target chest compression rate increased from 30.4% of patients in P1 to 65.6% in P2, adjusted odds ratios 4.27 (95% CI: 1.72-11.12, P = 0.002), and target depth increased from 23.2% in P1 to 46.9% in P2, adjusted odds ratios 2.92 (95% CI: 1.16-7.54, P = 0.024). CONCLUSIONS: After Advanced Resuscitation Training implementation, there were significant improvements in cardiopulmonary resuscitation quality and rates of return of spontaneous circulation and survival to discharge.

Treatment of upper extremity deep vein thrombosis with apixaban and rivaroxaban.

Randomized controlled trials leading to the approval of apixaban and rivaroxaban for venous thromboembolism (VTE) did not include patients with upper extremity deep vein thrombosis (UE-DVT). We sought to evaluate the safety and effectiveness of rivaroxaban and apixaban for the treatment of acute UE-DVT. Consecutive patients with VTE enrolled into the Mayo Clinic VTE Registry, between March 1, 2013 and December 31, 2019, were followed prospectively. Clinical, demographic and imaging data were collected at the time of study recruitment. Patients with a diagnosis of acute UE-DVT who received rivaroxaban, apixaban, LMWH or warfarin were included. Recurrent VTE, major bleeding, clinical-relevant non-major bleeding (CRNMB), and death were assessed at 3-month intervals. During the study period, 210 patients with acute UE-DVT were included; 63 were treated with apixaban, 39 with rivaroxaban, and 108 with LWMH and/or warfarin. Overall 51% had catheter-associated UE-DVT, 60% had a diagnosis of malignancy, and 14% had concurrent pulmonary embolism. Malignancy was more common in patients treated with LMWH/warfarin (67% vs 52%, P = .03). At 3 months of follow up, one (0.9%) recurrent VTE occurred in a patient treated with LMWH/warfarin and one (1.0%) patient treated with apixaban or rivaroxaban (P = .97). Major bleeding occurred in three patients treated with LMWH/warfarin, and in none of those treated with apixaban or rivaroxaban (P = .09). Clinical-relevant non-major bleeding occurred in one patient (0.9%) treated with LWMH/warfarin and two patients (2.0%) treated with apixaban or rivaroxaban (P = .53). Treatment of UE-DVT with apixaban or rivaroxaban appears to be as safe and effective as LMWH/warfarin.

Residual Tumor on Wide Excisional Margins After Treatment of Invasive Melanoma.

BACKGROUND/AIM: The surgical management of invasive melanoma has been debated for many years and recommended excisional margins have been established. We aimed to describe the factors and survival related to the presence of residual tumor in patients with invasive melanoma lymph nodes negative. PATIENTS AND METHODS: We performed a retrospective study by querying the National Cancer Database from 2004 to 2015. Associations were tested using a multivariate analysis. Overall survival was compared using the Kaplan-Meier method. RESULTS: A total of 26,440 patients met the inclusion criteria. For Breslow depth groups ≤1 mm and >2 mm, older age and location in the head and neck were factors associated to residual tumor in margins (p<0.05), whereas only location in the head and neck was associated to residual tumor for patients with Breslow depth between 1.01-2.00 mm (p<0.05). CONCLUSION: Knowledge of the factors associated with the residual tumor will help establish a patient-centered management and decrease the recurrence of disease.

Wide Excisional Surgery in Invasive Melanoma Treatment: Factors Driving Non-compliance With National Guidelines.

BACKGROUND/AIM: Margin size during wide excisional surgery for invasive melanoma treatment have been established by national guidelines. This study identified factors associated with wider than recommended excisional margins and its impact on survival. PATIENTS AND METHODS: The National Cancer Database was queried to identify patients with primary invasive melanoma. Statistical analysis was performed using univariate and multivariate analysis. Overall survival was compared using Kaplan-Meier method. RESULTS: A total of 26,440 patients were included in the analysis. Melanomas located on the trunk were more likely to be treated using wider than recommended excisional margins for certain Breslow depth groups (p<0.05), while the opposite was true for those being treated in an academic/research program (p<0.05). The practice of taking wider than recommended margins was not associated with improved survival. CONCLUSION: Tumor location and facility type influence non-compliance with the National Comprehensive Cancer Network guidelines. Lack of survival benefit in patients with wider excisional margins seems to support guideline recommendations.

Valchlor® in the Treatment of Lichen Planopilaris and Frontal Fibrosing Alopecia: A Single Arm, Open-label, Exploratory Study.

BACKGROUND: Lichen Planopilaris (LPP) is a lymphocyte-mediated scarring alopecia that frequently is treatment resistance to both topical and systemic therapies. AIMS AND OBJECTIVES: The object of this pilot study was to assess the effectiveness of topical mechlorethamine 0.016% gel (Valchlor®) in decreasing disease activity in LPP and the related clinical variant frontal fibrosing alopecia (FAA). METHODS: Twelve patients with biopsy-proven LPP/FAA who failed prior topical or systemic therapy with active disease were included. Participants applied mechlorethamine 0.016% gel to involved areas daily for 24 weeks. Outcome measures included LPP Activity Index (LPPAI) score, Physician Global Assessment (PGA) score, Dermatology Quality of Life Index (DQLI) score, and phototrichograms assessing follicular counts before and after six months of therapy. RESULTS: LPP Activity Index (LPPAI) before and after treatment was significantly different (5.0 before treatment, 2.0 after treatment; p value=0.006). Mean follicular density and follicular units were unchanged during the treatment period. CONCLUSION: Treatment with mechlorethamine 0.016% gel for 24 weeks resulted in statistically significant improvement of LLP/FFA with no change in phototrichogram parameters. Treatment duration was limited by high rate of contact dermatitis. Further investigation to optimize dosing frequency and to assess the role of combination topical therapy is needed.

Disparities influencing rates of urgent/emergent surgery for diverticulitis in the state of Florida.

BACKGROUND: Patients with diverticulitis have a 20% risk of requiring urgent/emergent treatment. Since morbidity and mortality rates differ between elective and urgent/emergent care, understanding associated disparities is critical. We compared factors associated with treatment setting for diverticulitis and evaluated disparities regarding access to Minimally Invasive Surgery (MIS) and development of complications. METHODS: The Florida Inpatient Discharge Dataset was queried for patients diagnosed with diverticulitis. Three multivariate models were utilized: 1) elective vs urgent/emergent surgery, 2) MIS vs open and 3) presence of complications. RESULTS: The analysis included 12,654 patients. Factors associated with increased odds of urgent/emergent care included being uninsured or covered by Medicaid, African American, obese, or more comorbid. MIS was associated with reduced odds of complications. Patients treated by high-volume or colorectal surgeons had increased odds of receiving MIS. CONCLUSIONS: Patients were more likely to receive MIS if they were treated by a colorectal surgeon, or a high-volume surgeon (colorectal, or general surgeon). Additionally, patients that were older, had increased comorbidities, or did not have health insurance were less likely to receive MIS.

The Multifactorial Contribution of Publications in Plastic Surgery Journals in Microsurgery Education.

BACKGROUND: Microsurgery is one of the most complex operative skills. Recent restrictions on residents' working hours challenge residency program directors to ensure skill acquisition with scant time dedicated to microsurgery practice. We aimed to summarize the contribution of plastic surgery journals in microsurgical education. METHODS: A comprehensive literature search was performed. RESULTS: We observed an increasing number of publications on microsurgery education over the years. This could be due to the adoption of new technologies developed in the last 2 decades, the concerns about quality of resident training in the context of reduced work hours, the well-described benefit of medical simulations in other specialties, and the pressure on trainees to be proficient before operating on patients. The variety of aspects addressed in plastic surgery publications is broad: simulators, courses, skills assessment, national surveys, and technology trends. CONCLUSION: There is an upward trend in the number of publications and plastic surgery journals, demonstrating a remarkable contribution to microsurgery training.