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INTRODUCTION: Nonoperative management (NOM) of locally advanced rectal cancer was described as early as 2004. Initial national data demonstrated increase in utilization of NOM from 1998 to 2010, but newer national utilization data are not available. METHODS: We performed a retrospective cohort study using the National Cancer Database to assess utilization and 5-y overall survival (OS) of NOM of locally advanced rectal cancer. All patients had American Joint Committee on Cancer stage 2 or 3 rectal cancer, were over 40 y old, received both chemotherapy and radiation therapy, and were not being treated with palliative intent. RESULTS: 74,780 patients were analyzed. 64,540 (86.2%) underwent a definitive resection, 10,330 (13.8%) had NOM. Utilization of NOM steadily increased from 11.3% in 2010 to 18.6% in 2018. Multivariate regression identified the highest predictors of utilization of NOM to be uninsured status, government insurance, Black race, and treatment at a community cancer center. Multivariate regression identified NOM as the highest hazard for mortality (hazard ratio = 2.286, confidence interval 2.209-2.366). After propensity score matching, the mean estimated 5-y OS was 52.0% for those managed operatively compared to 39.8% for those managed nonoperatively. CONCLUSIONS: From 2004 to 2018, the utilization of NOM of locally advanced rectal cancer significantly increased. However, there was a significant discrepancy in OS in comparison to surgical resection for these patients. Further study is needed to determine the long-term oncologic safety of NOM.
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BACKGROUND: Timing of surgery has been shown to affect outcomes in many forms of cancer, but definitive national data do not exist to determine the effect of time to surgery on survival in colon cancer. OBJECTIVE: This study aimed to determine whether a delay in definitive surgery in colon cancer significantly affects survival. DATA SOURCES: A retrospective cohort study using 2 independent population-based databases, The Surveillance, Epidemiology, and End Results Medicare-linked database and the National Cancer Database, was performed. STUDY SELECTION: All patients had American Joint Committee on Cancer stage 1 through 3 colon cancer. Patients were more than 18 years of age in the National Cancer Database cohort and older than 66 years of age in the Medicare cohort. Patients had a minimum of 3 years of follow-up. MAIN OUTCOME MEASURES: The main outcome was overall survival as a function of time between diagnosis and surgery in 4 intervals (1-2, 3-4, 5-6, >6 weeks). RESULTS: The Medicare cohort demonstrated an adjusted 5-year survival of 8% to 14% higher in patients with a surgical delay between 3 and 6 weeks, with significantly lower hazard ratios in that interval. The National Cancer Database cohort demonstrated an adjusted 5-year survival of 9% to 16% higher in patients with surgery 3 to 6 weeks after diagnosis, with comparatively similar improvements in survival hazard. LIMITATIONS: Because this was a retrospective study of administrative databases, with Medicare data limited to billing data, the causality of outcomes must be interpreted with caution. CONCLUSIONS: The ideal timing of definitive resection in colon cancer is between 3 and 6 weeks after initial diagnosis. All efforts should be made for patients to obtain definitive surgery within this interval to achieve a modest but significant improvement in overall survival. See Video Abstract at http://links.lww.com/DCR/B76. ¿CUÁNDO DEBEN SOMETERSE LOS PACIENTES CON CÁNCER DE COLON A UNA RESECCIÓN DEFINITIVA?: Se ha demostrado que el momento de la cirugía afecta los resultados en muchas formas de cáncer, pero no existen datos nacionales definitivos para determinar el efecto del tiempo hasta la cirugía en la supervivencia en el cáncer de colon.Determinar si un retraso en la cirugía definitiva en el cáncer de colon afecta significativamente la supervivencia.Un estudio de cohorte retrospectivo que utiliza dos bases de datos independientes basadas en la población; Se realizó la base de datos vinculada a la vigilancia, la epidemiología y los resultados finales y la base de datos nacional del cáncer.Pacientes con cáncer de colon en estadíos 1 a 3 del Comité Estadounidense Conjunto sobre el Cáncer. Los pacientes tenían más de 18 años en la cohorte de la National Cancer Database y más de 66 años en la cohorte de Medicare. Los pacientes tuvieron un mínimo de 3 años de seguimiento.El resultado principal fue la supervivencia general en función del tiempo entre el diagnóstico y la cirugía en 4 intervalos (1-2, 3-4, 5-6, y mas de 6 semanas).La cohorte de Medicare demostró una supervivencia ajustada de 5 años de 8 a 14% más en pacientes con un retraso quirúrgico entre 3 a 6 semanas, con razones de riesgo significativamente más bajas en ese intervalo. La cohorte de la National Cancer Database demostró una supervivencia ajustada a 5 años de 9 a 16% más en pacientes con cirugía de 3 a 6 semanas después del diagnóstico, con mejoras comparativamente similares en el riesgo de supervivencia.Dado que este fue un estudio retrospectivo de bases de datos administrativas, con datos de Medicare limitados a datos de facturación, la causalidad de los resultados debe interpretarse con precaución.El momento ideal para la resección definitiva en el cáncer de colon es entre tres y seis semanas después del diagnóstico inicial. Se deben hacer todos los esfuerzos para que los pacientes obtengan una cirugía definitiva dentro de este intervalo para lograr una mejora modesta pero significativa en la supervivencia general. Consulte Video Resumen en http://links.lww.com/DCR/B76.
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Colectomia/métodos , Neoplasias do Colo/mortalidade , Neoplasias do Colo/cirurgia , Tempo para o Tratamento/ética , Assistência ao Convalescente , Idoso , Idoso de 80 Anos ou mais , Neoplasias do Colo/diagnóstico , Neoplasias do Colo/epidemiologia , Intervalo Livre de Doença , Feminino , Humanos , Incidência , Masculino , Medicare , Estadiamento de Neoplasias , Estudos Retrospectivos , Análise de Sobrevida , Tempo para o Tratamento/normas , Estados Unidos/epidemiologiaRESUMO
Diverticular colitis, also known as segmental colitis associated with diverticulosis, is a colonic inflammatory disorder on the spectrum of inflammatory bowel disease (IBD). The disease consists of macroscopic and microscopic inflammation affecting inter-diverticular mucosa, sparing peri-diverticular mucosa, with inflammation confined to the descending and sigmoid colon. The disease likely arises from the altered immune response of an individual, genetically susceptible to the IBD spectrum of diseases. Patients with segmental colitis associated with diverticulosis (SCAD) are typically older, and likely represent a subgroup of IBD-susceptible patients who lacked an environmental trigger until that point in their life. Most patients remain in remission with initial treatments of mesalamine or topical steroids, and maintenance mesalamine afterwards. Only the most severe form of the disease necessitates immunomodulatory therapy and the consideration of surgery.
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BACKGROUND: The gold standard for surveillance of patients with anal lesions is unclear. OBJECTIVE: The aim of this study was to stratify patients for risk of progression of disease and to determine appropriate intervals for surveillance of patients with anal disease. DESIGN: This was a retrospective chart review for patients treated for anal lesions between 2007 and 2014. Only patients with ≥1 year of follow-up from index evaluation, pathology, documented physical examination, and anoscopy findings were included for analysis. SETTINGS: The study was conducted at an urban university hospital. PATIENTS: HIV-positive patients with anal lesions treated with excision and fulguration were included. MAIN OUTCOME MEASURES: Recurrence of anal lesions, progression of disease, and progression to cancer were measured. RESULTS: Ninety-one patients met inclusion criteria. The mean age was 41.6 years, and mean follow-up was 38.6 months (range, 11.0-106.0 mo). On initial pathology, 8 patients (8.8%) had a diagnosis of condyloma acuminatum without dysplasia, 20 patients (22%) had anal intraepithelial neoplasia I, 32 (35.2%) had anal intraepithelial neoplasia II, and 31 (34.1%) had anal intraepithelial neoplasia III. Sixty-nine patients (75.8%) had repeat procedures. Seven (87.5%) of 8 patients with condyloma and 6 (30%) of 20 patients with anal intraepithelial neoplasia I progressed to high-grade lesions. Five (15.6%) of 32 patients progressed from anal intraepithelial neoplasia II to III, and 2 patients with anal intraepithelial neoplasia III (6.5%) developed squamous cell carcinoma (2.3% for the entire cohort). LIMITATIONS: This was a single institution study. High-resolution anoscopy was not used. CONCLUSIONS: All of the HIV-positive patients with condyloma or anal intraepithelial neoplasia, regardless of the presence of dysplasia, should be surveyed at equivalent 3-month time intervals, because their risk of progression of disease is high. Video Abstract at http://links.lww.com/DCR/A389.
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Neoplasias do Ânus , Carcinoma de Células Escamosas , Condiloma Acuminado , Infecções por HIV/complicações , HIV/isolamento & purificação , Adulto , Canal Anal/diagnóstico por imagem , Canal Anal/patologia , Neoplasias do Ânus/etiologia , Neoplasias do Ânus/patologia , Neoplasias do Ânus/cirurgia , Biópsia/métodos , Carcinoma de Células Escamosas/patologia , Carcinoma de Células Escamosas/cirurgia , Condiloma Acuminado/complicações , Condiloma Acuminado/diagnóstico , Condiloma Acuminado/virologia , Progressão da Doença , Feminino , Seguimentos , Infecções por HIV/diagnóstico , Humanos , Masculino , Estadiamento de Neoplasias , Avaliação de Processos e Resultados em Cuidados de Saúde , Lesões Pré-Cancerosas/patologia , Proctoscopia/métodos , Recidiva , Risco Ajustado/métodosRESUMO
BACKGROUND: Missing life-threatening injuries is a persistent concern in any trauma program. Autopsy is a tool routinely utilized to determine an otherwise occult cause of death in many fields of medicine. It has been adopted as a required component of the trauma peer review (PR) process by both the American College of Surgeons and the Pennsylvania Trauma Foundation. We hypothesized that autopsy would not identify preventable deaths for augmentation of the PR process. MATERIALS AND METHODS: A retrospective chart review using our institutional trauma registry of all trauma deaths between January 2012 and December 2015 was performed. Per the protocol of our level 1 center, all trauma deaths are referred to the medical examiner (ME) and reviewed as part of the trauma PR process. All autopsy results are evaluated with relation to injury severity score (ISS), trauma injury severity score (TRISS), nature of death, and injuries added by autopsy. ME reports are reviewed by the trauma medical director and referred back to the trauma PR committee if warranted. Trauma injury severity score methodology determines the probability of survival (Ps) given injuries identified. A patient with Ps of ≥0.5 is expected to survive their injuries. Cohorts were created based on when in the hospitalization death occurred: <24 h, or immediate death; 24 to 48 h, or early death; and death >48 h, or late death. A comparison was conducted between the ISS and Ps calculated during trauma workup and on autopsy using chi-square and Fischer's exact tests. RESULTS: A total of 173 patient deaths were referred to the ME with 123 responses received. Average length of stay was 2.61 d. Twenty-six patients had autopsy declined by the ME, 25 received an external examination only, and 72 received a full autopsy. Autopsy identified one case that was reconsidered in PR (P = 0.603) and added diagnoses, but not injuries, to one patient in the early death group (P = 1) and two in the late death group (P = 0.4921). No preventable cause of death was uncovered, and educational use was minimal. Autopsy did identify injuries in seven cases that were initially not consistent with expected mortality, but postmortem Ps was consistent with expected mortality (P = 0.254). Mean ISS was 34.48, and mean Ps was 0.275 among all patients. The most commonly identified injuries added by autopsy were rib injuries, lung injuries, and intracranial hemorrhage. CONCLUSIONS: Autopsy does not identify causes of preventable in an otherwise highly functioning trauma program and may be a poor use of institutional resources. In fact, it adds few diagnoses when death occurs after a full trauma assessment has had time to take place. Autopsy may be of use to identify protocol failure in maturing trauma programs, to give answers to grieving families and in select situations where death was unanticipated even after a full evaluation took place.
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Autopsia , Causas de Morte , Revisão dos Cuidados de Saúde por Pares/métodos , Ferimentos e Lesões/mortalidade , Adulto , Idoso , Feminino , Humanos , Escala de Gravidade do Ferimento , Masculino , Pessoa de Meia-Idade , Pennsylvania , Sistema de Registros , Estudos Retrospectivos , Centros de Traumatologia/normasRESUMO
BACKGROUND: Most elderly trauma patients suffer blunt head injury and many utilize antithrombotic (AT) medications. The utility of delayed CT-head (D-CTH) in neurologically intact elderly patients using AT who have an intracranial hemorrhage (ICH) on presentation is unknown. We hypothesized that D-CTH would not alter clinical management and aimed to evaluate the role of D-CTH in this population. METHODS: A retrospective cohort study was performed. Patients ≥65 years sustaining blunt head injuries from January 2010 to July 2017 were identified using our level 1 trauma center database. AT-patients presenting with ICH who underwent D-CTH were included. Patients with worsened ICH were compared to those with stable to improved ICH on D-CTH. AT-patients were compared to a cohort of non-AT patients. Fisher's Exact and Mann-Whitney U tests were utilized and a power analysis conducted. RESULTS: 137 A T and 34 non-AT patients were identified. There was no difference in hemorrhage progression or appearance of new ICH. No patient had a change in management from D-CTH in either cohort. AT-patients were slightly older (p < 0.001), but cohorts were otherwise similar. 50 AT-patients with worsened ICH were compared to 87 with stable ICH. There was no difference in cohort demographics. Hemorrhage progression did not vary with type of AT used but did increase if multiple types of synchronous ICH were present (p < 0.001). CONCLUSIONS: Our data supports abstaining from routine D-CTH of elderly ICH patients with an intact neurologic examination who are utilizing aspirin, clopidogrel or warfarin. Conclusions cannot be drawn regarding new oral anticoagulants (NOACs) given low enrollment. Further multicenter study is required to provide adequate power and detect small levels of management change.
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Anticoagulantes/uso terapêutico , Diagnóstico Tardio/estatística & dados numéricos , Fibrinolíticos/uso terapêutico , Traumatismos Cranianos Fechados/diagnóstico por imagem , Hemorragias Intracranianas/diagnóstico por imagem , Tomografia Computadorizada por Raios X/estatística & dados numéricos , Centros de Traumatologia , Idoso , Idoso de 80 Anos ou mais , Anticoagulantes/administração & dosagem , Comorbidade , Feminino , Serviços de Saúde para Idosos , Humanos , Masculino , Sistema de Registros , Estudos RetrospectivosRESUMO
Purpose: Prior studies have identified a racial disparity in incidence and survival of squamous cell carcinoma of the anus (SCCA) in the young African American male population. We aim to determine whether racial disparities are independent of income and urban location. Methods: The National Cancer Institute's Surveillance of Epidemiology and End Results database was queried for data on patients with SCCA for the years of 2000-2013. Cox regression was used to determine the effect of race, county median family income, rural-urban continuum, and stage of disease on overall survival. Results: The incidence rate of SCCA was significantly higher in black men <50 years old than in white men. Black race had a hazard ratio of 1.55 (confidence interval [CI] 1.33-1.81) when controlling for age, stage, income, and urban-rural status. Each $10,000 increase in county median family income was protective with a hazard ratio of 0.90 (CI 0.86-0.94). Residence in a metropolitan area did not significantly affect survival. Conclusions: The lower survival of black men <50 years old with SCCA is independent of income, urban location, and stage of disease. Further efforts are needed to target this at-risk population and the authors suggest wide application of previously validated screening programs for anal dysplasia.
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BACKGROUND: With increased survival among patients with human immunodeficiency virus (HIV), surgeons have been seeing more cases of anal dysplasia and cancer. There is, however, no data on the incidence of surgical site infections (SSIs) in HIV-positive patients undergoing elective anorectal procedures, nor on the administration of prophylactic antibiotic agents. We reviewed a HIV-positive population that has undergone elective anorectal biopsy of areas of dysplasia observed on office anoscopy to assess the need for antibiotic prophylaxis. PATIENTS AND METHODS: A retrospective chart review was performed of all HIV-positive patients seen as outpatients in the Colorectal Surgery Division from 2007-2016. Demographics, dates of surgery and follow-up, antibiotic prophylaxis, and pre-operative CD4 count and HIV viral load were recorded for 229 patients. Post-operative examination notes were reviewed to determine the presence of SSIs. The proportion of patients who received prophylaxis was assessed and the SSI rate was calculated. RESULTS: Surgical site infections occurred in 2 of 237 (0.8%) cases without antibiotic prophylaxis and in none of the 38 cases with prophylaxis. This infection rate was found to be lower than that of the general surgery population, with no statistical difference from hemorrhoidectomy patients without HIV. One SSI occurred in a 51-year-old male with a pre-operative CD4 count of 612 per microliter and viral load of zero. Another occurred in a 57-year-old female with an unknown CD4 count and viral load. A χ2 analysis showed the incidence of SSIs in the groups with and without prophylaxis was not significantly different (p = 0.563). CONCLUSION: Surgical site infection rates in HIV-positive patients undergoing biopsies for anal dysplasia were similar to patients without HIV undergoing similar minor anorectal procedures, and no difference was noted in the rate of SSI with the administration of prophylactic antibiotic agents. We do not recommend routine use of prophylactic antibiotic agents in this population.
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Antibioticoprofilaxia , Neoplasias do Ânus/cirurgia , Infecções por HIV/complicações , Neoplasias Retais/cirurgia , Adolescente , Adulto , Antibacterianos/uso terapêutico , Neoplasias do Ânus/complicações , Contagem de Linfócito CD4 , Feminino , Infecções por HIV/tratamento farmacológico , Humanos , Masculino , Pessoa de Meia-Idade , Neoplasias Retais/complicações , Estudos Retrospectivos , Infecção da Ferida Cirúrgica/etiologia , Infecção da Ferida Cirúrgica/prevenção & controle , Carga Viral , Adulto JovemRESUMO
The synthesis and evaluation of a series of aryl-containing N-monosubstituted analogues of the lead compound 8-carboxamidocyclazocine were performed to probe a putative hydrophobic binding pocket of opioid receptors. High binding affinity to mu, kappa, and delta opioid receptors was observed for the 8-[N-(4'-phenyl)-phenethyl)carboxamido] analogue.
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Ciclazocina/análogos & derivados , Ciclazocina/síntese química , Receptores Opioides delta/efeitos dos fármacos , Receptores Opioides kappa/efeitos dos fármacos , Receptores Opioides mu/efeitos dos fármacos , Animais , Células CHO , Cricetinae , Cricetulus , Ciclazocina/farmacologia , Etilcetociclazocina/análogos & derivados , Etilcetociclazocina/síntese química , Etilcetociclazocina/farmacologia , Humanos , Interações Hidrofóbicas e Hidrofílicas , Ensaio Radioligante , Receptores Opioides delta/metabolismo , Receptores Opioides kappa/metabolismo , Receptores Opioides mu/metabolismo , Estereoisomerismo , Relação Estrutura-AtividadeRESUMO
[reaction: see text] Several aryl ketone precursors useful in the synthesis of known physiologically active compounds have been reduced to the corresponding nonracemic alcohols. The previously reported combination of a catalytic quantity of (R)-(-)-DTBM-SEGPHOS-ligated CuH and stoichiometric PMHS is shown to be very effective in these asymmetric hydrosilylations.
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The repair of nonmalignant postlaryngectomy pharyngotracheal fistulae is not commonly encountered in medical literature. This rare complication can occur years after laryngectomy for cancer and reconstruction of a neopharynx, and is often associated with adjuvant radiation to the area, making the choice of method for surgical repair critical for success. Optimally, a pedicled myofascial flap from the pectoralis major muscle, from outside the field of radiation, is used to reinforce the repair of the fistula. We present 2 rare cases.