The impact of age and comorbidity on localized pancreatic cancer outcomes: A US retrospective cohort analysis with implications for surgical centralization.

Introduction: Age and comorbidity are independently associated with worse outcomes for pancreatic adenocarcinoma (PDAC). However, the effect of combined age and comorbidity on PDAC outcomes has rarely been studied. This study assessed the impact of age and comorbidity (CACI) and surgical center volume on PDAC 90-day and overall survival (OS). Methods: This retrospective cohort study used the National Cancer Database from 2004 to 2016 to evaluate resected stage I/II PDAC patients. The predictor variable, CACI, combined the Charlson/Deyo comorbidity score with additional points for each decade lived ≥50 years. The outcomes were 90-day mortality and OS. Results: The cohort included 29,571 patients. Ninety-day mortality ranged from 2 % for CACI 0 to 13 % for CACI 6+ patients. There was a negligible difference (1 %) in 90-day mortality between high- and low-volume hospitals for CACI 0-2 patients; however, there was greater difference for CACI 3-5 (5 % vs. 9 %) and CACI 6+ (8 % vs. 15 %). The overall survival for CACI 0-2, 3-5, and 6+ cohorts was 24.1, 19.8, and 16.2 months, respectively. Adjusted overall survival showed a 2.7 and 3.1 month survival benefit for care at high-volume vs. low-volume hospitals for CACI 0-2 and 3-5, respectively. However, there was no OS volume benefit for CACI 6+ patients. Conclusions: Combined age and comorbidity are associated with short- and long-term survival for resected PDAC patients. A protective effect of higher-volume care was more impactful for 90-day mortality for patients with a CACI above 3. A centralization policy based on volume may have greater benefit for older, sicker patients. Key message: Combined comorbidity and age are strongly associated with 90-day mortality and overall survival for resected pancreatic cancer patients. When assessing the impact of age and comorbidity on resected pancreatic adenocarcinoma outcomes, 90-day mortality was 7 % higher (8 % vs. 15 %) for older, sicker patients treated at high-volume vs. low-volume centers but only 1 % (3 % vs. 4 %) for younger, healthier patients.

Bilateral Wilms Tumor in CLOVES Syndrome.

Wilms tumor is the most common pediatric renal mass and occurs in up to 10% of predisposition syndromes. One such syndrome is CLOVES syndrome, an extremely rare disorder within the umbrella of PIK3CA-related overgrowth spectrum disorders. This case presents the management of a bilateral Wilms tumor in a patient with CLOVES syndrome and highlights the many intricacies in caring for complex oncology patients. Particularly highlighted in this case is the delicate line in balancing the risks of treatment-related morbidity against the risks of recurrence in predisposed patients, while still abiding by established treatment guidelines.

Influencing Factors of Preference Signaling in the 2022 Urology Residency Match.

OBJECTIVE: To evaluate influencing factors of preference signaling (PS) among urology residency applicants during the 2022 American Urological Association (AUA) Match. METHODS: We emailed an anonymous, deidentified questionnaire survey to applicants to our institution for the 2022 AUA Match. The main question asked to applicants was "What factor(s) went into your decision to send 'Program X' a preference signal?" Certain questions allowed the selection of multiple options, and applicants were further asked to specify these by selecting a single most important option. Descriptive statistical analyses were conducted using IBM SPSS software. RESULTS: Out of 601 registrants to the AUA match, 324 individuals applied to our institution and therefore received a survey; 77 responded for a 24% response rate. A total of 383 PS were sent by the 77 applicants. Overall, 73% and 49% of the total 383 PS had program location and reputation, respectively, selected as an influencing factor. More than 1 influencing factor was considered in 73% of PS selections, with program location (45%) considered the most important factor. In relation to applicant competitiveness, 35% of PS were sent to perceived "target" programs, 31% to "reach" programs, and 8% to "safety" programs. Among respondents who matched, 75% matched at a home, away, or signaled program. CONCLUSION: Program location appears to be the most influential factor in sending a program a PS. Programs were also signaled based on applicant's perception of their own competitiveness. PS appears to have a possible beneficial impact on obtaining interviews and successfully matching.

Percutaneous drainage for non-operative management of emphysematous pyelonephritis: Clinical characteristics and predictors of success.

Emphysematous pyelonephritis (EPN) is a necrotizing renal infection that can rapidly progress without urgent intervention. The purpose of this study was to evaluate the safety and efficacy of percutaneous nephrostomy (PN) in the management of EPN, as well as the relationship of outcomes with initial classification by the Huang-Tseng classification system and other prognostic factors such as thrombocytopenia. A retrospective review of medical records revealed seven patients with EPN treated with PN. Thirty-day survival rate was 86%, with the only mortality due to an arrhythmia secondary to underlying cardiomyopathy rather than a complication from EPN or PN. A single nephrostomy procedure served as definitive treatment in 3 patients (43%). Reintervention due to recurrence of EPN symptoms was required in 4 patients (57%), all of which initially presented with Class 3 disease or higher. Two of these four patients required nephrectomy, while the other two were successfully managed with a second drainage procedure without further recurrence of symptoms. PN appears to be a safe and generally effective management option for EPN, especially in patients who are considered poor surgical candidates. PN may serve as definitive treatment in hemodynamically stable patients with lower class of disease. In patients with higher class of disease, PN may be definitive treatment in patients who lack additional risk factors such as thrombocytopenia or serve as an effective bridge to nephrectomy.

Yin-Yang: Programming Abstractions for Cross-Domain Multi-Acceleration.

FPGA accelerators offer performance and efficiency gains by narrowing the scope of acceleration to one algorithmic domain. However, real-life applications are often not limited to a single domain, which naturally makes Cross-Domain Multi-Acceleration a crucial next step. The challenge is, existing FPGA accelerators are built upon their specific vertically-specialized stacks, which prevents utilizing multiple accelerators from different domains. To that end, we propose a pair of dual abstractions, called Yin-Yang, which work in tandem and enable programmers to develop cross-domain applications using multiple accelerators on a FPGA. The Yin abstraction enables cross-domain algorithmic specification, while the Yang abstraction captures the accelerator capabilities. We also develop a dataflow virtual machine, dubbed XLVM, that transparently maps domain functions (Yin) to best-fit accelerator capabilities (Yang). With six real-world cross-domain applications, our evaluations show that Yin-Yang unlocks 29.4× speedup, while the best single-domain acceleration achieves 12.0×.

Predicting neurosurgical clearance in the polytrauma patient with concomitant traumatic brain injury.

The goal of this study is to develop a model based on previously used prognostic predictors in traumatic brain injury (TBI) patients with polytrauma, which will facilitate the decision-making of whether to clear these patients for non-cranial surgery. Data of eligible patients was obtained from a trauma database at a Level I trauma and academic tertiary referral center in the United States. The number of days seen by the neurosurgical service prior to clearance, injury severity score (ISS), post-trauma day 0 (PTD 0) of Glasgow Coma Score (GCS), intracranial pressure (ICP) score and computed tomography (CT) score, as well as the changes in GCS, ICP score and CT score between PTD 0 and day of clearance were the variables used in developing the model. The Neurosurgical Clearance Model (NCM) was developed using data from 50 patients included in the study. Patients were cleared by neurosurgeons 1.6 days later than it would appear possible based on a retrospective review of the patients' clinical conditions. A single model equation was developed, the ultimate result of which is a clearance probability value. The best cutoff clearance probability value was found to be 0.584 (or 58.4%) using Receiver Operator Characteristic curve analysis. Our data suggests that neurosurgeons are risk-averse in clearing polytrauma patients for non-cranial surgery. This pilot NCM, if reproduced and validated by other groups and in larger prospective studies, may become a useful tool to assist clinicians in this often-difficult decision-making process.

The Impact of Socioeconomic Deprivation on Clinical Outcomes for Pancreatic Adenocarcinoma at a High-volume Cancer Center: A Retrospective Cohort Analysis.

OBJECTIVE: To assess the impact of a granular measure of SED on pancreatic surgical and cancer-related outcomes at a high-volume cancer center that employs a standardized clinic pathway. SUMMARY OF BACKGROUND DATA: Prior research has shown that low socioeconomic status leads to less treatment and worse outcomes for PDAC. However, these studies employed inconsistent definitions and categorizations of socioeconomic status, aggregated individual socioeconomic data using large geographic areas, and lacked detailed clinicopathologic variables. METHODS: We conducted a retrospective cohort study of 1552 PDAC patients between 2008 and 2015. Patients were stratified using the area deprivation index, a validated dataset that ranks census block groups based on SED. Multivariable models were used in the curative surgery cohort to predict the impact of SED on (1) grade 3/4 Clavien-Dindo complications, (2) initiation of adjuvant therapy, (3) completion of adjuvant therapy, and (4) overall survival. RESULTS: Patients from high SED neighborhoods constituted 29.9% of the cohort. Median overall survival was 28 months. The rate of Clavien-Dindo grade 3/4 complications was 14.2% and completion of adjuvant therapy was 65.6%. There was no evidence that SED impacted surgical evaluation, receipt of curative-intent surgery, postoperative complications, receipt of adjuvant therapy or overall survival. CONCLUSIONS: Although nearly one-quarter of curative-intent surgery patients were from high SED neighborhoods, this factor was not associated with measures of treatment quality or survival. These observations suggest that treatment at a high-volume cancer center employing a standardized clinical pathway may in part address socioeconomic disparities in pancreatic cancer.

Cancer outcomes are independent of preoperative CA 19-9 in anatomically resectable pancreatic ductal adenocarcinoma: A retrospective cohort analysis.

BACKGROUND AND OBJECTIVES: Current guidelines recommend neoadjuvant therapy for pancreatic ductal adenocarcinoma (PDAC) patients with anatomically resectable tumors but elevated CA 19-9. However, this recommendation is based on data from anatomically resectable and borderline resectable PDAC patients. Therefore, we analyzed the association of preoperative CA 19-9 with oncologic outcomes in a cohort of anatomically resectable PDAC patients. METHODS: A single-institution PDAC database from 2007 to 2015 included patients who underwent guideline-based staging and were anatomically resectable. Patients with bilirubin above 1.5 after decompression, nonsecretors of CA 19-9, and borderline resectable patients were excluded. Statistical analysis included frequency testing and regression modeling for recurrence and survival. RESULTS: One hundred forty-four PDAC patients were identified; 16 (11.1%) had elevated preoperative CA 19-9 ≥ 1000. A CA 19-9 level ≥1000 was not associated with demographic, clinical, or pathological factors. After adjustment for potential confounders, CA 19-9 levels (continuous, median, 500 U/mL, or 1000 U/mL cut-offs) were not associated with recurrence or overall survival (OS). CONCLUSIONS: Although guidelines recommend CA 19-9 to determine the management of anatomically resectable PDAC patients, CA 19-9 was not associated with recurrence or OS in this cohort. Our findings do not suggest that CA 19-9 alone should determine the PDAC treatment strategy.

Paraganglioma of the testicle: A case presentation and review of the literature.

Paragangliomas are rare extra-adrenal neuroendocrine tumors and presentation within the scrotum is exceedingly rare. Only thirteen other cases have been reported in medical literature, with only one other case presenting within the testicle itself. We present the second known case of paraganglioma of the testicle in a patient who initially presented with a two-week history of right testicular pain with no associated dysuria and hematuria. Ultrasound imaging indicated a solid heterogenous mass in the right testicle concerning for malignancy and was treated surgically with right radical orchiectomy. Gross and histological investigation demonstrated a morphology and immunophenotype consistent with a paraganglioma.

Risk Factors and Mediators of Suicidal Ideation Among Korean Adolescents.

BACKGROUND: A significant number of Korean adolescents have suicidal ideations and it is more prevalent among adolescents than any other age group in Korea. AIMS: This study was conducted to attain a better understanding of the contributing factors to suicidal ideation among Korean adolescents. METHOD: We recruited 569 high school students in Grades 10 and 11 in Pyeongtaek, Korea. The Beck Scale for Suicidal Ideation was used to measure suicidal ideation as the outcome variable. The Interpersonal Needs Questionnaire, the Beck Hopelessness Scale, the School Related Stress Scale, the Olweus Bully/Victim Questionnaire, and the Youth Risk Behavior Surveillance questions were used to measure thwarted belongingness and perceived burdensomeness, hopelessness, school-related stress, bullying, and previous suicidal behaviors, respectively. Data analyses included descriptive statistics and structural equation modeling. RESULTS: The findings suggest that perceived burdensomeness, hopelessness, school-related stress, and previous suicidal behaviors have significant direct effects on suicidal ideation. Hopelessness fully mediated the relation between thwarted belongingness and suicidal ideation, and partially mediated between perceived burdensomeness, school-related stress, and suicidal ideation. CONCLUSION: These findings provide more specific directions for a multidimensional suicide prevention program in order to be successful in reducing suicide rates among Korean adolescents.

Progesterone and allopregnanolone improves stroke outcome in male mice via distinct mechanisms but neither promotes neurogenesis.

Based on the outcome of a number of experimental studies, progesterone (PROG) holds promise as a new therapy for stroke. To understand more about the mechanisms involved, we administered PROG (or the major metabolite, allopregnanolone, ALLO), intra-peritoneally, for a period of 24 h after transient middle cerebral artery occlusion to male mice variably expressing intracellular progesterone receptors (iPR) A/B. Effects on infarct volume and neurogenesis were then assessed up to 1 month later. Predictably, infarct volume in wild-type mice receiving either drug was significantly smaller. However, mice heterozygous for iPRs A/B showed protection by ALLO but not by PROG. There was robust amplification of cell division in the wall of the lateral ventricle on the injured side of the brain, these cells migrated into the striatum and lateral cortex, and a significant number survived for at least 3 weeks. However, very few doublecortin-positive cells emerged from the subventricular zone and subsequent expression of NeuN in these newborn neurons was extremely rare. Neither PROG nor ALLO amplified the rate of neurogenesis, suggesting that the long-term benefits of acute drug administration results from tissue preservation. Male mice derive long-lasting benefit from progesterone and allopregnanolone after ischemic stroke. In mice heterozygous for iPRs, only allopregnanolone proved effective, suggesting distinct mechanisms. Abundant newborn cells were found in the wall of the lateral ventricle on the injured side (many doublecortin-positive), some migrated into the striatum and lateral cortex, but very few survived as mature neurons. Neurosteroid administration did not amplify this process.